Maternal health challenges & successes: an overview focussing on low-income settings Oona Campbell 9 March 2012 Improving health worldwide www.lshtm.ac.uk
High maternal mortality historically, for UK & rich Pictures of Monument to Princess Charlotte died 1817 St. George s Chapel, Windsor Castle and portrait of a wealthy pregnant woman painted to leave a memento in case she died Year MMR Population 1500-1750 European nobility ~2000 1930-32 E&W Social Class I&II 444 E&W Social Class IV 389 2008 Afghanistan 1400 Swaziland 420 UK 12
Dramatic declines in high-income populations 700 600 500 Maternal mortality ratios, England & Wales, 1850-2005 Declines coincide with: Antibiotics Blood transfusions Management of hypertensive diseases of pregnancy 400 Maternal deaths in rich countries eliminated 300 200 100 0 Deaths by cause & sex England & Wales 2009: 63 maternal deaths 66 breast cancer deaths in men
Background A woman dying each minute: day in, day out Photo of pregnant women with lifetime risk of death painted on their bodies MDG 5 improve maternal health; an important global health challenge Ensuring women give birth with a skilled birth attendant, and can access emergency obstetric care, is crucial
2015 1990 Global Commitment 700 Maternal mortality ratios, England & Wales, 1850-2005 and Global Targets 1990-2015 600 500 400 300 200 100 0 UK Global
Epidemiology of Maternal Death Maternal deaths per 100,000 live births, 2008 <100 100-299 300-499 500-999 1000+
Maternal mortality ratio Direct causes What are the causes of death? 1000 Haemorrhage Hypertensive diseases of pregnancy Sepsis Obstructed labour Unsafe abortion As well as other underlying conditions (indirect causes) 900 800 700 600 500 400 300 200 100 0 Sub-Saharan Africa Haemorrhage Hypertensive diseases Sepsis/Infection Obstructed labour Other direct Abortion Indirect causes Unclassified
Epidemiology of Maternal Death Complications difficult to predict or prevent Treatment needs some skill
What needs to be done? 1. Renewed focus on delivery & emergency obstetric care, & family planning and abortion Combined with: 2. More health professionals 3. Greater financial resources 4. Robust tracking of progress & accountability 5. Greater political commitment
Global Strategy for Women s and Children s Health (United Nations, 2010) Every Woman Every Child: 3 strategic areas Reducing financial barriers Creating stronger policy environment towards women s and children s health Strengthening and improving delivery of health services Photo of Ban Ki Moon at world economic summit
Challenges & successes
Services availability: Emergency Obstetric Capability, Zambia health facilities (n=1370) Gabrysch 2010 Categorisation of all Zambian health facilities according to their EmOC functions (n=1370) No delivery service Substandard delivery service BEmOC-4 BEmOC-2 BEmOC-1 BEmOC CEmOC-1 CEmOC 39 42 24 30 155 239 375 466 0 100 200 300 400 500 Number of facilities
Distance from services: Access to obstetric care in Zambia (Gabrysch et al 2011) Urban population: 3,460,000 Urban Rural population: 7,057,000 Rural 14/17 0 20 40 60 80 100 % of Population within 15km of BEmOC % of Population within 15km of any delivery service
Staffing: doctor density in Zambia compared to Sri Lank a (Gabrysch et al 2011) Northern North North-Central Luapula Southern Eastern Uva Western East Sabaragamuwa Southern Zambia Sri Lanka - Doctors - Doctors per per 3600 3600 births births by by province Northwestern North-Western SRI ZAMBIA LANKA Copperbelt Central Lusaka Western 3 3 20 20 40 60 80 100 120 120 140 140..
Poor Quality of Care in Facilities: time to treatment (Ivory Coast): near misses Uterine Rupture Uterine Rupture Uterine Rupture Uterine Rupture Uterine Rupture Uterine Rupture 0 2 4 6 8 10 12 call doctor obtain kit kit complete kit other 16 Gohou et al 2004
Economic costs: catastrophic consequences of unaffordable emergency care (Borghi et al 2006) Country/year % GDP/capita for normal delivery in hospital % GDP/capita for caesarean section Ghana, 2002 5-6 16-35 Burkina Faso 2006 43 138 National policies to remove user fees for delivery care Dzakpasu (2010)
Percent of deliveries Ghana: skilled attendance increasing; inequality decreasing 80 70 60 57 50 40 40 44 44 47 30 20 10 0, Ghana Demographic and Health Survey 2008; Dzakpasu et al 2012
Quality of care: can be poor: (Khayat & Campbell 2000) Evidence based practices in Lebanese hospitals: 1997 Perineal shaving for all 92% All women tied during delivery 59% Adopts any position likes during labour 38% All mothers helped breastfeed 23% Can be improved Gabrysch et al 2009) Increase in facility use following adoption of culturally sensitive practices in Ayacucho, Peru: 6% (1999) to 83% (2007)
Global financial resources have not been adequate but are improving (Pitt et al 2011) Percent of DALYs Maternal & newborn health not given financial priority despite a burden of disease larger than for HIV, TB, or Malaria 9 8 7 6 5 4 3 Global development assistance to maternal & neonatal health was $563million (2003) & $1227million (2008) 2 1 0
Unmet need for Contraception, 1990-1995 & 2000-2005: appalling but improving Sedgh et al 2007 & UNFPA 2010 23% in least developed vs. 9% in developing countries 137 million women worldwide
Abortion Policies/Provision improving in some places
Conclusions
Achievable Target? 75% in 25 years 700 Maternal mortality ratios, England & Wales, 1850-2005 and Global Targets 1990-2015 (and transposed to 1925-1950) 600 500 400 300 200 100 0
2015 2008 1990 Progress 700 Maternal mortality ratios, England & Wales, 1850-2005 and Global MMR 1990-2008; Target 2015 600 500 400 300 200 100 0
Maternal deaths per 100000 live births 700 Progress in LMICs 600 500 400 300 200 100 0 Sri Lanka Thailand Malaysia Honduras Egypt Matlab, Bangladesh Bangladesh MM Survey 2001 China India
Photo of woman burdened by carrying a child A topic for women s day?? Bhavna Bahri Gregory John Smith Child birth and maternal mortality pose many challenges: Women in need of care. Women in their traditional role burdened, and weak Photo of woman uplifted by child But also Women as skilled birth attendants providing care that prevents death Women as survivors strong, resilient and creators of the future
8th of March is the day of the rebellion of the working women against the kitchen slavery March 8 th is the day we ensure other women don t lose their lives giving life
Too many women are still dying in their prime years Maternal mortality is an MDG that 189 countries have signed up to We need to get on with what works Copyright ICDDR,B/06-1109/Bitu/Map
Thank you