Evidence Based

Approaches for Reduction

of Maternal Mortality

Hemant Dwivedi

Session Objectives

To review:

Magnitude of Maternal mortality

Causes of Maternal mortality
Interventions to reduce maternal mortality
Traditional birth attendant
Antenatal care
Risk screening
Reduce Unwanted Fertility
Skilled attendant at childbirth
Emergency obstetrics Care
Current Program Strategies
What we can do?
Current Approach to Reduction of Maternal Mortality

Maternal Mortality: A Global Tragedy

Annually, 536,000 women

die of pregnancy related
complications

99% in developing
world

~ 1% in developed
countries

25% global burden by

India

Every minute one

Maternal Death occur
Current Approach to Reduction of Maternal Mortality

Maternal

and Infant Mortality are two

critical indicators that measure not only
health conditions, but overall
development level of a country.

Both

are key goals in the National Rural

Health Mission (NRHM) and the
Millennium Development Goals (MDG#
4 and 5).

Maternal Mortality Ratio

Year

MMR(INDIA)

1998-99 :

407

367

2001 03 :

301

358

2004 06 :

254

303

XI Plan Goal (2012) :

100

119

MDG Target (2015) :

136

ORISSA

Recent Trends MMR India

(SRS-04-06)
States of India

MMR

Kerala

95

Tamil Nadu

111

West Bengal

141

Andhra Pradesh

154

Bihar/Jharkhand

312

Madhya Pradesh/ Chhattisgarh

335

Orissa

303

Assam

480

India

254
Current Approach to Reduction of Maternal Mortality

Causes of Maternal Mortality in India

(SRS-2003)

Current Approach to Reduction of Maternal Mortality

But WHY Do These Women Die?

Three Delays Model

Delay in Decision to Seek Care

Lack of understanding of complications

Acceptance of maternal death

Low status of women

Socio-cultural barriers to seeking care

Delay in Reaching Care

Mountains, islands, rivers poor organization

Delay in Receiving Care

Supplies, personnel

Poorly trained personnel with punitive attitude

Finances
Current Approach to Reduction of Maternal Mortality

Interventions to Reduce
Maternal Mortality
Historical Review

Traditional Birth Attendants

Antenatal Care

Risk Screening

Current Approach

Reduce Unwanted Fertility

Skilled Attendant at Delivery

Emergency Obst. Care

Current Approach to Reduction of Maternal Mortality

Historical Review of Interventions

The flawed assumption:
Most life-threatening obstetric
complications can be predicted or
prevented

Current Approach to Reduction of Maternal Mortality

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Interventions:
Traditional Birth Attendants
Advantages

Community-based

Sought out by women

Low tech

Can perform clean

delivery

Disadvantages

Technical skills
limited

May keep women

away from life-saving
interventions due to
false reassurance

Current Approach to Reduction of Maternal Mortality

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Interventions:
Traditional Birth Attendants
Conclusion: TBAs are useful in the
maternal health network, but there will not
be a substantial reduction in maternal
mortality by deliveries conducted through
TBAs.

Maternal Deaths prevented-3 percent

Current Approach to Reduction of Maternal Mortality

12

Interventions: Antenatal Care

Antenatal care clinics started in USA, Australia, Scotland

between 19101915

Concept - Screening healthy women for signs of

risk/disease

No substantial reduction in maternal mortality

However, widely used as a maternal mortality reduction

strategy in 1980s and early 1990s

Is ANC important? YES!!

Early detection of problems and Birth Preparation

Maternal Deaths prevented-11 percent

Current Approach to Reduction of Maternal Mortality

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Maternal Mortality: UK 18401960

Improvements in
nutrition, sanitation
Maine 1999.

Antenatal
care

Antibiotics, banked blood,

surgical improvements

Current Approach to Reduction of Maternal Mortality

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Interventions: Risk Screening

Disadvantages

Very-poorly predictive

Costly: Early and longer stay in health facilities

If risk-negative, gives false security

Conclusion: Cannot identify those at risk of

maternal mortality Every pregnancy is at risk, if
not proved, otherwise.
Current Approach to Reduction of Maternal Mortality
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Historical decline in Maternal

mortality in the West

Not much decline till 1930

Rapid decline after 1940s

While infant mortality declined since 1800s

gradually as socio-economic conditions
improved.(Community based interventions)

Factors affecting maternal mortality declineIncreased availability of blood, antibiotics, safe

surgery.

Current Approach to Reduction of Maternal Mortality

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Are there populations who are rich,

well nourished and educated but
have high maternal mortality?

Yes in USA there are such populations eg.

Faith Assembly of God who are rich, well
nourished, and educated : their MMR was 872 in
1982 while in that year MMR in US general
population was only 8 per 100,000 live births.

What is the key difference between these two

groups? Use of modern obstetric care.

Current Approach to Reduction of Maternal Mortality

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MM: What the Evidence Shows

Once a woman is pregnant usually most
serious obstetric complications cannot be
predicted or prevented ,but they can be

treated.

About 15 %
do develop obstetric complications.

Current Approach to Reduction of Maternal Mortality

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Do women die immediately after

developing complications in delivery?
Average Complications to death interval

Hemorrhage

PPH: 2 Hours

( 5.7 hrs*)

APH: 12 Hours(11.5 hrs)

Ruptured uterus

1 Day

Eclampsia

2 Day

Obstructed Labour

3 Days

Infection

6 Days

(* Study in Maharashtra Ganatra et al. WHO bulletin 1998, 76(6):591-598.

(1.7 Days)
(2.4 Days)

Current Approach to Reduction of Maternal Mortality

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Current Approach to Reduction of Maternal Mortality

20

So
All pregnant women
need Access to*
Emergency Obstetric Care
(EmOC)

* Not the same as Institutional Delivery [ID]

Current Approach to Reduction of Maternal Mortality

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Interventions: Skilled
Attendant at Childbirth
SBA- An accredited health professional- such as Midwife,
Doctor, Nurse-Who have been educated and trained to
proficiency in the skills needed to manage normal
pregnancy, child birth and the immediate post- natal
period, and the identification, management and referral of
complication in women and newborn.

Proper training for range of skills

Assess danger signs and Recognize onset of complications

Observe woman, monitor fetus/infant

Perform essential basic interventions

Refer mother/baby to higher level of care if complications arise

requiring interventions outside realm of competence
Current Approach to Reduction of Maternal Mortality

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Maternal Mortality Reduction

Sri Lanka 19401985
Health system improvements:

Introduction of system of health facilities

Expansion of midwifery skills

Decreased use of home delivery and delivery

by untrained birth attendants

Spread of family planning

Current Approach to Reduction of Maternal Mortality

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85% births attended

by trained personnel

Maternal Mortality Reduction

Sri Lanka 19401985

Current Approach to Reduction of Maternal Mortality

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Interventions:
Skilled Attendant at Childbirth

Proven effective

Malaysia: basic maternity services 320 157

Cuba: national priority 118 31

China: facility based childbirth 1500 50

Malaysia (41)vs. Indonesia (230):

Trained community midwives (2 years) vs.

untrained midwives (4 years)

Current Approach to Reduction of Maternal Mortality

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Maternal deaths per 1000000 live births

The higher the proportion of deliveries attended by skilled attendant

in a country, the lower the countrys maternal mortality ratio
2000
1800
2

R = 0.74
1600

Log. (Y)

80

90

1400
1200
1000
800
600
400
200
0
0

10

20

30

40

50

60

70

100

% skilled attendant at delivery

Current Approach to Reduction of Maternal Mortality

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Countries

MMR & SBA

MMR

SBA %

Afghanistan

1800

14

Nepal

830

11

Bangladesh

570

13

Bhutan

440

37

Pakistan

320

31

India

254

43*

Sri Lanka

58

96

South Asia

500

37

Global

400

63

Current Approach to Reduction of Maternal Mortality

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Interventions:
Emergency Obst care

Vast Majority of deaths (75%) due to Direct Obstetric

complications

These complications occur even in well nourished and well

educated women

Can not usually be predicted

Can not be prevented : some exceptions such as AMTSL

for preventing PPH, IP for Post partum infections and
provision of safe and early abortion services

Overlap with SAB

Emoc facilities provide a critical back up for SAB

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Current Approach to Reduction of Maternal Mortality

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Interventions: Reduce
Unwanted fertility

Huge unmet demand for spacing and

permanent methods

Significant proportion of maternal deaths

attributable to unsafe abortions

Nearly One third of fertility: unwanted

Access to quality contraceptive services will

help in reducing unwanted fertility which in
turn will reduce numbers of maternal deaths
Current Approach to Reduction of Maternal Mortality

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What proportion of maternal deaths

these strategies can prevent?

TBA training

03 %

ANC

11 %

Family Planning

26 %

Health Centers (BEmOC) 25 %

HC & Urban Hospitals (C) 60 %

HC & rural Hospitals

67 %

Current Approach to Reduction of Maternal Mortality

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Programmatic Interventions
Reduce Maternal Mortality
1.

Access to Information and Services for

Contraception Too early and too frequent,
too many

2.

Access to skill Birth attendance SBA &

BEmOC (obs. First aid)

3.

Access to Emergency Obstetric Care

4.

Access to safe abortion services

5.

Access to ANC and PNC Services

Current Approach to Reduction of Maternal Mortality

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Organizing Maternal Health Services

with active Referral Linkages

CEmOC

CEmOC Services
BEmOC Services

Midwifery Services

SDH/DH
CHC / Block PHC

PHC (New)

Sub Centre

Current Approach to Reduction of Maternal Mortality

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Maternal Health Services

Good quality maternal health

services are not universally
available and accessible

> 39% receive no antenatal

care

~ 40% of deliveries
unattended by skilled
provider

~ 60% receive no
postpartum care during 1st
6 weeks following delivery

15% unmet need of FP

Current Approach to Reduction of Maternal Mortality

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What was planned and what happened?

(Time, Resource &Energy)
5%

TBA Training
TBA

10%

ANC
Coverage

30%

ANC Coverage

SBA
EmOC

55%

EmOC & Safe

Abortion Services

Planned

SBA ?
Current Approach to Reduction of Maternal Mortality

Safe Abortion?
35

Program Design: The Causal Chain

This is what links actions to outcomes
and impact.
Must
Links
If

be evidence-based, not faith-based

must be tested and monitored

one link breaks, the chain is broken

Current Approach to Reduction of Maternal Mortality

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JSY

JSY Plans
Causal Chain
Instit.
Deliv.

Better
Ob.
Care

EmOC
for
Complic.
Deliv.
Lives
Saved

Current Approach to Reduction of Maternal Mortality

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JSY Plans
Evidence Chain

JSY
Instit.
Deliv.

Better
Ob.
Care

Evidence
Needs more evidence

EmOC
for
Complic.
Deliv.

Current Approach to Reduction of Maternal Mortality

Lives
Saved
38

Orissa Scenario

250

190

Current Approach to Reduction of Maternal Mortality

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What we can Do
ACCESS TO Skilled

attendance at birth,

Emergency
Family

obstetric care

planning

Pre-natal

and post-natal care

- ARE ABSOLUTELY ESSENTIAL

But reduction of MMR to Western levels goes beyond health

it requires better nutrition, better hygiene, better
education of mothers and better gender equality, in other
words, better overall development of people.
Current Approach to Reduction of Maternal Mortality

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Current Approach to Reduction of Maternal Mortality

41

Estimation of mortality from the main obstetric complications worldwide and impact of possibly preventable deaths.-WHO-19

Sl.
No.

Cause of Death

Number
of Death

% of
Deaths

Possible
preventable
%
Number

01.

Hemorrhage

127 000

25%

55%

70 000

02.

Sepsis

76 000

15%

75%

57 000

03.

64 000

12%

65%

42 000

04.

Preeclampsia/eclamps
ia
Obstructed labour

38 000

8%

80%

30 000

05.

Unsafe abortion

67 000

13%

75%

50 000

06.

Other direct causes

39 000

8%

---

---

07.

Indirect cause

100 000

20%

20%

20 000

TOTAL

510 000

100%

269 000

Current Approach to Reduction of Maternal Mortality

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UN Signal Functions of EmOC

Basic

Parenteral antibiotics, oxytocics,

anti-convulsants
Manual removal of the placenta
Removal of retained products (e.g., MVA)
Assisted vaginal delivery
Neonatal resuscitation (new)

Comprehensive = Basic +

Surgery
Blood transfusion

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Figure: 4.9.
To provide skilled care at and after child birth and to deal with

50

400 Maternal Mortality ratio per 100000

live births

8-9 years
Malaysia 1951-61
Sri Lanka 1956-1965
Bolvia Late 1990s

200

6-7 years
Sri Lanka 1974-1981
Thailand 1974-1981
Egypt 1993-2000
Chile 1971-1977
Colombia 1970-1975

100

4-6 years
Honduras 1975-81
Thailand 1981-1985
Nicaragua 1973-1979

Current Approach to Reduction of Maternal Mortality

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