Averting Maternal Death and Disability

(AMDD)

Averting Maternal Death and Disability

(AMDD)

Developed for use in AMDD-partnered projectsFebruary 2002

By

Nadia Hijab & Czikus Carriere

Developed for use in AMDD-partnered projectsFebruary 2002

By

Nadia Hijab & Czikus Carriere

Program OrientationA Tool for Self-Learning

 

Program OrientationA Tool for Self-Learning

 

This Presentation Covers:This Presentation Covers:

• Causes of Maternal Death and Disability• Evolution of Understanding of the Problem• Central Role of Emergency Obstetric Care • UN Process Indicators • The AMDD Program

What Is Maternal Death?What Is Maternal Death?

The death of a woman while she is pregnant

The death of a woman while she is pregnant

…From any cause related to

or aggravated by the pregnancyWorld Health Organization (WHO)

within 42 days of the

termination of the pregnancy…

within 42 days of the

termination of the pregnancy…

…or…

WHO Estimates 515 000 Maternal Deaths Each YearWHO Estimates 515 000 Maternal Deaths Each Year

MORE THAN ONE WOMAN

DIES EVERY MINUTE from pregnancy-related causes

MORE THAN ONE WOMAN

DIES EVERY MINUTE from pregnancy-related causes

What Is Maternal Disability?What Is Maternal Disability?

Short- or Long-term Illness

Caused by

Obstetric Complications

Short- or Long-term Illness

Caused by

Obstetric Complications

The Most Serious Is Obstetric Fistula (An Abnormal Passage Between Vagina and Bladder or Rectum Often Caused by Obstructed Labor when it is Not Treated with

Cesarean Section)

The Most Serious Is Obstetric Fistula (An Abnormal Passage Between Vagina and Bladder or Rectum Often Caused by Obstructed Labor when it is Not Treated with

Cesarean Section)

What Do Women Die Of?What Do Women Die Of?

They Die Of Obstetric Complications

That Need Not Be Fatal

They Die Of Obstetric Complications

That Need Not Be Fatal

OBSTETRIC COMPLICATIONSOBSTETRIC COMPLICATIONS

• Hemorrhage 21%• Unsafe Abortion 14%• Eclampsia 13%• Obstructed Labor 8%• Infection 8%• Other 11%

• Hemorrhage 21%• Unsafe Abortion 14%• Eclampsia 13%• Obstructed Labor 8%• Infection 8%• Other 11%

Account for about 3/4 of Maternal DeathsAccount for about 3/4 of Maternal Deaths

DIRECT DIRECT

OBSTETRIC COMPLICATIONSOBSTETRIC COMPLICATIONS

• Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis

• And Increasingly HIV / AIDS

• Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis

• And Increasingly HIV / AIDS

Account for about 1/4 of Maternal DeathsAccount for about 1/4 of Maternal Deaths

INDIRECT INDIRECT

Most Obstetric Complications Occur Suddenly

Most Obstetric Complications Occur Suddenly

If women do not receive medical treatment on time,

they will probably suffer disability…

If women do not receive medical treatment on time,

they will probably suffer disability…

Or DieOr Die

Without WarningWithout Warning

WHERE DO WOMEN DIE TODAY?WHERE DO WOMEN DIE TODAY?

99% of Maternal Deaths Today

Occur in

Africa, Asia and Latin America

99% of Maternal Deaths Today

Occur in

Africa, Asia and Latin America

WHAT ABOUT THE REST OF THE WORLD?

WHAT ABOUT THE REST OF THE WORLD?

Maternal Mortality Used to be Very High in Europe and the U.S.

So was Infant Mortality.

Maternal Mortality Used to be Very High in Europe and the U.S.

So was Infant Mortality.

In 1915,

Maternal and Infant Mortality Rates

Were as High in the U.S.

As They Are in Africa Today

WHAT HAPPENED NEXT?WHAT HAPPENED NEXT?

Better Living Conditions

Reduced Infant Mortality in the U.S.

By over 40%

Between 1915 and 1933

Better Living Conditions

Reduced Infant Mortality in the U.S.

By over 40%

Between 1915 and 1933

BUT MATERNAL MORTALITY

BUT MATERNAL MORTALITY

“The well known triad

of fever, haemorrhage and toxaemia predominated…”

(Irvine Loudon)

“The well known triad

of fever, haemorrhage and toxaemia predominated…”

(Irvine Loudon)

REMAINED THE SAMEREMAINED THE SAME

…Until the late 1930s…Until the late 1930s

There was then a

“steep and sustained decline

which has continued in most Western countries

at much the same rate

for over fifty years” (Irvine Loudon)

There was then a

“steep and sustained decline

which has continued in most Western countries

at much the same rate

for over fifty years” (Irvine Loudon)

What Happened To Reduce Maternal Mortality

In The West?

What Happened To Reduce Maternal Mortality

In The West?

Effective treatment for obstetric complications

was developed and used,

e.g., antibiotics for infection,

blood transfusions for hemorrhage

Effective treatment for obstetric complications

was developed and used,

e.g., antibiotics for infection,

blood transfusions for hemorrhage

Most Obstetric ComplicationsMost Obstetric Complications

Can Neither

Be Predicted

Nor Prevented…

Can Neither

Be Predicted

Nor Prevented… But If Women Receive Effective Treatment

In Time,

But If Women Receive Effective Treatment

In Time,

…Almost All Can Be Saved…Almost All Can Be Saved

How Much Time Do We Have?

How Much Time Do We Have?

It is estimated that, if untreated, death occurs on average in:

It is estimated that, if untreated, death occurs on average in:

2 hours from Postpartum Hemorrhage

12 hours from Antepartum Hemorrhage

2 days from Obstructed Labor

6 days from Infection

2 hours from Postpartum Hemorrhage

12 hours from Antepartum Hemorrhage

2 days from Obstructed Labor

6 days from Infection

To Avert Death and Disability…

To Avert Death and Disability…

…We Need To EnsureThat Women have Access To…

…We Need To EnsureThat Women have Access To…

Emergency Obstetric CareEmergency Obstetric Care

(EmOC)(EmOC)

How Can We Improve Access

To EmOC?

How Can We Improve Access

To EmOC?

By making sure health facilities provide the

services needed to save women’s lives.

By making sure health facilities provide the

services needed to save women’s lives.

Eight key functions “signal” a facility’sability to provide EmOC

Eight key functions “signal” a facility’sability to provide EmOC

EmOC Key FunctionsCover These Services:

EmOC Key FunctionsCover These Services:

• Antibiotics (intravenous or by injection)

• Oxytocic Drugs

(ditto)

• Anticonvulsants

(ditto)

• Manual Removal of Placenta

• Removal of Retained Products

• Assisted Vaginal Delivery

• Surgery (Cesarean Section)

• Blood Transfusion

Basic and Comprehensive EmOC FacilitiesBasic and Comprehensive EmOC Facilities

Antibiotics (intravenous or by injection)• Oxytocic Drugs (ditto)• Anticonvulsants (ditto)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery

Antibiotics (intravenous or by injection)• Oxytocic Drugs (ditto)• Anticonvulsants (ditto)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery

BASICBASICEmOC Facilities Provide The First Six Services

• Antibiotics (intravenous or by injection)

• Oxytocic Drugs (ditto)• Anticonvulsants (ditto)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery

COMPREHENSIVECOMPREHENSIVE

Basic and Comprehensive EmOC FacilitiesBasic and Comprehensive EmOC Facilities

EmOC Facilities Provide All Eight Services

• Surgery (Cesarean Section)• Blood Transfusion

THE GOOD NEWSTHE GOOD NEWS

Not all these functions need hospitals and doctors

Well-trained nurses and midwives can perform most functions at Basic EmOC Facilities

An Important Point

For Resource Poor Areas

An Important Point

For Resource Poor Areas

How Can We Tell We Are Making a Difference?

How Can We Tell We Are Making a Difference?

If we know we have provided enough EmOC…

If we know we have provided enough EmOC…

…and if we know that these services are being used by women suffering obstetric complications…

…and if we know that these services are being used by women suffering obstetric complications…

WE CAN BE CONFIDENT

THAT WE ARE SAVING WOMEN’S LIVES

WE CAN BE CONFIDENT

THAT WE ARE SAVING WOMEN’S LIVES

How Do We Know Which Women

Will Experience Complications?

How Do We Know Which Women

Will Experience Complications?

WE DON’TWE DON’T

…But we do know that of any population of pregnant women at least 15% will experience an obstetric complication

…This is as true of pregnant women in the US and Europe as of women in Africa, Asia and Latin America

Nobody Knows Why This Happens.It Is a Fact of Life

Nobody Knows Why This Happens.It Is a Fact of Life

Can We Really TellIf Services Are Functioning?

Can We Really TellIf Services Are Functioning?

In 1991,

UNICEF and Columbia University developed

6 Process Indicators to do just that

In 1991,

UNICEF and Columbia University developed

6 Process Indicators to do just that

These were issued by UNICEF/WHO/UNFPA in 1997:

Guidelines for Monitoring Availability

and Use of Obstetric Services

These were issued by UNICEF/WHO/UNFPA in 1997:

Guidelines for Monitoring Availability

and Use of Obstetric Services

…And Are Being Used?…And Are Being Used?

In general, process indicators show you the changes in the

conditions

that lead to an outcome(such as death or disability)

In general, process indicators show you the changes in the

conditions

that lead to an outcome(such as death or disability)

Process IndicatorsProcess Indicators

Access to…Access to…

THE 6 PROCESS INDICATORSTHE 6 PROCESS INDICATORS

tell us about changes in:tell us about changes in:

Utilization of…Utilization of… and Quality of…and Quality of…

EmOC ServicesEmOC Services

INDICATOR # 1INDICATOR # 1

For every 500,000 population,there should be at least:

For every 500,000 population,there should be at least:

1 Comprehensive EmOC Facility

4 Basic EmOC Facilities

1 Comprehensive EmOC Facility

4 Basic EmOC Facilities

INDICATOR # 2INDICATOR # 2Geographical Distribution

of EmOC FacilitiesGeographical Distribution

of EmOC Facilities

EmOC Facilities should be well-distributed to serve 500,000 people

EmOC Facilities should be well-distributed to serve 500,000 people

Minimum: 1 Comprehensive and 4 Basic EmOC FacilitiesMinimum: 1 Comprehensive and 4 Basic EmOC Facilities

INDICATOR # 3INDICATOR # 3

Proportion of All Births in EmOC Facilities

Proportion of All Births in EmOC Facilities

At Least 15%

of All Births in the Community

Should Take Place in EmOC Facilities

At Least 15%

of All Births in the Community

Should Take Place in EmOC Facilities

INDICATOR # 4INDICATOR # 4

Met Need for EmOC ServicesMet Need for EmOC Services

At Least 100% of Women Estimated to Have Obstetric

Complications Should Be Treated in EmOC Facilities

At Least 100% of Women Estimated to Have Obstetric

Complications Should Be Treated in EmOC Facilities

INDICATOR # 5INDICATOR # 5

Cesarean Sections As a Percentage of All Births

Cesarean Sections As a Percentage of All Births

Minimum: 5%

Maximum: 15%

Minimum: 5%

Maximum: 15%

INDICATOR # 6INDICATOR # 6

Case Fatality RateCase Fatality Rate

Proportion of Women

With Obstetric Complications

Admitted to a Facility

Who Die:

Proportion of Women

With Obstetric Complications

Admitted to a Facility

Who Die:

Maximum Acceptable Level:

1%

CALCULATING ALL 6 INDICATORSCALCULATING ALL 6 INDICATORS

• Gives you an indication of where the problems lie and where action is needed.

• Also, these indicators are sensitive to change: within months, you can know if your project is making a difference

• Gives you an indication of where the problems lie and where action is needed.

• Also, these indicators are sensitive to change: within months, you can know if your project is making a difference

ACCESS TO EmOCACCESS TO EmOC

Problems:• Does Indicator # 1

show you need more EmOC facilities?

• Does Indicator # 2 show you need better distributed EmOC facilities?

Problems:• Does Indicator # 1

show you need more EmOC facilities?

• Does Indicator # 2 show you need better distributed EmOC facilities?

Action:• Most countries

already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population

Action:• Most countries

already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population

UTILIZATION OF EmOCUTILIZATION OF EmOC

• Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population?

• Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities)

• Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section?

• Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population?

• Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities)

• Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section?

ProblemsProblems

UTILIZATION OF EmOCUTILIZATION OF EmOC

• Do you have enough qualified staff?• Do you need to train staff on management of

emergency obstetric complications?• Does hospital management need improvement?• What’s the supply situation like?• What’s the equipment situation like?

• Do you have enough qualified staff?• Do you need to train staff on management of

emergency obstetric complications?• Does hospital management need improvement?• What’s the supply situation like?• What’s the equipment situation like?

If all the above is in place, conduct focus groups in the community to find out why

women are not coming for care

If all the above is in place, conduct focus groups in the community to find out why

women are not coming for care

Action: Collect More Info First

Action: Collect More Info First

QUALITY OF EmOCQUALITY OF EmOC

Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities?

Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities?

Problem:Problem:

QUALITY OF EmOCQUALITY OF EmOC

• Find out if your EmOC facilities are really functioning

• Check staff numbers, skills, management capacity, supplies and equipment

• Lobby your health ministry for more support – and get the community to lobby with you

• Find out if your EmOC facilities are really functioning

• Check staff numbers, skills, management capacity, supplies and equipment

• Lobby your health ministry for more support – and get the community to lobby with you

Action:Get More Info

Action:Get More Info

Any Country Can Avert

Maternal Death And Disability

If It Makes Good EmOC

Any Country Can Avert

Maternal Death And Disability

If It Makes Good EmOC

Available And Accessibleon Time

Available And Accessibleon Time

The AMDD ProgramThe AMDD Program

• The AMDD Program Was Established in 1999 at Columbia University’s School of Public Health, Heilbrunn Department of Population and Family Health

• The AMDD Program Is Dedicated to Improving the Availability, Quality and Utilization of Life-saving Obstetric Services in Developing Countries

• AMDD Partners Projects in Close to 50 Countries, Within a Framework That Links Technical Know-How With Management Capacity and Human Rights

• AMDD Is Funded by a Generous Grant From the Bill and Melinda Gates Foundation

AMDD PartnersAMDD PartnersProject Partners:• United Nations Children’s Fund (UNICEF): projects in Bangladesh, Bhutan,

India, Nepal, Pakistan and Sri Lanka• United Nations Fund for Population Activities (UNFPA): projects in India,

Morocco, Mozambique and Nicaragua• Regional Prevention of Maternal Mortality (RPMM) Network: teams and

projects in19 sub-Saharan African countries• CARE: projects in Ethiopia, Rwanda, Tanzania, Peru and Tajikistan• Save the Children: projects in Mali and Vietnam• Reproductive Health for Refugees (RHR) Consortium: projects in 12 countries

Project Partners:• United Nations Children’s Fund (UNICEF): projects in Bangladesh, Bhutan,

India, Nepal, Pakistan and Sri Lanka• United Nations Fund for Population Activities (UNFPA): projects in India,

Morocco, Mozambique and Nicaragua• Regional Prevention of Maternal Mortality (RPMM) Network: teams and

projects in19 sub-Saharan African countries• CARE: projects in Ethiopia, Rwanda, Tanzania, Peru and Tajikistan• Save the Children: projects in Mali and Vietnam• Reproductive Health for Refugees (RHR) Consortium: projects in 12 countries

AMDD PartnersAMDD Partners

Technical Partners:• Family Health International• John Snow International• Indian Institute of Management

at Ahmedabad (IIMA)• JHPIEGO• Engender Health

(formerly AVSC International)

RESOURCESRESOURCESUNICEF/WHO/UNFPA, Guidelines for Monitoring the Availability and Use of Obstetric Services, UNICEF, New York, October 1997

Maine, Deborah, Safe Motherhood Programs: Options and Issues, Columbia University, New York, 1991

UNFPA and AMDD, Reducing Maternal Deaths: Selecting Priorities, Tracking Progress, Distance Learning Courses on Population Issues, Turin, UN System Staff College, 2002

Loudon, Irvine, “On Maternal and Infant Mortality 1900-1960”, Social History of Medicine, April 1991, Vol. 4, No.1, pp 29-73

Created byNadia Hijab & Czikus Carriere

Created byNadia Hijab & Czikus Carriere