1. Reducing Maternal Mortality: examples of health technologies in Asia and Africa Fifth Annual Meeting of the African Science Academy Development Initiative (ASADI) Ayo Ajayi, November 10, 2009

2. What we know…

3. Country Rankings for Neonatal and Maternal Deaths Ranking for numbers Ranking for numbers of neonatal deaths of maternal deaths 1India1 2China9 3Pakistan3 4Nigeria2 5Bangladesh8 6Ethiopia4 7Dem. Rep. Congo4 8Indonesia11 9Afghanistan7 10Tanzania6 WHO/UNICEF/UNFPA estimates of maternal mortality for 2000 2.5 million neonatal deaths Approximately 66% of global total 325,000 maternal deaths Approximately 61% of global total

4. Causes of Maternal Mortality in Asia Hemorrhage is the leading cause of maternal mortality in Asia. Other causes include embolism, ectopic pregnancy, anesthesia-related, include: malaria, heart disease. Source:" WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, vol 367, April 1, 2006.

5. Postpartum Hemorrhage  14 million cases of postpartum hemorrhage (PPH) per year  PPH causes up to 60% of all maternal deaths in developing countries  PPH often needs a quick response, which is especially difficult if delivery is at home, or in high volume, low resource facilities

6. Case Study: Pakistan Verbal Autopsy of Maternal Deaths in 2 Districts Findings Most of the deaths were:  in the lower socio-economic group  in the postpartum period (71%)  within 24 hours 40 %, mostly of PPH  in health facilities (Govt. 37, Pvt. 34) (Sukkur & Malir districts 2004-2006)

7. Simple steps… a balanced approach to PPH prevention An evidence-based intervention for skilled birth attendants (SBAs), combined with a community-based strategy, can prevent 50- 60 % of PPH Active management of the third stage of labor for SBAs  Community-based distribution of misoprostol

8. Evidence Supporting Use of Oxytocin in the Active Management of the 3 rd Stage of Labor (ATMSL)  Reduces incidence of PPH by 60%  Reduces the quantity of blood loss—thereby decreasing incidence and severity of anemia  Reduce emergencies and related cost, transport  Reduces the use of blood transfusion  Routine use of 10 IU of oxytocin can reduce the incidence of PPH, but it is difficult to ensure safe injection Active Management Physiologic Management OR and 95% CI Bristol Trial ‘88 50/846 (5.9%) 152/849 (17.9%) 3.13 (2.3-4.2) Hinchingbrooke Trial ‘98 51/748 (6.8%) 126/764 (16.5%) 2.42 (1.78-3.3)

9. For Births That Occur Without Skilled Care Community-based distribution of misoprostol is an effective strategy Why?  We cannot predict PPH on the basis of risk factors.  In many countries very few deliveries are attended by a skilled attendant.  Once severe PPH occurs, death follows very rapidly  Timely referral and transport to facilities is not always available or affordable  Availability of EOC services is grossly limited.

10. Eclampsia and pre-eclampsia in Kano State  In Kano state, eclampsia was the commonest cause of maternal deaths and contributed 46.3% of all the deaths in one study[i] and 31.3% in another[ii].[i][ii] [i][i] Society of Gynaecology and Obstetrics of Nigeria (SOGON). Status of emergency obstetric service in six states of Nigeria- A needs assessment report. June 2004 [ii] [ii] Adamu YM, Salihu HM, Sathiakumar N and Alexander R. Maternal mortality in Northern Nigeria: a population based study. Eur J Obs Gynae Rep Biol 2003; 109(2): 153-159

11. Patient Data Biichi General Hospital 95 5% Danbatta General Hospital 1528% Doguwa General Hospital 583% Gwarzo General Hospital 915% Minjibir General Hospital 794% Murtala Mohammed specialist Hospital 79943% Rano General Hospital 1538% Rogo General Hospital 1156% Tudun Wada general Hospital 1106% Wudil General Hospital 19411% Total 1846100%

12.  On the basis of the available evidence, The World Health Organisation (WHO) has recommended MgSO4 as the most effective, safe and low cost drug for the treatment of severe pre-eclampsia and eclampsia

13. Provider acceptability  Whereas 77.5% of the participants have heard of MgSO4, only 28.4% have ever administered it  83.4% knew the drug was used for treatment of severe preeclampsia/eclampsia  10.7% have heard of Magpie trial  Common sources of information: colleagues, journals and clinical instructors

14. Age distribution among patients treated

15. Highest formal education attained by the patients treated

16. Case Outcomes Maternal Alive164389% Dead774.2% Missing1266.8% Total1846100% Peri-Natal 147279.7% 23912.9% 1357.3% 1846100%

17. MMR and attributable deaths from eclampsia comparison  Facility based MMR pre intervention (2007) was 3195/ 100 000 live births while post intervention (2008) was 2146/ 100 000 live births  This demonstrated a reduction in MMR of 32.8% over the one year period of the intervention  Maternal attributable deaths from eclampsia fell by 66% across the 10 health facilities

18. Impact Product development Regulatory processes Effective use Introduction strategies Research Product development Regulatory processes Scaled up effective use Introduction strategies Research Financial commitment and political leadership Engagement of affected communities Value Chain for Public Health Impact

19. Conclusion – What does this all mean?  If public health impact is our goal, we must keep the entire value chain in mind as we identify and introduce new interventions  Even in the world’s most remote regions, simple and appropriate health technologies can be used to save the lives of mothers and children  Innovation plays an important role in meeting the needs of the most vulnerable, not just innovation in technology, but processes and behavior change.

20. Acknowlegements 1. Deborah Ambruster, PATH - POPPHI Project, DC 2. Jamil Tukur & Andrew Karlyn, Population Council, Abuja Ayo Ajayi, MD, MPH Vice president – Field Programs aajayi@path.org 206.285.3500 www.path.org