SALSO COURSE

Maternal Mortality

Introduction World wide, pregnancy and childbirth claim the lives of

an estimated 514,000 women each year. This translates to one woman dying every minute.

Maternal mortality is one of the measures of the QUALITY of health care system.

In Malaysia, significant reduction in MMR over the last 50 yrs: 540/100,000 LB in 1950 139/100,000LB in 1970 44/100,000 LB in 1991 28.1/100,000 LB in 2000

National objective - to reduce MMR to <20/100,000 LB.

Successes in Maternal Mortality Reduction

-

200

400

600

800

1,000

1,200

1,400

1,600

1840 1860 1880 1900 1920 1940 1960 1980 2000

Mat

ern

al M

ort

alit

y R

atio

Mat

ern

al D

eath

s p

er 1

00,0

00 L

ive

Bir

ths

China

Malaysia

USA

England & Wales

Sweden

Source: England, Wales, Sweden, USA: VanLerberghe and DeBrouwere, Safe Motherhood Strategies, A Review of the Evidence, 2001 Malaysia, China: Koblinsky, Et al., Issues in Programming for Safe Motherhood, 2000

Maternal Death

The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its

management, but not from accidental or incidental causes

Classification

Direct Deaths resulting from obstetric complications in

pregnancy, labour and puerperiumIndirect

Deaths resulting from previous existing disease or diseases that developed during pregnancy and which was aggravated during pregnancy

Fortuitous Deaths from other causes not related to or influenced by

pregnancy

Only direct and indirect deaths are included in MMR calculation.

Principles of CEMD System

Confidentially concerning patient and care given.Non-punitive in action.Comprehensive - every maternal death must be

investigated.Seamless-intersectoral collaboration (between public

health, hospital and private sectors).

Flow Chart On The Organization Of Investigation Of Maternal Mortality

DEATH IDENTIFIED BY COORDINATORINVESTIGATED BY INVESTIGATORMCHO NOTIFIED

FORMS FILLED BY INVESTIGATORAND OTHERS AT DISTRICT LEVEL &SUBMITTED TO MCHO

MCHO OBTAINS CODES FROM SECRETARIAT,WRITES COMBINED SUMMARY & SUBMITS TO NATIONAL ETHICAL COMMITTEE

REVIEW BY NTC

REPORTSACTION

Maternal mortality rate

Malaysia 1991-1996

4447.8 45.8

39

46.9

40.7

0

10

20

30

40

50

60

1991 1992 1993 1994 1995 1996

MM

R/ 1

00,0

00 L

B

Maternal mortality rate

Sarawak 1997-2003

35.7

47.149.6

33.1 32.5 30.6 28.8

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003

MM

R/ 1

00,0

00 L

B

Causes of Maternal Deaths Malaysia

1991-1996

0%

5%

10%

15%

20%

25%

30%

35%

40%

PPH HDP Embolism Medical Ob trauma Others

199119921993199419951996

Maternal Deaths Malaysia

PPH leading cause of maternal death (about 25%), commonly due to retained placenta and uterine atony

HDP next common cause, most deaths occuring postpartum. Associated with eclampsia, cardiopulmonary complications, cerebral haemorrhage, severe preeclampsia and DIVC

Thromboembolism

Maternal Deaths Malaysia

Associated medical conditions e. g. rheumatic heart disease especially mitral stenosis

Obstetric trauma include uterine rupture, uterine inversion and cervical, vaginal and uterine tears

Others include antepartum haemorrhage, sepsis, miscarriage, ectopic, associated with anaesthsia and unknown

Causes of Maternal Deaths Sarawak

1999-2003

0%

10%

20%

30%

40%

50%

60%

PPH Medical Sepsis HDP Unspecified Others

1999

2000

2001

2002

2003

Maternal Deaths Sarawak

Postpartum haemorrhage is the leading cause of maternal mortality (about 35%)

Medical conditions next most common (25%)Sepsis is third (11%)Hypertensive disorders of pregnancy (8%)Relatively large proportion unspecifiedOthers include ectopic, miscarriage, APH,

amniotic fluid embolism and cancers

General summary

Patients profile:Age - majority between 20-39Parity - over 60% multipEducation - 60% primary/secondary schoolingOccupation - 60% housewifesMarital status - 3% unmarriedFamily Planning - >55% no FPCitizenship - 160 non-citizens

Delivery characteristics:

Stage of pregnancy - >60%postpartum

<15%intrapartum

Place - >70% govt hosp.

Mode - SVD 40-60%

CS - ‘97 - 35.4%

‘00 - 20.8%

- The areas with the most potential for preventing maternal deaths are direct deaths

- More emphasis are needed on family planning- Continuous training for health care providers

involved to be familiar with manuals and protocols by MOH

Post Partum HaemorrhageContributes about 20%Uterine atony & retained or adherent placenta -

main causeRisk factors - >40yrs , multiparity Home delivery - 19-37% of deathsRisk of dying from PPH for mothers delivering at

home is 3-5x higher than govt. facility. Additional risks - untrained attendants and no adequate ANC

Contributing factors - -recurring problem of delayed or unavailable emergency

transportation to hospital -geographical remoteness -inaccessabilty to health care facilities

Recommendations :- family planning- Adequate ANC counselling and accurate risk

assessment- Availability facilities for adequate resuscitation-blood

and blood products- Emergency transport arrangements to higher level of

care- Early admission for patients living far from health

centres

Obsteric trauma

Most frequent causes - uterine rupture , pelvic haematoma, cervical lacerations, uterine inversion

Risk factors - high parity - injudicious use of oxytocicsRemediable clinical factors-- inappropriate utilisation of oxytocics- Failure to diagnose - Failure to appreciate severity of clinical problem- Late referral - Delayed involvement of senior staff

Recommendations- Need for proper protocol & guidelines on

augmentation & induction of labour- increase awareness of problems especially uterine

rupture, difficult deliveries, grand multips and scarred uterus

- Need for birth attendants to be able to recognise inversion and able to institute appropriate treatment

- Train birth attendants on management of third stage

Hypertensive disorders of pregnancy

1/3 were primigravidaThe immediate association with death were

eclampsia,cardiopulmonary complications,cerebral h’age,severe PE & DIVC.

Deaths could have been prevented if health care providers were more aggressive and vigilant in their management.

Proteinuria in pregnant women should be carefully investigated and monitored.

24hr urine protein - gold standard but not always practical. Dipstick commonly used- protein 2+ cut off for abnormal

Magnesium sulphate- not widely used in management of eclampsia- Prevention and treatment for eclampsia- Consider prophylactic MgSO4 in cases of severe PE- Drug availability to nurses/midwifes who could

administer it IM

Obstetric embolismAmniotic fluid & blood clot embolism.Only 11/91 had post mortem confirmation.Subjective clinical assessment unreliableAny women with signs and symptoms of VTE

should have objective tests performed expeditiously to avoid risks, inconvenience and costs of inappropriate anti coagualtion

AFE - previously high mortality rate , now 16-30% due to better intensive care and recognition of the fact that milder cases do occur

Recommendations- awareness of the need for thromboprophylaxis for at risk cases.- quality assurance checklists to evaluate the number of at risk mothers

who actually receive thromboprophylaxis.- objective tests should be performed to evaluate all cases of suspected

DVT and PTE- D-dimer assays can be used as a quick test to help decide on cases

which may requre objective testing- Amniotic fluid registry could help improve our understanding on this

condition- MO’s need to be aware of a possible AFE if the baby is born in a

sudden unexpectedly poor condition- A multidisciplinary approach to resuscition of the collapsed patient

provides best results

Home delivery

Cause - majority were PPH due to retained placenta and uterine atony. There were also death due to uterine rupture

<20% conducted by trained staff

Recommendations- Should be discouraged- All delivered by trained staff- ABC - alternative for those who refuse hosp.

delivery, only low risk- Those from remote areas brought out and housed

near ABC/health centres- Flying squad in remote areas to retrieve mothers

Heart Diseases in PregnancyMajority of deaths in post partum periodCommonest pathology - RHD with MSHealth care provider must understand changes in pregnancy -proper history taken and examination done-once diagnosed -investigate-ECG,Echo,CXRMost cases - patient or spouse does not volunteer the relevant history at

antenatal visits- Doctors fail to examine heart or misses findings- Pathological murmurs mistaken for physiological ones

Ideally- seen in preconception clinic- Contraceptive advice - permanent contraception in those

with Eisenmenger’s syndrome, pulmonary hypertension and cardiomyopathy

- manage in combined clinic

HIV/AIDS Increasing trend in many Asian countries 12 deaths ‘97-’00 They were in an advanced stage of their disease at the

time of presentation for antenatal care or for delivery Oral thrush/respiratory symptoms were primary

presentation Diagnosis was delayed in 50% of cases In those known HIV cases management was inadequate Majority had no knowledge of their seropositivity prior

to pregnancy and also they were from lower socio-economic stratum and had lower education level

Utilisation of point-of-care HIV testing during labour should be seriously considered for those who present with no prior HIV testing prenatally, so that not to deny the unborn child of the benefit of antiretroviral therapy intrapartum to reduce maternal to child transmission.

Benefits of CEMD

1.Improvement in the reporting system of maternal deaths.Since the CEMD was established in’91, it has succeeded in enhancing data capture on maternal deaths.

2. Changing trends in maternal deaths.Direct maternal death:81%(’91) to 63%(’94), 58.1%(’96) and 56.4(‘00). Indirect: 8%(’91) to 15% (’96), 10.5%(‘00)

Cont…

3. Impact on policies and practices.Specific financial allocation for purchase of equipments &

improvement of the Ix system have been made after the CEMD was started.

Various policies,strategies & specific were developed such as:

Cont…

A. Infrastructure strengthening:Alternative birthing centre.Improvement of communication.Equipment.Training –national/state level, training curriculum,

educational materials/training modules.

Cont…

B. Improvement of work process.Use of partogram for home deliveries.Home based maternal health records.Development of mx protocols.Establishment of combined clinics.Identification of areas for further research.