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Maternal Mortality & the MDGs Deborah Maine Professor, International Health Boston University, School of Public Health
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MDG Goal: Improve maternal health Target: Reduce the MM Ratio by 3/4 by 2015 Indicators: l Maternal mortality ratio l Proportion of births attended by skilled health personnel
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The MDG for MM Is it realistic ?
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History MMRs Sri Lanka: 1947 -- 1500 1960 -- 250 1980 -- 100 Malaysia: 1950 > 500 1975 < 100
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To reduce MM … l Need to understand the epidemiology of maternal mortality [MM] l A counterintuitive phenomenon l Many “obvious” approaches don’t work, e.g. risk screening, training TBAs
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Maternal Mortality RegionMM RatioLifetime Risk 1 in … Africa83020 Asia33094 Latin America190160 North America172,500 World40074
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Causes of Direct Obstetric Deaths The “Big 5” l Hemorrhage l Infection l Hypertensive diseases l Obstructed labor l Unsafe induced abortion
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The Way Programs Should Work Evidence Interventions Indicators Strategy
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Interventions Indicators Strategy Assumptions The way it often works
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Assumption If we just take very good care of pregnant women, few will develop serious obstetric complications.
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History: Prenatal Care l 1910-15 first clinics in UK (and US) l By 1930, 80% pregnant women in UK have prenatal care l But maternal mortality did not decline
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TBAs & “Clean Delivery” In Matlab, Bangladesh, TBAs were trained to use clean delivery practices. The did use these practices, but maternal deaths due to infection did not decline.
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Assumption Through prenatal screening, We can identify the women who will need medical care
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The Math of Prediction It works for groups but not for individuals.
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Example: Matlab, Bangladesh 1968-70 Maternal Age 10-1420-29 MM Ratio 1770450 Relative Risk 3.91 # Births 50911,286 # Deaths 951
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Example: United Kingdom 1985-87 Maternal Age20-2445+ MM Ratio37188 Relative Risk1 5.1 # Deaths242
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Risk and Prediction (cont.) A big risk in a small population = few deaths A small risk in a big population = many deaths
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In Short... Once a woman is pregnant most serious obstetric complications cannot be predicted or prevented, but they can be treated.
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So All pregnant women need access to emergency obstetric care (EmOC)
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Sri Lanka & Malaysia How did they do it ? l Expanding access to effective maternity care by midwives and doctors l Improving utilization and quality of care with emphasis on making life-saving care free. The World Bank, 2003
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Assumption EmOC is “Hi-Tech”
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Signal Functions of Basic EmOC : l Parenteral antibiotics, oxytocics, anticonvulsants l Manual removal of placenta l Removal of retained products l Assisted vaginal delivery l Neonatal resuscitation (new) Should be at health centers
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Signal Functions of Comprehensive EmOC: l All Basic EmOC functions l Blood transfusion l Surgery (c-section) Should be at District Hospitals
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EmOC is not “Hi Tech” It is mostly 1950s medicine !
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EmOC is the foundation Emergency Obstetric Care Skilled Attendant Referral Risk Screening Social Mobilization Waiting Homes TBA Training Antenatal Care
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Assumption EmOC is too expensive Community-based workers are more affordable
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A cost-effectiveness exercise: unit cost Dollars $350 $10,000 $30,000
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Cost (cont.) Suppose, per district, there are: l 100 MCHW s l 4 health centers l 1 district hospital
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Estimated program cost (in $000s) Dollars 30 40 35
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Estimated obstetric deaths prevented (%) 50 Percent 25 15
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Estimated cost per death averted ($000) $580 $845 $217
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In short … Something that is not effective can never be cost-effective.
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Measuring Progress: Are we measuring the right things?
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The Way It Should Work Evidence Interventions Indicators Strategy But sometimes …
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MDG Goal: Improve maternal health Target: Reduce the MM Ratio by 3/4 by 2015 Indicators: l Maternal mortality ratio l Proportion of births attended by skilled health personnel
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Promoting SBAs What is the evidence base for this policy?
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Source: Safe Motherhood Initiative website and Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA (2001)
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This shows: the relationship between delivery by SBAs and MMR is not strong for high-mortality countries
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Source: Saving Lives: Skilled Attendance at Childbirth, W. Graham, 2000.
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This shows: the relationship between delivery by midwives and reduced MMR is not clearcut – probably due to regional variation in what midwives are trained and permitted to do.
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Skilled Attendants need to be part of a functioning health system To Be Effective
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Sri Lanka, 1970s > Health Facilities SBAs
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Many Proposed Programs Health Facilities SBAs
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In Reducing Maternal Deaths There are really only 3 issues: l COVERAGE OF SERVICES l QUALITY OF CARE l UTILIZATION OF SERVICES
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The Road toMaternal Mortality Reduction: Shortcuts or Detours ?
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Pseudo-Interventions l “Safe Birth Kits”: No evidence of effectiveness in reducing maternal deaths, but consume effort, attention and funds. l Advocacy for Advocacy: If not linked to programs, advocacy can be a detour.
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1-Complication MM Programs Example: Home-based prevention of post-partum hemorrhage (PPH) Hemorrhage = 25% of maternal deaths Perhaps ½ preventable = 12.5%
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Semi-Skilled Attendants If you leave the skills out of Skilled Birth Attendant what do you get?
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Institutional Delivery Targets Easy to measure, but no indication of quality of care You can reach the target But miss the goal !
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“In the Meantime …” If we don’t get started now fixing health systems in 20 years we will still be in the meantime.
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General Lesson: We must build health systems l Need a strong evidence base l Training and equipment are never enough l Management systems are crucial l Even skilled personnel need support l Learn from expensive failures
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