Reducing Maternal Mortality; Lessons Learnt

Baizury Bashah Klinik Kesihatan Putrajaya Presint 9

Contents

Definition Millennium Development Goal #5 Malaysian achievement How Malaysia fares compared to other countries WHO recommendations

Malaysian initiatives
Summary

Definition
Maternal death 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

Maternal mortality ratio

Number of maternal deaths during given time period _______________________________________ X 100,000 Number of Life birth during same period of time

This measure captures the probability of dying once a woman is pregnant, and so is also referred to as the obstetric risk

Maternal mortality rate:

Number of maternal deaths in a population X100,000 Number of women aged 1549 years (reproductive age)

Prerequisite for good measurement

Countries must have:

an established system for registration of births, deaths and causes of death

well-functioning health information systems that combine data from facilities, administrative sources and surveys

Table 1. Sources of maternal mortality data used in generating the 2010 maternal mortality ratio estimates
Group
Source of maternal mortality data Number of countries/ territories % of countries/ territories in each category % of births in 181 countries/ territories covered

Civil registration characterized as complete, with good attribution of cause of death Countries lacking good complete registration data but where other types of data are available No national data on maternal mortality

65

35.9

15.7

89
27 181

49.2
14.9 100.0

80.3
4.0 100.0

Total

Definitions of misclassification, incompleteness and underreporting

Misclassification

Refers to incorrect coding in civil registration, due either to error in the medical certification of cause of death or error in applying the correct code
Incompleteness

Refers to incomplete death registration. Includes both the identification of individual deaths in each country and the national coverage of the register
Underreporting

Is a combination of misclassification and incompleteness

Guess which group Malaysia belongs to??

Estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), number of maternal deaths, lifetime risk , 2010
Country MMR Range of MMR uncertainty Lower estimate Malaysia Thailand
Singapore Philippines

Upper estimate

Number of maternal deaths

Lifetime risk of maternal death, 1:

PM (%)*

Gp

29 48 3 99 220

12 33 2 66 130

64 70 7 140 350

170 400 2 2300 9600

1300 1400 25,300 300 210

2.4 1 0.3 6.3 5.0

C B A B B

Indonesia

*Proportion of maternal deaths among deaths of women of reproductive age (PM)

Source: , WHO 2012 . Trends in Maternal Mortality 1990 to 2010

Contents

Definition Millennium Development Goal #5 Malaysian achievement How Malaysia fares compared to other countries WHO recommendations

Malaysian initiatives
Summary

MDG #5
TARGET 5A : Reduce by three-quarters (75%) between 1990 and 2015, the maternal mortality ratio Target 5B:

Achieve, by 2015, universal access to reproductive health

MDG 5 to improve maternal health

Targets 5.1 5.2 MDG indicators MMR Proportion of birth attended by skilled health professionals Contraceptive prevalence rate Adolescent birth rate Baseline 44/100,000 LB (1991) 74.2% (1990) 54.6% (1994) 28 births per 1000 adolescent 78% (1990) Target (2015) 11/100,000 LB 95.0% Latest achievement 26.1 (2010) 98.6% (2011)

5.3 5.4

To increase To decrease

51.8% ( 2004) 14 births per 1000 adolescent (2010) 94% (2011)

5.5

Antenatal care coverage (1 visit)

90.0%

5.6

Unmet need for family planning

24.5 % (2004)

To decrease

Contents

Definition Millennium Development Goal #5 Malaysian achievement How Malaysia fares compared to other countries WHO recommendations

Malaysian initiatives
Summary

MDG 5a: Maternal Mortality Ratio (MMR) Achievement against Set Target MDG 5

Target

(no. of deaths)

(131) (137) (134) (128) (126) (110p)

Source: Department of Statistics Malaysia

(50)

MMR by ethnicity ( 1997-2007)

Target : 11/100,000LB by 2015

Ethnic Grp Malay Chinese Indians Other bumi

1997 33.6 (100)

18.6 ( 20) 36.7 ( 13) 27.4 ( 17)

1999 34.0 (104)

12.4 (14) 31.1 (11) 39.2 (20)

2001 33.5 (100)

15.3 (15) 40.7 (14) 49.4 (31)

2003 28.8 (80)

16.4 (15) 18.6 (6) 33.4 (19)

2006 25 ( 68)
16.5 ( 14) 13 ( 44) 26.2 (15

2007 28.4 ( 78)

12.9 (10) 23.6 (7) 40.8 (24)

2009 30 (88)
16( 20) 37 (11) 50.1 (32)

2011p
26.1(79) 6.7(5) 15.6(4) 44.8(29)

Only the Chinese has achieved the targeted MMR of 6.7/100,000 LB

At what point during pregnancy and childbirth do women die?

MATERNAL DEATHS by PHASE OF PREGNANCY : MALAYSIA 1991-2008

60%-75% : During Postpartum 15 -25% : Antenatal

Source: Reports on the Confidential Enquiries into Maternal Deaths in Malaysia

Maternal deaths by phase of pregnancy/delivery : Malaysia 2011-2012

Source : BPKK, KKM

Post partum 48hrs 42 days

Health personnel from Klinik Kesihatan & Klinik Desa can contribute more by
doing quality , regular post natal care Identify red flag signs & symptoms

Timely referral to M&HO / FMS or hospital

Causes of maternal death (direct/indirect) Obstetric Malaysia 2011-2012

embolism Hemorrhage Medical conditions HDP

Direct cause
Source : BPKK

Indirect cause

MMR PLACE OF DELIVERY

Home deliveries associated with high MMR 50-80 per 100,000 deliveries

Home deliveries on the rise; causing sepsis??

Maternal deaths; preventable / non preventable Malaysia 2011-2012

Source : BPKK, KKM

Contributory factors Clinical factors (analysis based on preventable deaths 2012)

Percentage

Contributory factors Non-clinical factors (analysis based on preventable deaths 2012)

Percentage

Contributory factors Patient Factors (analysis based on preventable deaths 2012)

Percentage

Contents

Definition Millennium Development Goal #5 Malaysian achievement How Malaysia fares compared to other countries WHO recommendations

Malaysian initiatives
Summary

How does Malaysia fare? (1980 2010)

Maternal Mortality Ratio per 100,000 LB by Region and Country

Source - WHO World Health statistics 2012

Contents

Definition Millennium Development Goal #5 Malaysian achievement How Malaysia fares compared to other countries WHO recommendations

Malaysian initiatives
Summary

6 key messages from WHO researchinformed viewpoint

Maternal health has many valued outcomes, but maintaining focus on maternal death is crucial in areas where the mortality burden is high Many single interventions are available, but none alone can reduce the rate of maternal mortality in a population Strategies will work if the component packages are effective and the means used for their distribution achieve high coverage of the intended target group

6 key messages from WHO researchinformed viewpoint

The epidemiology of maternal mortality requires prioritisation of the intrapartum period A health centre intrapartum-care strategy can be justified as the best bet to bring down high rates of maternal mortality There are further opportunities to alter the risks of maternal death outside the intrapartum period antenatal care, postpartum care, family planning, and safe abortion

WHO recommendations
WHO recommendations Non-pregnant women of reproductive age: all (4) Periconceptual folic acid supplementation (women planning Pregnancy) Iron supplementation (in areas of high iron deficiency anaemia) Access to care to screen/diagnose health problems (e.g. worm infestation, severe anaemia, heart disease, HIV, asthma, diabetes) Salt iodisation Non-pregnant women of reproductive age: ill (6) Non-pregnant women of reproductive age: not wanting child Female condom Emergency contraception Male sterilisation x Malaysia All

All

WHO recommendations
WHO recommendations Pregnant women not wanting child, Prevent unsafe induced abortion (2) Where legally, politically, and culturally acceptable
(medical abortions could potentially be delivered at the household level, and attain high coverage, thereby averting a substantial proportion of maternal deaths)

Malaysia

Mifepristone / misoprostol (medical abortion) Vacuum aspiration All pregnant women (26) Calcium (reduce risk of PE)

Intrapartum women (delivery and immediate postpartum) (17)

All postpartum women (13) Insecticide treated bednets (malaria vs dengue) Pregnant, intrapartum, postpartum women with complications (45) Calcium supplementation (in women at high risk of PE) Post induced-abortion contraceptive advice

All

WHO recommendations
WHO recommendations Malaysia

*Stimulate nipples post term to induce labour *Intraumbilical vein injection with saline solution and oxytocin to reduce need for manual removal of placenta (Prevent need for manual removal of placenta; retained placenta; postpartum haemorrhage)

x
x

* WHO. Reproductive Health Library, version 9. World Health Organization. http://www.rhlibrary.com/default.asp (accessed Sept 5, 2006).

Contents

Definition Millennium Development Goal #5 Malaysian achievement How Malaysia fares compared to other countries WHO recommendations

Malaysian initiatives
Summary

Confidential enquiries into maternal deaths (CEMD)

Previously: at clinic, district, state level attended by all involved, national level by a committee Presently:

all the above +

national level every 3 months, attended by representatives from the states, by zones

Problems identified
Social difficulties on the rise
Need to involve other agencies since Medical Social worker in health facilities is scarce

Certification of death by non medical personnel

Police not to issue burial permits without knowing the cause of death

Post mortem for unsure cause of death

Problems identified
Geographical difficulties still exist especially in E Malaysia
Making trained personnel more accessible by rotation Upgrade facilities

Restrictions on management
E.g Need to have 2 specialists signatures for Xray examination in pregnant ladies

Strategies
Pre pregnancy care optimise health, for men too Guidelines primary & secondary care Personalised care

Continuation of thrombolytic Rx in primary care

Setting up of EPAU / PAC in secondary care Notification of high risk admissions & discharges

Combined clinic

Strategies
Family planning service in secondary care Setting up of low risk birthing centre
Higher risk can be given more attention Revival of ABC Alternative to home deliveries

Private wing for full paying patients more options for patients

Others
Malaysia towards health transformation, integration between public & private ?Delivery can either be in public or private health facilities

Contents

Definition Millennium Development Goal #5 Malaysian achievement How Malaysia fares compared to other countries WHO recommendations

Malaysian initiatives
Summary

Summary
WHO does not recognise Malaysias data (MOH, Pendaftaran) Malaysias MMR is still NOT on target Only the Chinese population has achieved the targeted MMR of , 11/100,000LB (6.7/100,000 LB) Up to 75% of maternal death occur during post partum period

Summary
Around 50% of death is preventable, half due to cardiac diseases Haemorrhage, embolism, HDP, Sepsis are the major direct causes of death

Home delivery is associated with high MMR

Summary
Malaysia complies to many of WHO relevant recommendation Malaysia need to look outside of the box, e.g:
delivery can be at public or private health facilities Personalised care add in patients in fb for easy access to advice

Thank you
baizuryfms@yahoo.com