Maternal MortalityUnderstanding the Biological and Social Contexts

Jeromeo Jose11382333

Biological and Social Foundations of HealthMAHESOS

The great divide of Maternal Mortality

Everyday, 800 women die from pregnancy and

childbirth

Developing countriesDeveloped Countries

99%

• Who are the most susceptible?– Women living in rural

areas and poor communities

– Young adolescents– Women who do not

receive care (pre, during and post)

The Philippine Context

'08 '09 '10 '110

50

100

150

200

250

162

221

Philippines Maternal Mortality

RP MDG

Source: Department of Health

What do we mean by maternal death?

• a maternal death 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 (ICD-10)

Medical causes of death and treatment (WHO, 2011)

• Post partum hemorrhage– World’s leading cause of maternal mortality– 127,000 maternal deaths annually– may cause up to 50% percent of all maternal

deaths in developing countries– Medicines • Oxytocin: 10 IU in 1-ml ampoule• Sodium chloride: injectable solution 0.9%

isotonic or Sodium lactate compound solution – injectable (Ringer’s lactate)

Medical causes of death and treatment (WHO, 2011)

• Severe Pre-eclampsia and Eclampsia– Major health problems in developing countries.– Every year, eclampsia is associated with an

estimated 50 000 maternal deaths worldwide.– Medicines

• Calcium gluconate injection (for treatment of magnesium toxicity): 100 mg/ml in a 10-ml ampoule

• Magnesium sulfate: injection 500 mg/ml in a 2-ml ampoule, 500 mg/ml in a 10-ml ampoule

Medical causes of death and treatment (WHO, 2011)

• Maternal sepsis– Infection can follow an abortion or childbirth and is a major

cause of death. – Sepsis not related to unsafe abortion accounts for up to

15% of maternal deaths in developing countries. – Medicines

• Ampicillin: powder for injection 500 mg; 1 g (as a sodium salt) in vial

• Gentamicin: injection 10 mg; 40 mg /ml in a 2-ml vial

• Metronidazole: injection 500 mg in a 100-ml vial• Misoprostol: tablet 200 μg

Medical causes of death and treatment (WHO, 2011)

• Sexually transmitted infections– Nearly a million people acquire a sexually transmitted infection,

including HIV, every day. – The results of infection include acute symptoms, chronic infection, and

serious delayed consequences such as infertility, ectopic pregnancy, cervical cancer, and the untimely deaths of infants and adults.

– Medicines• Uncomplicated genital chlamydial infections: Azithromycin:

capsule 250 mg; 500 mg or oral liquid 200 mg/5 ml• Gonococcal infection – uncomplicated anogenital infection:

Cefixime: capsule 400 mg• Syphilis: Benzathine benzylpenicillin: powder for injection

900 mg benzylpenicillin in a 5-ml vial; 1.44 g benzylpenicillin in a 5-ml vial

Maternal Death Review18 deaths in 82 LGUs (9 audited cases)

Top causes of maternal

deaths

Placenta Previa/PPH Eclampsia Sepsisothers

56%22%11%11%

Gravida Status

Gravida Percentage

Prima Gravida 11%

2 – 4 33%

Multi Gravida 53%

Interventions: Preventive measures:

1. Map catchment areas2. Augment human resources (competency & number) / health

facilities /equipment3. Implement well-coordinated referral and return referral

systems, including transportation to and from home to facility4. Improve access to medicines for obstetric emergencies like anti-

hypertensive meds

1. Pregnancy Tracking System, early detection of high-risk patients

2. Birthing plans for high-risk patients3. Skills Training (BEMONC, Life-saving

Skills) for birth attendants4. FP counselling and access to FP

commodities

Re-ferral Hos-pital44%

RHU/BHS12%

Home

44%

SBA=67% vs Hilot=33%Hilots now referring pregnant

women albeit usually late

Maternal Deaths

Systems Approach to addressing Maternal Mortality

• 6 Building Blocks (Technical) – Governance, Human Resource, Financing,

Medicines, Health Info, Service Delivery. (WHO)• Local leadership is the key to changing systems

and innovating programs that lead to better health outcomes (ZFF, 2012)– Focused on Mayors and MHOs who decide to

change the health system, through meaningful engagements and new arrangements with other stakeholders.

Road Map

• A way to analyze the health situation in municipalities including gaps and challenges

• A road map to weigh options and set priorities• A scorecard to measure accomplishment.

Intervention on Health Systems Transformation: Municipal Basic Health System’s Technical Roadmap

Leadership & Governance Health Financing Health Human

ResourceAccess to

Medicine & Technology

Health information

SystemHealth Service Delivery

Municipal Health Governance

Municipal Health Action

PlanHealth Resource

Generation and Management

LGU Budget for Health

(15% IRA)

RHU

and BHS Resource management

Health Human Resource Adequacy at

the RHU(MD 1:20,000)

(Nurse 1:20,000)

Drug

Management System

Presence of Essential

Medicine at the RHU

(Stock Basis)

Data Collection,

Utilization and

Information Disse

mination

Accomplished Baseline Data

Collection

Baranga

y Heal

th Infrastructu

re

Presence of Barangay Health Stations(1 BHS:1 Braangay or 1 BHS per

Catchment)

Maintenance and Operations

Utilization

Actual budget Utilization

(95% Utilization)

RHU HHR Competency Available Transportation for Emergency

Regular Data Gathering and

Recording

Materna

l and Chil

d Care

Sustainable Maternal

Health Care

Initiatives

Pre-Natal Services(at least 80%)

Full Implementation of Magna Carta for

Public Health WorkersExpanded and Functional

Local Health Board

Facility-Based Devleiries(85%)

BLGU Health Budget

(5% of Barangay IRA)

Skilled Birth Attendants(85%)

Installed Performance Management System Sustainable

Breastfeeding

Initiatives

Exclusive Breastfeeding for Infants (70%)

RHU Medicine Tracking and

Inventory System

Maternal/Infant Death Review

Newborns Initiated Breastfeeding (85%)

Barangay Health Governance

Functional Barangay

Health Governance

Body(with functional

CHT) Local

Philhealth Administratio

n

4-in-1 Accreditation Sustainable Essential

Intrapartum and Newborn Care InitiativesHealth Human

Resource Adequacy in BHS

(1 Midwife: 1 Brgy; with consideration to

GIDA)(BHW to HH 1:20HH)

Sustainable Infant and Child Care Initiatives

Fully Immunized Child (95%)

Regular IEC for Enrolled Indigent(for Q1 and Q2)

Monthly Updated Health Data

BoardUnder-5 Malnutrition

Prevalence Rate(Below 17.3%)

BHS HHR Competency(Basic BHW Training

Course and CHT Training)

Accomplishment, Utilization and

Dissemination of the DILG, DOH LGU Scorecards

Reproductive

Health

Sustainable Adolescent Reproductive Health Initiatives

Reimbursement Filing

(PCB, MCP, TB-DOTS) Sustainable

Family Planning Initiatives

Provision of FP Commodities and Services

(RHU)

Implemented and Integrated

Barangay Health Plan

Contraceptive Prevalence Rate (63%)

System for BHW Recruitment and

Retention Mechanisms Creation of

Citizen’s ChraterOrdinance and

System for Claims Disposition and

Utilization Monitoring

Ratio of Community-

Based Pharmaccy(1 BNB/CBP

catchment or 1 BNB per

barangay)

Unmet Needs (50% under NHTS)

WaSH

Sanitary Toilets(86%)

Ordnance and Timely Provision of BHW

HonorariumAccess to Safe Water

(87% of HH)

Progress of LGUs vis-a-vis building blocks

Leadership & Governance

Majority have reactivated and expanded membership of their local health boards

Activating barangay health boards a work in progress in most LGUs

Human ResourcesMost have hired additional personnel but ideal ratios have yet to be met

Financing

33 of 82 (40%) LGUs have 4-in-1 Philhealth accreditation

Non-ARMM LGUs have increased health budgets to 10% or above

Still working on having barangays raise their health budgets to 5%

Continuous & close coordination with DOH-ARMM & Philhealth led to release of much-needed reimbursements to LGUs in the region

Medicines

Procurement and inventory systems have been fixed at the RHU but availability of medicines in barangay health stations needs to improve in cohorts that have ended the 2-year partnership

Accessibility, procurement & inventory systems are being improved in other LGUs

Service Delivery LGUs have created their own innovative programs to address issues

Information systems

Systems of reporting & recording have improved

Need to improve ability to analyze data

Need to strengthen mortality audit system

Progress of LGUs vis-a-vis building blocks

Health Outcomes (SLAM, Cohort 3)

'08 '09 '10 '11 '12 '130

50

100

150

200

250

207

73

153

106

70

212

SLAM and Cohort 3 MMR

Cohort 3 SLAM

141

68

41

0

Cohort 3

Sources: FHSIS for ZFF ARMM municipalities

Working on Health Seeking Behavior

'08 '09 '10 '11 '120

5

10

15

20

25

30

35

40

2.475.30 5.94 16.96 22.12

16.52 14.91 33.622.47

5.30

12.9915.59

29.44

Facility Based Deliveries Trend (ARMM)

Cohort 1 Cohort 3ARMM Cohort

'08 '09 '10 '11 '120

10

20

30

40

50

60

70

80

51.44 49.12 39.74 41.88 34.21

73.41 69.53 72.41

51.44 49.12

62.18 60.31 59.68

Deliveries Attended by Skilled Birth Attendants (ARMM)

Cohort 1 Cohort 3ARMM Cohort

Sources: FHSIS for ZFF ARMM municipalities

Conclusions

• Medical and social factors are important to be understood.

• There is a technical solution that can be implemented – medical response, strengthening the health system (6BB)

• Leadership will ensure that more stakeholders gain ownership of the issue.

No mother should die giving life...