1. Barbara Deller, CNM, MPH Mary Ellen Stanton, CNM. MSN, FACNM October 27, 2006 Saving Mothers: Evidence and Issues

2. 2 Purpose of this Session Take a look at…. Progress towards maternal survival New Evidence Issue & Discussion

3. 3 “A woman who is pregnant has one foot in the grave”... Local Proverb, Chad

4. 4 The Lifetime Risk of Maternal Death in some places in the world it is staggering 1:94 1:16 1:2,800 1:160 Source: WHO, UNICEF and UNFPA. Maternal Mortality in 2000; Lancet Neonatal Survival Series, 2005 The chance of a woman dying as a result of pregnancy is 150 x greater in sub-Saharan Africa than it is in the United States

5. 5 Have we made progress? MDG 5 Target Reducing Maternal Mortality: Getting on with What Works, US Launch of The Lancet Maternal Survival Series, Ronsmans and Koblinsky, Oct 5, 2006

6. 6 Recent Successes in Maternal Mortality Reduction Morocco 36% decline Egypt 52% decline Bangladesh 34% decline Sources: Morocco: DHS 1992; Bangladesh: National Institute of Population Research and Training 2002; Bolivia DHS 1994, DHS 2003. Egypt: DHS 2000. Egypt Ministry of Health and Population; Indonesia: DHS 1994, DHS 2002; Guatemala: Duarte et al. 2003; Kenya DHS 1998, DHS 2003; Senegal DHS 1992, DHS 2005. Data point plotted is midpoint of date range. Indonesia 21% decline Bolivia 45% decline Guatemala 30% decline Kenya 30% decline Senegal 28% decline

7. 7 Progress in reducing maternal mortality Globally 1 –essentially no change via estimates since 1990 –> 500,000 deaths annually –MMR 400/100,000 live births (US 17) –2005 estimates not yet available In specific countries 2 –Wide variability –Other surveys show good progress in some countries –Overall lack of progress in sub-Saharan Africa Source: 1 WHO Maternal Mortality in 200: Estimates Developed by WHO, UNICEF, UNFPA 2 Demographic and Health Surveys, Macro Int.

8. 8 The Poor Are Hardest Hit Source: C Ronsmans and Koblinsky, presentation at US Launch of The Lancet’s Maternal Survival Series, 5 Oct 06, Washington, DC

9. 9 Geographical variation in the distribution of causes of maternal deaths

10. 10 Leading Causes of Maternal Death Cause of deathDeveloped countries AfricaAsiaLatin America/ Caribbean Hemorrhage13% 34%31% 21% Hypertensive disorders 16% 9% 26% Sepsis/infections2%10%12%8% Abortion8%4%8%12% Obstructed labor0%4%9%13% Anemia0%4%13%0% HIV/AIDS0%6%0% Source: Khan et al, WHO analysis of causes of maternal death: a systematic review, The Lancet, March 28, 2006 -- % rounded; not included on this table: ectopic pregnancy, embolism, other direct causes, other indirect causes, unclassified deaths

11. 11 Because Maternal Mortality is “relatively rare,” Severe acute maternal morbidity (SAMM) may be important in measuring progress SAMM—”near miss”--“A very ill pregnant or recently delivered woman who would have died had it not been that luck and good care was on her side” — differs from complications Systematic review -- 30 reports --prevalence –Disease-specific (e.g. eclampsia) 0.80% - 8.23% –Management specific (e.g. hysterectomy) 0.01%-2.99% –Organ system dysfunction/failure—0.38%-1.09% Inverse trend in prevalence with development status of the country Need better definitions before uptake Source: reported in Say, WHO systematic review of maternal morbidity and mortality, Reproductive Health, 2004

12. 12 Caesarean sections by type and facility WHO global survey, 2005

13. 13 WHO Global Survey, 2005 -- Latin America Caesarean Rates and Pregnancy Outcomes Median C/S rate 33%, 51% in private hospitals C/S rate was positively associated with –Increase in a severe maternal morbidity and mortality (index) –Postnatal tx with antibiotics –Fetal death and neonatal mortality and morbidity –C/S did not improve perinatal outcomes Preterm delivery rates and neonatal mortality rose at rates of C/S between 10 and 20% Limitations included: –3 of 11 countries (Haiti, USA, Paraguay) and 3 selected institutions originally selected did not participate –Limited standardization of diagnoses Source: Villar, et al. Caesarean delivery rates and pregnancy outcomes: 2005 Global Survey…in Latin America, 2006.

14. 14 CHALLENGE We do know a lot about what interventions work but... we still face many issues in programming to bring life-saving interventions to childbearing women to reduce maternal mortality

15. 15 In the developing world where 50% of births occur in home...... what strategy should we invest in for maximum reduction in maternal mortality? Bring skilled care to mothers at home Bring misoprostol (and other evidence- based home care) to homes where there is no skilled care Bring mothers to skilled care

16. 16 Skilled care at home Women’s choice Success in UK, Denmark, Malaysia Inefficient Requires links to EmOC Quality uncertain/supervision difficult

17. 17 Effective interventions at home without SBA Evidence of some effective interventions related to significant maternal complications that don’t require SBA (Lancet does not agree) –Oral misoprostol –Iron supplementation TBA meta analysis did not show effectiveness in reducing maternal mortality If trained de novo— huge investment Supervision and logistics difficult Lancet advocates pragmatism

18. 18 Oral misoprostol Rural India, 2006 1620 women, placebo-controlled trial Misoprostol: oral, stable, positive safety profile— can be used in the absence of a skilled birth attendant Misoprostol associated with –Reduction in PPH (12% to 6.4%; p<0.0001) –Reduction in acute severe PPH (1.2% to 0.2%; p<0.0001) –Decrease in mean PP blood loss (262.3 to 214.3ml; p<0.0001) –Transitory chills and fever Source: Derman, et al, Oral misoprostol in preventing postpartum hemorrhage in resource-poor communities: A randomized controlled trial, The Lancet, Oct. 7, 2006.

19. 19 SBA at the facility (includes EmOC or link) Can maintain normality (vs hospital) Can provide robust interventions Promotes 24/7 Scale-up team model can be 10x solo practitioners No RCTs Does not ensure quality—studies document –Negligence –Iatrogenic complications –Abuse

20. 20 Strategy Proposed in The Lancet: Team of skilled birth attendants in health center Care during delivery is the priority All women should be able to deliver in health centres, with midwives working in teams Target the women in greatest need: poor and rural women in sub-Saharan Africa and South Asia Reducing Maternal Mortality: Getting on with What Works, US Launch of The Lancet Maternal Survival Series, Ronsmans and Koblinsky, Oct 5, 2006

21. 21 Considerations Design programming approach based upon MMR, cause of death, current availability and cadres of providers Can chose more than one approach—keeping in mind that everything costs Plan for scale to achieve public health impact Phasing strategies Different approaches with massive deprivation and marginal exclusion Lancet: Need a new era of strategic thinking to address stagnation: Vision Funds Human resources Track progress

22. 22 Our Pearls The chance of a woman dying as a result of pregnancy is 150 times greater in Sub-Saharan Africa than in the U.S. This is the health indicator with the greatest disparity between the developed and the developing work. Postpartum hemorrhage (PPH) is, by far, the biggest maternal killed, responsible for greater than 30% of maternal deaths in Asia and Africa. PPH is preventable.

23. 23 “ Women are not dying because of diseases we cannot treat...... they are dying because societies have yet to make the decision that their lives are worth saving ”.... Mahmoud Fathalla