Averting Maternal Death and Disability AMDD

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Averting Maternal Death and Disability (AMDD)
Program Orientation A Tool for Self-Learning  

• Developed for use in AMDD-partnered
  projectsFebruary 2002
• By
• Nadia Hijab Czikus Carriere

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This Presentation Covers

• Causes of Maternal Death and Disability
• Evolution of Understanding of the Problem
• Central Role of Emergency Obstetric Care
• UN Process Indicators
• The AMDD Program

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What Is Maternal Death?

• The death of a woman while she is pregnant

or
within 42 days of the termination of the
pregnancy
From any cause related to or aggravated by the
pregnancy World Health Organization (WHO)
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WHO Estimates 515 000 Maternal Deaths Each Year

• MORE THAN ONE WOMAN DIES EVERY MINUTE from
  pregnancy-related causes

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What Is Maternal Disability?

• Short- or Long-term Illness
• Caused by
• Obstetric Complications

The Most Serious Is Obstetric Fistula (An
Abnormal Passage Between Vagina and Bladder or
Rectum Often Caused by Obstructed Labor when it
is Not Treated with Cesarean Section)
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What Do Women Die Of?
They Die Of Obstetric Complications That Need
Not Be Fatal
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OBSTETRIC COMPLICATIONS
DIRECT

• Hemorrhage 21
• Unsafe Abortion 14
• Eclampsia 13
• Obstructed Labor 8
• Infection 8
• Other 11

Account for about 3/4 of Maternal Deaths
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OBSTETRIC COMPLICATIONS
INDIRECT

• Are Due to Pre-existing Conditions, including
  Malaria, Anemia and Hepatitis
• And Increasingly HIV / AIDS

Account for about 1/4 of Maternal Deaths
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Most Obstetric Complications Occur Suddenly
Without Warning
If women do not receive medical treatment on
time, they will probably suffer disability
Or Die
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WHERE DO WOMEN DIE TODAY?

• 99 of Maternal Deaths Today
• Occur in
• Africa, Asia and Latin America

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WHAT ABOUT THE REST OF THE WORLD?

• Maternal Mortality Used to be Very High in Europe
  and the U.S.
• So was Infant Mortality.

In 1915, Maternal and Infant Mortality Rates
Were as High in the U.S. As They Are in Africa
Today
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WHAT HAPPENED NEXT?

• Better Living Conditions
• Reduced Infant Mortality in the U.S.
• By over 40
• Between 1915 and 1933

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BUT MATERNAL MORTALITY
REMAINED THE SAME

• The well known triad
• of fever, haemorrhage and toxaemia predominated
  
• (Irvine Loudon)

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Until the late 1930s

• There was then a
• steep and sustained decline
• which has continued in most Western countries
• at much the same rate
• for over fifty years
• (Irvine Loudon)

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What Happened To Reduce Maternal Mortality In
The West?

• Effective treatment for obstetric complications
• was developed and used,
• e.g., antibiotics for infection,
• blood transfusions for hemorrhage

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Most Obstetric Complications

• Can Neither
• Be Predicted
• Nor Prevented

• But If Women Receive Effective Treatment
• In Time,

Almost All Can Be Saved
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How Much Time Do We Have?

• It is estimated that, if untreated, death
  occurs on average in

• 2 hours from Postpartum Hemorrhage
• 12 hours from Antepartum Hemorrhage
• 2 days from Obstructed Labor
• 6 days from Infection

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To Avert Death and Disability
We Need To Ensure That Women have Access To
Emergency Obstetric Care
(EmOC)
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How Can We Improve Access To EmOC?
By making sure health facilities provide the
services needed to save womens lives.
Eight key functions signal a facilitys ability
to provide EmOC
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EmOC Key FunctionsCover These Services

• Antibiotics (intravenous or by injection)
• Oxytocic Drugs (ditto)
• Anticonvulsants (ditto)
• Manual Removal of Placenta

• Removal of Retained Products
• Assisted Vaginal Delivery
• Surgery (Cesarean Section)
• Blood Transfusion

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Basic and Comprehensive EmOC Facilities
BASIC
EmOC Facilities Provide The First Six Services

• Antibiotics (intravenous or by injection)
• Oxytocic Drugs (ditto)
• Anticonvulsants (ditto)
• Manual Removal of Placenta
• Removal of Retained Products
• Assisted Vaginal Delivery

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Basic and Comprehensive EmOC Facilities
COMPREHENSIVE
EmOC Facilities Provide All Eight Services

• Antibiotics (intravenous or by injection)
• Oxytocic Drugs (ditto)
• Anticonvulsants (ditto)
• Manual Removal of Placenta
• Removal of Retained Products
• Assisted Vaginal Delivery

• Surgery (Cesarean Section)
• Blood Transfusion

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THE GOOD NEWS

• Not all these functions need hospitals and
  doctors

• Well-trained nurses and midwives can perform
  most functions at Basic EmOC Facilities

An Important Point For Resource Poor Areas
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How Can We Tell We Are Making a Difference?

• If we know we have provided enough EmOC

• and if we know that these services are being
  used by women suffering obstetric complications

WE CAN BE CONFIDENT THAT WE ARE SAVING WOMENS
LIVES
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How Do We Know Which Women Will Experience
Complications?
WE DONT
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But we do know that of any population of
pregnant women at least 15 will experience an
obstetric complication
This is as true of pregnant women in the US and
Europe as of women in Africa, Asia and Latin
America
Nobody Knows Why This Happens. It Is a Fact of
Life
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Can We Really TellIf Services Are Functioning?
And Are Being Used?

• In 1991,
• UNICEF and Columbia University developed
• 6 Process Indicators to do just that

These were issued by UNICEF/WHO/UNFPA in
1997 Guidelines for Monitoring Availability and
Use of Obstetric Services
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Process Indicators

• In general, process indicators show you
  the changes in the
  conditions
• that lead to an outcome
• (such as death or disability)

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THE 6 PROCESS INDICATORS
tell us about changes in

• Access to

Utilization of
and Quality of
EmOC Services
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INDICATOR 1
For every 500,000 population, there should be at
least
1 Comprehensive EmOC Facility 4 Basic EmOC
Facilities
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INDICATOR 2
Geographical Distribution of EmOC Facilities
EmOC Facilities should be well-distributed to
serve 500,000 people
Minimum 1 Comprehensive and 4 Basic EmOC
Facilities
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INDICATOR 3
Proportion of All Births in EmOC Facilities
At Least 15 of All Births in the Community
Should Take Place in EmOC Facilities
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INDICATOR 4
Met Need for EmOC Services
At Least 100 of Women Estimated
to Have Obstetric Complications Should Be
Treated in EmOC
Facilities
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INDICATOR 5
Cesarean Sections As a Percentage of All Births
Minimum 5 Maximum 15
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INDICATOR 6
Case Fatality Rate
Proportion of Women With Obstetric Complications
Admitted to a Facility Who Die
Maximum Acceptable Level 1
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CALCULATING ALL 6 INDICATORS

• Gives you an indication of where the problems lie
  and where action is needed.
• Also, these indicators are sensitive to change
  within months, you can know if your project is
  making a difference

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ACCESS TO EmOC

• Problems
• Does Indicator 1 show you need more EmOC
  facilities?
• Does Indicator 2 show you need better
  distributed EmOC facilities?

• Action
• Most countries already have enough facilities
  they may just need to upgrade services
  to ensure 1 Comprehensive
  and 4 Basic EmOC facilities per 500,000 population

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UTILIZATION OF EmOC
Problems

• Does Indicator 3 show that births in your EmOC
  facilities are fewer than 15 of all births in
  the population?
• Does Indicator 4 show that Met Need is less
  than 100? (I.e. that not all women who
  experience obstetric complications are using EmOC
  facilities)
• Does Indicator 5 show that less than 5 of all
  births in the population are by Cesarean section?

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UTILIZATION OF EmOC
Action Collect More Info First

• Do you have enough qualified staff?
• Do you need to train staff on management of
  emergency obstetric complications?
• Does hospital management need improvement?
• Whats the supply situation like?
• Whats the equipment situation like?

If all the above is in place, conduct focus
groups in the community to find out why women are
not coming for care
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QUALITY OF EmOC
Problem
Does Indicator 6 show that more than
1 of women treated for obstetric complications
are dying at your EmOC facilities?
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QUALITY OF EmOC
Action Get More Info

• Find out if your EmOC facilities are really
  functioning
• Check staff numbers, skills, management capacity,
  supplies and equipment
• Lobby your health ministry for more support and
  get the community to lobby with you

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Any Country Can Avert

Maternal Death And Disability If
It Makes Good EmOC
Available And Accessible on Time
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The AMDD Program

• The AMDD Program Was Established in 1999 at
  Columbia Universitys School of Public Health,
  Heilbrunn Department of Population and Family
  Health
• The AMDD Program Is Dedicated to Improving the
  Availability, Quality and Utilization of
  Life-saving Obstetric Services in Developing
  Countries
• AMDD Partners Projects in Close to 50 Countries,
  Within a Framework That Links Technical Know-How
  With Management Capacity and Human Rights
• AMDD Is Funded by a Generous Grant From the
  Bill and Melinda Gates Foundation

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AMDD Partners

• Project Partners
• United Nations Childrens Fund (UNICEF) projects
  in Bangladesh, Bhutan, India, Nepal, Pakistan and
  Sri Lanka
• United Nations Fund for Population Activities
  (UNFPA) projects in India, Morocco, Mozambique
  and Nicaragua
• Regional Prevention of Maternal Mortality (RPMM)
  Network teams and projects in19 sub-Saharan
  African countries
• CARE projects in Ethiopia, Rwanda, Tanzania,
  Peru and Tajikistan
• Save the Children projects in Mali and Vietnam
• Reproductive Health for Refugees (RHR)
  Consortium projects in 12 countries

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AMDD Partners

• Technical Partners
• Family Health International
• John Snow International
• Indian Institute of Management
  at Ahmedabad (IIMA)
• JHPIEGO
• Engender Health
  (formerly AVSC International)

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RESOURCES

• UNICEF/WHO/UNFPA, Guidelines for Monitoring the
  Availability and Use of Obstetric Services,
  UNICEF, New York, October 1997
• Maine, Deborah, Safe Motherhood Programs
  Options and Issues, Columbia University, New
  York, 1991
• UNFPA and AMDD, Reducing Maternal Deaths
  Selecting Priorities, Tracking Progress, Distance
  Learning Courses on Population Issues, Turin, UN
  System Staff College, 2002
• Loudon, Irvine, On Maternal and Infant
  Mortality 1900-1960, Social History of Medicine,
  April 1991, Vol. 4, No.1, pp 29-73

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Created byNadia Hijab Czikus Carriere