1. STATE OF MATERNAL HEALTH IN GHANA, CAUSES OF MATERNAL MORTALITY, PERENATAL MORTALITY, STRATEGIES FOR REDUCING MM AND NNM Emmanuel K Srofenyoh

2. Outline of Presentation  Introduction  Global and National Magnitude of the Problem  Strategies to reduce mortalities and morbidities.  Conclusions

3.  The issue of the unacceptably high maternal mortality in developing countries has remained an unrelenting challenge to major world bodies and advocates over the past decades and threatened to remain so over decades to come.  In 2005, there were an estimated 536 000 maternal deaths worldwide." WHO 2009a.

4. Maternal Health: Scope of Problem Current Approach to Reduction of Maternal Mortality 4  180–200 million pregnancies per year  75 million unwanted pregnancies  50 million induced abortions  20 million unsafe abortions (same as above)  600,000 maternal deaths (1 per minute)  1 maternal death = 30 maternal morbidities  99% in developing world  ~ 1% in developed countries

5. Burden of the problem - Why all the worry? – cont. RegionRisk of Dying Africa1 in 16 Asia1 in 65 Latin America & Caribbean1 in 130 Europe1 in 1400 North America1 in 3700 All developing countries1 in 48 All developed countries1 in 1800 Ghana1 in 35 Women's lifetime risk of dying from Pregnancy.

6. Neonatal Health: Scope of Problem Current Approach to Reduction of Maternal Mortality 6  3 million neonatal deaths (first week of life)  3 million stillbirths

7. Why is it Necessary for Every Country to make efforts to protect Women and ensure their Survival?

8.  Economic Reasons: 1. Death of a woman in reproductive age has clear implications for a country’s Productive capacity, labour supply, economic well being. 2. A woman’s wage earnings are critical to the family unit, community and to over all poverty reduction effort and benefist family welfare more than men’s wage earnings. 3. Also when a woman dies the children or her dependants has a diminished prospect of leaving a productive life (World Bank 1999).

9. Other reasons  Intrinsic value of women: protecting them is therefore an end in itself  Human right and social justice dimensions (ICPD, CEDAW).

10. UN Millenium Development goals

11. GHANA’S GOAL BY 2015  REDUCE MATERNAL MORTALITY (by 3/4) FROM THE 2000 LEVEL TO 54/100,000 LIVE BIRTHS.  REDUCE U5 MORTALITY (2/3)TO 40/1000 LIVEBIRTHS

12. WHAT IS GHANA’S MMR?  National Sisterhood Survey (1993): 214/100,000  WHO/Hill Estimates (1995): 586/100,000  UNICEF Estimates (1996): 740/100,000  WHO/UNICEF/UNFPA(2000): 540/100,000 (140- 1000)  Health Institutions (2006): 187/100,000 -Average Annual Institutional 957 DEATHS Maternal Health survey 2007 - 451/100,000 Recent WHO estimate for Ghana 350/100,000.

13. Numbers of death by region REGION20012002200320042005200620072008 Upper East5259344635433427 Upper West4217161921203022 Northern59497766839111591 Brong-Ahafo110102841041051167681 Ashanti184172173161178175191222 Eastern1399211310915711813398 Central1008671 578512592 Western8386826376126103101 Volta9491847175655552 Greater Accra9183120114125118161167 National Total9548378548249129571023953

14. MATERNAL MORTALITY RATIO SCENARIOS 2005 – 2015 With radical interventions Without interventions/with current traditional interventions 214/100,000 LB 54/100,000 LB

15. Trend in Institutional MMR: GHANA 2002 - 2006 1.87 1.97 1.86 2.05 2.04 0 0.5 1 1.5 2 2.5 3 20022003200420052006 Year MMR/1000 Live Births

16. Trends in Antenatal Care Coverage (at least one) - GDHS

18. Postnatal Care Coverage 2002-2006 57.8% (2008) 53.4 55.7 53.3 55 53.7 52 52.5 53 53.5 54 54.5 55 55.5 56 20022003 20042005 2006 Year % Coverage

19. Caesarean Section Rate, 2002 - 2006 6.9 6.1 5.7 5.8 5.6 4 4.5 5 5.5 6 6.5 7 20022003200420052006 Year Rate (%)

20. Classification  Immediate Cause of Death  Direct  Indierct  Avoidable Factors

21. Global Causes of Maternal Mortality Current Approach to Reduction of Maternal Mortality 21

23. Causes of Maternal Death in Ridge CauseFreq%tage Direct Causes Hypertensive disoders934.6% Obstetric Hemorrhage623.1% Septic abortion13.8% Pueperal Sepsis with Septicaemia13.8 % Ruptured Ectopic Gestation13.8% Indirect causes HIV in Pregnancy311.5 % Malaria with severe IVH13.8 % Severe anaemia In pregnancy13.8 % SCD with VOC and Septicaemia13.8 % Others Acute Collapse with severe respiratory Distress27.7% Total26100

24. Common Maternal Morbidities Recorded in Ghana Fistula (leaking urine and faeces) Infertility Anaemia Chronic Pelvic Pain

25. Interventions to Reduce Maternal Mortality Current Approach to Reduction of Maternal Mortality 25 Historical Review  Traditional birth attendants  Antenatal care Current Approach  Family Planning  Skilled attendant at delivery,  Provision of Emergency obstetric care services

26. Interventions: Traditional Birth Attendants Advantages  Community-based  Sought out by women  Low tech  Teaches clean delivery Disadvantages  Technical skills limited  May keep women away from life- saving interventions due to false reassurance 26 Current Approach to Reduction of Maternal Mortality

27. Maternal Mortality Reduction Sri Lanka 1940–1985 Current Approach to Reduction of Maternal Mortality 27 Health system improvements:  Introduction of system of health facilities  Expansion of midwifery skills  Decreased use of home delivery and delivery by untrained birth attendants  Spread of family planning

28. Maternal Mortality Reduction Sri Lanka 1940–1985 Current Approach to Reduction of Maternal Mortality 28 85% births attended by trained personnel

29. Interventions: Traditional Birth Attendants Current Approach to Reduction of Maternal Mortality 29 Conclusion: TBAs are useful in the maternal health network, but there will not be a substantial reduction in maternal mortality by TBAs delivering clinical services alone

30. Maternal Mortality: UK 1840–1960 Current Approach to Reduction of Maternal Mortality 30 Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care Maine 1999.

31. Interventions: Skilled Attendant at Childbirth (Can avoid 13 t0 33%) Current Approach to Reduction of Maternal Mortality 31  Proper training, range of skills  Assess risk factors  Recognize onset of complications  Observe woman, monitor fetus/infant  Perform essential basic interventions  Refer mother/baby to higher level of care if complications arise requiring interventions outside realm of competence  Have patience and empathy WHO 1999.

32. Skilled Attendance

33. Current Approach to Reduction of Maternal Mortality 33 The higher the proportion of deliveries attended by skilled attendant in a country, the lower the country’s maternal mortality ratio % skilled attendant at delivery Maternal deaths per 1000000 live births

34. Signal Functions of EmOC ( for every 500,000 population 1 comprehensive and 4 basic) Basic EmOC  1. Administer parenteral antibiotics  2. Administer parenteral oxytocic drugs  3. Administer parenteral anticonvulsants for preeclampsia  and eclampsia  4. Perform manual removal of placenta  5. Perform removal of retained products  6. Perform assisted vaginal delivery Comprehensive  7. Perform surgery (caesarean section)  8. Perform blood transfusion  A Basic EmOC facility is one that is performing all of functions 1 to 6.  A Comprehensive EmOC facility is one that is performing all of functions 1 to 8.

35. Why EmONC  By far most important Intervention  15% of pregnancies develop complications and becomes emergencies.  These complications cannot be predicted and many cannot be prevented.  These emergencies can kill rapidly.  Early identification and expeditious management can avoid death in many cases

36. Some major questions that need be answered  Are there enough facilities that provide EmONC?  Are they well distributed?  Do women use these services, if not why?  Are the women using the services those who really need them?

37. Some major questions that need be answered  Are facilities providing critical life-saving services?  Is the quality of the services adequate?  Are other interventions needed?

38. FACTORS INFUENCING MATERNAL DEATHS DELAY ONE:Recognizing danger signs  Simply does not know the signs and symptoms  Some signs are initially innocuous and pose serious threat in their extreme forms eg. PIH  Difficulty in assessing severity. Bleeding and Prolonged labour

39. DELAY TWO : Deciding to seek care  Other decision makers not available  TBAs make not act on time  Lack of trust for staff  Fear of poor care  Fear of being mistreated by staff  Cost of services

40. DELAY THREE : Reaching Care  Poor roads  Scarce vehicles  Vehicles refuse to carry pregnant women with complications for fear of soiling their vehicle or even dying in their vehicle.  Cost of transport  Lack of companion

41. DELAY FOUR: Receiving care at Health Facility.  LACK OF EMERGENCY PREPAREDNESS  INADEQUATE SKILLS AND KNOWLEDGE  SHORTAGE OF STAFF.  POOR STAFF ATTITUDE  LACK OF EQUIPMENT AND SUPPLIES  POOR INFRASTRUCTURE

42. Conclusion The only ways we as a nation can achieve our vision with regards to maternal health are to ensure that:  Women do not carry pregnancy against their wishes.  Those who wish to have babies have access to skilled and professional care.  And those who develop complications have rapid access to EmONC services.