Why mother’s die??

THE REALITY….

One woman dies every minute

somewhere in the world because of

a complication related to pregnancy

or childbirth

80% of these death could be

prevented

MATERNAL MORTALITY

“The death of a woman while pregnant or within 42

days of termination of pregnancy, from any cause

related to or aggravated by the pregnancy or its

management, but not from accidental or

incidental causes”

- by FIGO

CLASSIFICATION

DirectDeaths resulting from obstetric

complications in pregnancy, labour and puerperium

IndirectDeaths resulting from previous existing

disease or diseases that developed during pregnancy and which was aggravated during pregnancy

FortuitousDeaths from other causes not related to

or influenced by pregnancy

LateDeath after 6 weeks until 1 year after

delivery

Classifiction Examples

Direct Thromboembolism

Haemorrhage

Ectopics

Hypertensive disease of pregnancy

Sepsis

Amniotic fluid embolism

Indirect Cardiac disease

Suicide

Epilepsy/CNS haemorrhage

Infections

Respiratory/gastrointestinal diseases

MMR

(Maternal mortality ratio)

Maternal mortality ratio (MMR) is the number of

women who die during pregnancy and childbirth, per

100,000 live births.

No of women dies

100,000 live births

National MMR have reached a plateau

between 28-30/100,000 LB the last 10 years

OUR STATE….

There is marked reduction in MMR in our state

YEAR MMR ( per 100,000 live

births)

2008 30.8

2009 26

2010 21.3

2011 21.7

2012 26.6

2013 9.3 (*** achieve MDG 5

target)

0

5

10

15

20

25

30

35

2008

2009

2010

2011

2012

2013

MMR

MMR

Causes of maternal death (malaysia)

4 MAIN CAUSES OF MATERNAL DEATH IN

SARAWAK

1. Post partum haemorrhage

2. Pulmonary embolism

3. Eclampsia

4. Cardiac disease

Maternal death according to

antenatal care

Phase of maternal death

MILLENIUM

DEVELEPMENTAL GOAL

(MDG)

MDG 5A: IMPROVE MATERNAL

HEALTH

TARGET Reduce maternal mortality ratio by

three quarters between 1990 and 2015

Indicators

- Maternal mortality ratio

- Proportion of birth attended by skilled health

MDG 5 target for state by 2015 – 11.08/100,000

LB

MDG 5B- IMPROVE MATERNAL

HEALTH

TARGET Universal access to

reproductive health by 2015

Indicators

- Contraceptive prevalence rate

- Adolescent birth rate

- Antenatal care coverage

- Unmet need for family planning

ISSUES & CHALLENGES….

HIGH RISK GROUPS

Remote communities

Illegal immigrants

High risk pregnancies

** SPECIAL ATTENTION

** CLOSE MONITORING

DEFICIENCIES NOTED FROM STATE

CEMD

Directives & guidelines not followed

Lack of blood & blood products in DH

Substandard management of PPH at DH

Delays in transferring ill patients to specialist hospitals

Obstetric patients only seen by MA in A&E or OPD

Unsafe clinical practices in LW

Inadequate post natal care

Failure to offer TOP in early pregnancy by physicians and cardiologists

More specialists & specialist hospitals!

Lessons from National CEMD

More than 60% of maternal deaths occurred

during the postnatal period

The risk of maternal deaths higher in women over

40 yrs and in mothers who already had 6 or more

children

Deaths due to obstetric embolism is rising

Unbooked cases have higher risk of mortality

Home deliveries is unsafe

WHAT SHOULD WE DO???

Plan of Action: 1 Hospital Directors should address individual hospital

needs in terms of manpower and O&G medical

equipment and ambulances

Monitoring & resuscitative equipments are old and

lacking

JKN to highlight & forward asset request to MOH

To make carboprost (haemabate), intrauterine

balloon (Bakri balloon) & magnesium sulphate

available in all DH and health centers that conducts

deliveries

Need for equipped ambulance and transport for

‘home visiting’

Plan of Action: 2

All previous and future directives from JKNS and

O&G guidelines MUST be implemented and

practiced

Staff should be briefed

Should be kept in a file and made easily

accessible in LW and A&E/OPD for reference

Perhaps LW nursing sister can be assigned?

Plan of Action: 3

All antenatal and postnatal mothers should be

considered as HIGH RISK when attending

OPD/A&E and MUST reviewed by a medical

officer

Low tolerance for admission

All repeat A&E visits for the same complaints

should be admitted for further monitoring and

management

Plan of Action: 4

Ensuring the level of blood and FFP in every

hospital is always at optimal level

Yellow alert should be at 70% optimum stock

Red alert should be at 50% optimum stock

Increase FFP stock by 20% if possible

A laboratory staff should be assigned to be in

charge

Stock level should be checked daily

Plan of Action: 5

Improving the management of PPH in district

hospitals:

1. Compulsory regular obstetric drills (3x/year)

2. ‘Red Alert’ system to be implemented

3. PPH box to be made available and regularly

checked

4. Carboprost at least 4 ampoules must be made

available in LW

5. BAKRI balloons once used have to be indented

6. ‘PPH management flowchart’ have to be on the

notice board

7. Ambulance driver should called once Red Alert is

activated

Plan of Action: 6

Reduce delays in transferring ill obstetric patients

Refer to specialist early!

Utilise the BUDDY SPECIALIST system

Discuss various scenarios and decide best way to

reduce transit time

All hospital directors to be well versed with SOP

on using medevac services

Plan of Action: 7

Improve O&G clinical services at the district

hospital level through:

1. CME activities (monthly)

2. Clinical audit of near misses and bad outcome

(monthly)

3. ‘Buddy Specialist’ to do supervisory visits (6

monthly)

4. Regular drills for obstetric emergencies

Plan of Action 8 Start Pre-pregnancy care & family planning services in all hospitals in 2011 (MDG 5)

Counseling for family planning for all postnatal patients compulsory

IUCD should be made an acceptable alternative to BTL, particularly in specialist hospitals where the waiting list for BTL is longer than 6 months

‘High risk patients’ needs to be identified and managed accordingly (inc. postnatal BTL)

Plan of Action 9

Audit

Audit activities for all ‘near misses’ &

complications should be carried out on weekly

basis

The only way to identify weaknesses and to

improve services

Feedback on audit activities by each hospital

should be made compulsory