1. Maternal mortality rate in Yazd-Iran during 10 years (2002-2011) DR.Karimi Zarchi M Gynecological oncology felloship, shahid sadoughi university of Medical Sience

2. Definitions 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.  Death must be attributed directly or indirectly to pregnancy or childbirth  Requires medical certification or verbal autopsy  Cannot be obtained through surveys or censuses  No deaths beyond 42 days due to pregnancy complications accounted for Definition Implications Pregnancy-related death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.  Cause of death certification not needed  Can be obtained through surveys or censuses UN Interagency maternal mortality estimates conform to the definition of maternal death

3. Maternal Mortality: A Global Tragedy Annually, 536,000 women die of pregnancy related complications –99% in developing world –~ 1% in developed countries –25% global burden by India Every minute one Maternal Death occur Current Approach to Reduction of Maternal Mortality 3

4. Maternal Death Watch 380 women become pregnant 190 women face unplanned or unwanted pregnancy 110 women experience a pregnancy related complication 40 women have an unsafe abortion 1 woman dies from a pregnancy-related complication Current Approach to Reduction of Maternal Mortality 4

5. The fifth MDG(Millennium Development Goal) aims to improve maternal health, with a target of reducing the MMR by 75% between 1990 and 2015. The percentage reductions for the 10 countries that have already achieved MDG 5 by 2010 are: Estonia(95%), Maldives(93%), Belarus(88%), Romania(84%), Bhutan(82%), Islamic Republic of Iran(81%), Equatorial Guinea(81%), Lithuania(78%), Nepal(78%) and Viet Nam(76%)

6. Estimates of maternal mortality ratio,number of maternal deaths by United National Millennium Development Goal region,2013 RegionMMRRange of MMR uncertainty Number of maternal deaths Lower estimate Upper estimate World210160290289000 Developed regions1612232300 Developing regions230180320286000 Northern Africa69471102700 Sub-Saharan Africa510380730179000 Eastern Asia3321546400 Southern Asia19013028069000 Oceania190100380510

7. Trends in estimates of maternal mortality ratio(maternal deaths per 100000 live births), 1990-2013, by country CountryMMR% Change in MMR between 1990 and 2013 19901995200020052010 Afghanistan1200 1100730400-67 India560460370280190-65 Indonesia430360310250190-56 Iraq11084717767-37 Egypt12096756245-62 Iran8360443123-72 Saudi Arabia4131241916-65 Bahrain21222716223

8. Maternal mortality ratio in Iran (2002 – 2011)

9. Birth and maternal mortality in some Iranian universities(2007-20011) UniversityBirth (5 years) Maternal mortality (5 years) Percent of all births in 5 years Percent of all deaths in 5 years Tehran (Shahid Beheshti,Tehran) 91379114517.149.45 Esfahan 332849576.243.71 Kashan 2903390.540.59 Sistan & Balochestan 3746111737.0211.27 Zabol 40350210.761.37 Kerman 190903603.724.91 Kohkeloieh & Boyer Ahmad 74040231.391.50 Hormozgan 168263672.534.36 Yazd 113015291.721.89

10. Birth and maternal mortality in Yazd(2002-2011) Birth (2002-2011) 222433 Maternal Death (2002-2011) 40 Maternal Mortality Ratio 17.9

11. The most common causes of maternal death in 2011,Iran

12. The most common causes of maternal death in Yazd, 2002-2011

13. Percent of maternal deaths by place of birth, Iran

14. Percent of maternal deaths by place of birth in Yazd,2002-2011

15. Percent of maternal deaths by type of delivery, Iran

16. Percent of maternal deaths by type of delivery in Yazd, 2002 - 2011

17. Percent of delays leading to maternal death, Iran

18. According to the results, it seems necessary considering the quality of services provided in the hospital emergency obstetric,92.5% of mothers had died in childbirth in hospitals(92.5% in Yazd & 94% in Iran). 55% of mothers had died giving birth by cesarean section in Yazd (63% in Iran). As of Huchon and Heyl study.Therefore reducing cesarean rates can also reduce maternal mortality.

19. In most studies, the most common cause of maternal death is hemorrhage. Rajai and et al study was one of these cases,the hemorrhagy was reported by 34.1% as the most common cause of maternal mortality in Hormozgan. Hemorrhage is one of the reasons that are preventable. Improving care before,during and after delivery is effective in contrlling bleeding. And finally providing timely emergency obstetric will result in saving the lives of mothers(41% in 2011).

20. Interventions to Reduce Maternal Mortality Historical Review Traditional Birth Attendants-3 percent Antenatal Care -11 percent Risk Screening About 15 % Current Approach Reduce Unwanted Fertility Skilled Attendant at Delivery Emergency Obst. Care Current Approach to Reduction of Maternal Mortality 20

21. Risk Screening Conclusion: Cannot identify those at risk of maternal mortality — Every pregnancy is at risk, if not proved, otherwise.

22. Do women die immediately after developing complications in delivery? Average Complications to death interval Hemorrhage PPH: 2 Hours ( 5.7 hrs*) APH: 12 Hours(11.5 hrs) Ruptured uterus 1 Day Eclampsia 2 Day(1.7 Days) Obstructed Labour 3 Days Infection 6 Days(2.4 Days) (* Study in Maharashtra – Ganatra et al. WHO bulletin 1998, 76(6):591-598. Current Approach to Reduction of Maternal Mortality 22

23. Current Approach to Reduction of Maternal Mortality 23

24. Maternal Health Services Good quality maternal health services are not universally available and accessible –> 39% receive no antenatal care – ~ 40% of deliveries unattended by skilled provider –~ 60% receive no postpartum care during 1st 6 weeks following delivery –15% unmet need of FP Current Approach to Reduction of Maternal Mortality 24

25. Are there populations who are rich, well nourished and educated but have high maternal mortality? Yes in USA there are such populations – eg. Faith Assembly of God who are rich, well nourished, and educated : their MMR was 872 in 1982 while in that year MMR in US general population was only 8 per 100,000 live births. What is the key difference between these two groups? Use of modern obstetric care. 25Current Approach to Reduction of Maternal Mortality

26. So All pregnant women need Access to* Emergency Obstetric Care (EmOC) * Not the same as Institutional Delivery [ID] 26Current Approach to Reduction of Maternal Mortality

27. Thanks a lot

28. Current Approach to Reduction of Maternal Mortality 28 REFRANCE: Maine D. 1999. What's So Special about Maternal Mortality?, in Safe Motherhood Initiatives: Critical Issues. Berer M et al (eds). Blackwell Science Limited: London. World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.