The WHO MultiCountry Survey The WHO MultiCountry Survey on Maternal and Newborn on Maternal and Newborn

Health - 2010-11Health - 2010-11Prof. Dr. Syeda Batool Mazhar

FRCOG (U.K), FCPS (PK)Head of Department, MCH Centre, PIMS, Islamabad

BackgroundThe world has seen two important changes in maternal health: • Substantial reduction in global maternal mortality • Increase in proportion of childbirths in health facilities.Progress though remarkable is insufficient to meet the MDG’s• Estimated 287,000 women died in 2010 of causes related to

pregnancy and childbirth• A substantial proportion of childbirths are still taking place in

communities without skilled birth assistance• In many settings, women prefer to deliver in the community due

to concerns about perceived quality of care in health facilities.• Thus quality of care is increasingly critical to accelerate reduction

in maternal mortality & stimulate demand for institutional births. .

BackgroundQuality of care is a multidimensional concept resulting in patient and provider satisfaction and improved health outcomes that includes

• Appropriate use of effective clinical and non-clinical interventions• Strengthened health infrastructure • Health providers’ attitude

“As part of strategies to improve maternal health care, great emphasis has been placed on maximizing coverage that can be

objectively monitored and evaluated, however other dimensions of quality are more challenging”

The WHO Multi Country Survey on The WHO Multi Country Survey on Maternal and Newborn Health Maternal and Newborn Health

2010-112010-11

Primary Objective

• To study the incidence and the management of maternal and neonatal conditions highly associated with maternal and neonatal mortality in a worldwide network of health facilities.

The WHO Multicountry Survey on The WHO Multicountry Survey on Maternal & Newborn Health 2010-11Maternal & Newborn Health 2010-11

Secondary Objectives

• To assess the quality of care by the maternal near miss indicators and

the use of effective preventive and therapeutic interventions.

• To examine the relationship of the use of effective preventive and

therapeutic interventions with severe perinatal morbidity and

mortality

• To consolidate the WHO Multicountry, Maternal and Perinatal Health

network and strengthen research capacity of health facilities

worldwide.

Materials and methods

29 countries, 357 health facilities Americas - 8 countries

Africa - 7 countries Asia - 14 countries 314,623 deliveries

SELECTED COUNTRIES IN WHO MULTICOUNTRY SURVEY

Group I Low MMR

Group II Moderate MMR

Group III High MMR

Group IV Very High MMR

(MMR<20) (MMR 20-99) (MMR 100-299) (MMR 300+)

Japan Qatar

Argentina Brazil China Jordan Lebanon Sri Lanka Mexico Mongolia Nicaragua Occupied Palestinian T Peru Philippines Paraguay Thailand Viet Nam

Ecuador India Cambodia Nepal Pakistan

Afghanistan Angola Democratic Republic of the Congo Kenya Niger Nigeria Uganda

Materials and methods

The WHO MultiCountry Survey on The WHO MultiCountry Survey on Maternal and Newborn Health Maternal and Newborn Health

2010-11 2010-11

Punjab:

• Rawalpindi Medical College• Nishtar Hospital Multan• Bahawalpur Victoria Hospital• DHQ Hospital Toba Tek Singh• THQ Hospital Muridke• Sheikh Zayed Hospital Lahore • Services Hospital Lahore. Federal Capital: PIMS, Islamabad

Sindh:

• Civil Hospital Karachi• Sobhraj Hospital Karachi• Korangi Hospital Karachi• Qatar Hospital Karachi• Taluka Hospital Rohri• Civil Hospital Jakobabad• Civil Hospital Badin

& FGSH, Islamabad

16 health facilities with annual delivery rates > 1000, randomly selected in Sind, Punjab and Islamabad.

Materials and methodsStudy PopulationStudy Population

All women giving birth in selected study

hospitals

Materials and methodsStudy PopulationStudy Population

All deaths of women during pregnancy, childbirth or within seven days of

termination of pregnancy(regardless of the gestational age and the

delivery status)

Materials and methodsStudy PopulationStudy Population

All maternal near miss cases, regardless of the gestational age and the delivery status

Eligibility CriteriaEligibility Criteria

The Study Population

Most of eligible women are giving

birth

Eligibility CriteriaEligibility Criteria

The Study Population

But, few eligible women are not

giving birth

Eligibility CriteriaEligibility Criteria

The Study Population

All delivering women+ all near miss cases and deaths of non delivering women

Maternal Mortality

Definition:

• Maternal death (MD)is the death of a woman while pregnant or within 42 days of termination of pregnancy,

• Irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management

• But not from accidental or incidental causes.

World Health Organization

05_

XX

X_M

M1

8

Maternal Near Miss MortalityMaternal Near Miss Mortality

Definition:"A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42

days of termination of pregnancy"

This definition by WHO reconciles previous maternal near miss definitions and is aligned with "maternal death" definition of ICD10

Why maternal near miss Mortality ?

• Near miss/SAMM cases share many characteristics with maternal deaths

• Can directly inform on obstacles that had to be overcome after the onset of an acute complication.

• Corrective actions for identified problems can be taken to reduce related mortality and long-term morbidity

05_

XX

X_M

M2

0

WHO Maternal Near Miss identification criteriaWHO Maternal Near Miss identification criteria

A set of organ dysfunction markers including Basic laboratory tests & Management-related markers

Clinical criteria based on the clinical assessment where laboratory and other techniques are not available

Results

We Report the main findings of the WHO Multi country Survey on Maternal and Newborn Health which evaluated

• The burden of pregnancy-related complications,

• The coverage of key maternal health interventions

Summary of Global MCSurvey Results

• Countries 29• Total Women 314,623• Maternal near miss 2529• Maternal deaths 514 • Severe maternal outcome (MNM+MM) 1%• Potential life-threatening conditions 7%

Summary of Global MCSurvey Results

• Most frequent complications in women with severe maternal outcomes:

Postpartum hemorrhage (26 %). Pre-eclampsia /eclampsia (26 %).

• The observed mortality in high mortality countries including Pakistan, was 2-3 times higher than expected for the assessed severity despite a high coverage of essential interventions.

Total no of patients n.= 13175

No delivery in participating facility (women with organ dysfunction)n=53

Delivery in participating facility (women with or without organ dysfunction)

n=13122

Abortive outcome n=11

Antepartum n=8

Postpartum n=34

Near miss n=10

Maternal death n=1

Near miss n=4

Maternal death n=4

Near miss n=28

Maternal death n=6

No near miss with out complication

n=12017

No near miss with complication

n=1026

Near miss n=52

Maternal death n=27

STUDY FLOW CHART: PAKISTAN

Frequency And Severity Of Pregnancy-related Complications

Pakistan EMRO WORLD

WOMEN 13175 49484 308985

Women with complications

1158 (8.7%) 3088 (6.2 %) 22915 (7.4%)

Women with SMO 132 (1 %) 416 (0.84 %) 3043 (0.98 %)

Maternal near miss cases

94 555 2529

Maternal deaths 38 59 514

Maternal mortality ratio

299 123 170

Maternal nearmiss : maternal mortality ratio

3:1 10:1 5:1

Maternal mortality ratio(WHO MCS 2011)

Coverage Of Key InterventionsPakistan(%) EMRO(%) World(%)

prophylactic oxytocin

97.9 96.7 90.1

therapeutic oxytocin

93.6 85.7 86.4

magnesium sulphate for eclampsia

93.3 91.8 86.8

prophylactic antibiotic for c section

80.9 77.9 87.7

parentral antibiotic for sepsis

88.5 82.0 77.0

Corticosteroids for preterm birth

57.7 40.6 37.1

Coverage of key interventions by country group

Low- MMR countries

Moderate-MMR countries

High MMR countries

Very-High MMR countries

Prophylactic oxytocin

82% 91% 88% 92%

Therapeutic oxytocin

82% 88% 84% 86%

MgSO4 for eclapmsia

75% 89% 80% 87%

Prophylactic antibiotic for c sec

36% 92% 83% 82%

Parentral antibiotics for sepsis

69% 84% 63% 89%

Interventions related to postpartum hemorrhage

prevention of PPHn=13175

intervention N %

Use of oxytocin 12875 96.4%

Misoprostol 7227 54.9%

Ergotamine 2893 22%

Other uterotonics 213 1.6%

Interventions related to postpartum hemorrhage

treatment of PPHn=187

intervention N %

Oxytocin 175 93.6

Misoprostol 158 84.5

Ergometrine 107 57.2

Other uterotonics 34 18.3

Any uterotonics 177 94.6

Artery ligation 19 1

Balloon or condom tamponade 63.2

Hysterectomy 19 10.2

Severe maternal outcomes 38 20.3

Deaths 13 6.9

Interventions related to preterm labour

N=1449Yes%

Use of corticosteroids 47.9

Betamimetics 1.5

NSAIDS 0.6

Ca channel blockers 6.6

Oxytocin antagonist 0.4

MgSO4 0.5

Bed rest 34.2

Hydration 36.1

No treatment for PTL 42

Pregnancy Complications and Severe Maternal Outcome

Statistically sig diff b/w SMO and non-SMO group for maternal education p= 0.000Statistically sig diff b/w SMO and non-SMO group for no of previous c section P=0.027

Maternal complications Hemorrhage related severe maternal

outcome

Maternal complications Infection related severe

maternal outcome

SMO n=132

Maternal Complications In Severe Maternal Outcome

Hypertensive Disorders

Maternal complications other complications related severe maternal outcome

Anesthesia for LSCSN= 4202 %

Gen anesthesia 464 11%

Epidural 48 1%

spinal 3690 89%

Maternal intensive care useMaternal intensive care use

Pakistan EMRO World

ICU admission rate 0.5% 1% 0.6%

ICU admission rate among women

with SMO 32.6% 48.5% 31.7%

SMO rate among women admitted

to ICU 61.4% 61.4% 49.6%

Proportion of maternal deaths assisted without

ICU admission

44.7% 42.4% 69.6%

Facilities in study hospitals in Pakistan

Yes No

NICU 63.4% 36%

Appropriate adult ICU 57.7% 42.3%

Appropriate neonatal ICU

60% 39%

Ambulance 100%

Blood bank 94.6% 3.6%

Medical staff availability in study hospitals

(Pakistan)24/7 Inside facility%

24/7 Outside facility%

Partially available%

Peadiatrician 41 39 19

Obstetrician 73 26.6

Anesthetist 70 16.9 12.4

Perinatal outcome

VariablesAll women

Pakistan Women with SMO Pakistan

Preterm births 11.2 53.2

Fetal deaths 3.2 39.2Early neonatal deaths (intra-hospital) 2.1 14.9Neonatal intensive care unit admission 7.4 33.3

Birth weight distribution among live births

<1750g 2.1 18.7

1750-2249g 5.5 25.0

2250-2499g 3.3 6.2

2500-3999g 86.6 47.9

>4000g 2.6 2.1

Outcome of newbornsp-value

Discharged

(n = 12590)

Died

(n = 293)

Birth weight

Low birth weight 1304 (10.4%) 186 (63.5%) <0.001

Normal birth weight 11286 (89.6%) 107 (36.5%)

Relation Of Birth Weight With Neonatal

Outcome

Discussion

“Beyond the coverage of essential interventions – the next challenge for reducing global maternal mortality “

• The high coverage of essential interventions suggests that these interventions are available & used in majority of studied health facilities

• Mismatch between high coverage of essential interventions and the substantial variations in health outcomes implies that there are other factors driving these outcomes.

• Delays in implementing these interventions or interventions poorly implemented could explain part of the excessive mortality and morbidity observed in some settings.

• Verticalization of care (i.e. few effective interventions implemented in disconnection of comprehensive care) could be an issue

DiscussionOther elements of care and quality may be playing a strong role

in severe maternal morbidity survival as in • Postpartum haemorrhage, prophylactic and therapeutic uterotonics are

essential but shock management and prompt surgical care are also critical.

• Magnesium sulphate is fundamental to the management of eclampsia, but other aspects of care (such as pre-delivery stabilization, severe hypertension management or airway management for adequate oxygenation and prevention of aspiration pneumonia) are also essential.

• The prevalence of infection increased as case severity increased.• The prevalence of sepsis and other systemic infections is more than four

times the prevalence of puerperal endometritis. This may indicate that the prevention, early identification and appropriate management of secondary infections (e.g. postoperative infection, aspiration pneumonia) and other non-obstetric infections should be regarded as a high priority

Discussion

• Assessment of severity is often incomplete: there is an apparent underestimation of severity due to paucity of information related to organ dysfunction.

• In settings where important constraints in the assessment of severity exist, poor assessments of severity may contribute to delays in the implementation of effective interventions and poor clinical management.

• Health systems issues (such as referral processes), underlying undernutrition, pre-existing moderate to severe anaemia and other factors could also have played a role.

Discussion

Neonatal OutcomeIt is the MOM… • Poor maternal health & nutrition• Poor maternal education• Lack of birth spacing• Poor antenatal care (ANC)• Unskilled deliveries• Lack of clean delivery practices• Improper neonatal resuscitation• Poor post natal care• Poor infant feeding practices

Strengths of WHO MC Survey • It is one of the largest studies exploring the management of

severe complications and the prevalence of maternal near miss using standardized definitions across several countries. This study captured approximately 0.7% of the maternal deaths during a 3-month period in the world.

• Several procedures were adopted to ensure appropriate implementation and high quality data (such as training, pre-data entry visual check of the data collection forms, automated queries, double-checking selected medical records, and thorough audit of unclear cases, particularly maternal deaths)

• Ensuring standardization of processes is a challenging task by minimizing methodological heterogeneity and maximized data quality .

Limitations of WHO MC Survey • The magnitude and the no’s of personnel involved (> 1500 ) • The data source-Routine hospital records, could be suboptimal. • Only short-term ( 7 days) intra-hospital data collected. A small no of

survivors may have died in the remaining puerperal and NN period.• In settings where basic laboratory tests are not available there is a

possibility of under-identification of near miss cases and under-estimation of severity. In such settings, a large proportion of women with unrecognized organ dysfunctions may die in absence of appropriate life support, worsening the ratio of MD to MNM.

• The study design did not assess labor duration, hence no data available on the prevalence of obstructed labor.

• As the WHOMCS conducted in secondary and tertiary facilities it may not represent maternal outcomes and coverage of essential interventions in smaller facilities or in the community.

Generalisability and Applicabilityof WHO MC Survey

• In view of study characteristics, the present findings should

not be regarded as representative of countries, but indicative of the situation in a large sample of health facilities.

• The situation in lower-level facilities is likely to be different, particularly in terms of coverage of essential interventions.

• The coverage of facility-based care in a given geographical area may influence the frequency of complications observed at the facility level.

Conclusions• Implementing the systematic identification of near miss case,

mapping the use of critical interventions and analysing the

corresponding indicators are the initial steps for using the

maternal near miss concept as a tool to improve MN health.

• These findings are a good starter for a more comprehensive

dialogue with governments, professional and civil societies,

health systems or facilities for promoting best practices,

improving quality of care and achieving better MCH.

THE WAY FORWARD

“Translating Research

Into Experience”• Identification of priorities in

maternal and newborn health

• Policy making and advocacy• Publication of study related

papers in reputed medical journals

References• World Health Organization, UNICEF, UNFPA and the World Bank. Trends in maternal mortality:

1990 to 2010. Geneva: World Health Organization, 2012 (World Health Organization website. Available: http://whqlibdoc.who.int/publications/2012/ 9789241503631_eng.pdf. Accessed 2012 April 8).

• United Nations. Global Strategy for Women's and Children's Health. New York: United Nations, 2010 (World Health Organization website)

• Souza JP, Gülmezoglu AM, Carroli G, Lumbiganon P, Qureshi Z; WHOMCS Research Group. The World Health Organization multicountry survey on maternal and newborn health: study protocol. BMC Health Serv Res. 2011 Oct 26;11: 286.

• World Health Organization: Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health. Geneva: World Health Organization, 2011 (World Health Organization website. Available: http://whqlibdoc. who.int/publications /2011/ 9789241502221_eng.pdf. Accessed 2012 Nov 12)

• Beyond the coverage of essential interventions – the next challenge for reducing global maternal mortality: findings of the World Health Organization Multi-country Survey on Maternal and Newborn Health. Souza JP, Gülmezoglu AM, Joshua Vogel, Carroli G, Lumbiganon P et al. Lancet, May 2013. Accepted. Awaiting publication.

ACKNOWLEDGEMENT• The Multicountry Survey on Maternal and Newborn Health acknowledges the

extensive network of institutions and individuals who contributed to the project design and implementation, including researchers, study coordinators, data collectors, data clerks and other partners including the staff from the Ministries of Health and WHO offices.

• Members of the WHO MCS Research Group include: João Paulo Souza (WHO – Global Study Coordinator), Ahmet Metin Gülmezoglu (WHO – Global Study Coordinator), Guillermo Carroli (Centro Rosarino de Estudios Perinatales - CREP, Argentina – Coordinator for Latin America), Pisake Lumbiganon (Khon Kaen University, Thailand – Coordinator for Asia), Zahida Qureshi (University of Nairobi, Kenya – Coordinator for Africa) and the country coordinators from 29 selected countries.

• For Pakistan, support of WHO Country Office led by Dr K Bille, Dr Nima Abid, Dr Shadoul, Dr Iqbal Kahut and Dr Zareef is appreciated. The federal MNCH cell staff, Islamabad, in particular Dr Salim assisted in the selection of facilities as well as in coordination. The office of Federal Director General Health, Dr Rashid Juma and Executive Director, PIMS, provided excellent administrative guidance as necessary. The central office in PIMS, Islamabad and its staff as well as residents who assisted the central office are acknowledged for their contribution.

ACKNOWLEDGEMENT• Pakistan Country Coordinator: Prof. Dr Syeda Batool Mazhar• Punjab Province Coordinator: Prof. Dr Arif Tajjammul Assistant Coordinator: Dr Alia Bashir• Sind Province Coordinator: Prof. Dr Shereen Bhutta Assistant Coordinator: Dr Haleema Yasmin• • HOSPITAL COORDINATORS: SELECTED HOSPITALS• Prof. Dr Ghazala Mahmud & Dr Nasira Tasnim Unit I, MCH Centre, PIMS, Islamabad• Prof. Dr Syeda Batool Mazhar & Dr Shagufta Yasmin Unit II, MCH Centre, PIMS, Islamabad• Dr Riffat Shaheen & Dr Fariha Rahim Federal government Services Hospital, Islamabad• Prof. Dr Asma Usmani Benazir Bhutto Hospital, Rawalpindi, RMC• Prof. Dr Rizwana Chaudary & Dr Naheed Unit I, Holy Family Hospital, Rawalpindi ,RMC• Prof. Dr Fehmida Shaheen Unit II, Holy Family Hospital, Rawalpindi, RMC• Prof. Dr Shagufta Sayyal District Headquarter Hospital, Rawalpindi, RMC• Prof. Dr M. Saeed & Dr M.Ikram Shiekh Zayed hospital, Lahore• Prof. Dr Naheed Fatima Unit I, Bahawalpur Victoria Hospital.• Dr Tasneem Akhter Unit II, Bahawalpur Victoria Hospital, • Prof. Dr Samee & Dr Hajra Masood Nishtar Hospital Multan• Prof. Dr Saqib Siddiq, Dr Rubina Services Hospital Lahore• Dr. Shamama, District Headquarter Hosp, Toba Tek Singh• Dr Nuzhat Alam THQ Hospital, Muridke • Prof. Dr Nargis soomro Unit I, Civil Hospital Karachi, DMC• Prof. Dr Subhana Tayyab Unit II, Civil Hospital Karachi, DMC• Prof. Dr Ayesha Khan Unit III, Civil Hospital Karachi, DMC• Dr Syed Hasan Ala Qatar Hospital, Karachi• Dr Tahira Jabeen Korangi Hospital, Karachi• Dr Sonia Sobhraj Hospital, Karachi• Dr Naheed Soomro Civil Hospital, Jacobabad• Dr Shabana Solangi Taluka Hospital, Rohri• Dr Hakimzadi Civil Hospital, Badin

THANK YOU