Maternal mortality

Maternal mortality

• 1.
  Maternal Mortality Understanding theBiological and Social Contexts Jeromeo Jose 11382333 Biological and Social Foundations of Health MAHESOS
• 2.
  The great divideof Maternal Mortality Everyday, 800 women die from pregnancy and childbirth Developing countries Developed Countries 99% • Who are the most susceptible? – Women living in rural areas and poor communities – Young adolescents – Women who do not receive care (pre, during and post)
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  The Philippine Context 162 221 0 50 100 150 200 250 '08'09 '10 '11 Philippines Maternal Mortality RP MDG Source: Department of Health
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  What do wemean by maternal death? • a maternal death is 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 (ICD-10)
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  Medical causes ofdeath and treatment (WHO, 2011) • Post partum hemorrhage – World’s leading cause of maternal mortality – 127,000 maternal deaths annually – may cause up to 50% percent of all maternal deaths in developing countries – Medicines • Oxytocin: 10 IU in 1-ml ampoule • Sodium chloride: injectable solution 0.9% isotonic or Sodium lactate compound solution – injectable (Ringer’s lactate)
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  Medical causes ofdeath and treatment (WHO, 2011) • Severe Pre-eclampsia and Eclampsia – Major health problems in developing countries. – Every year, eclampsia is associated with an estimated 50 000 maternal deaths worldwide. – Medicines • Calcium gluconate injection (for treatment of magnesium toxicity): 100 mg/ml in a 10-ml ampoule • Magnesium sulfate: injection 500 mg/ml in a 2-ml ampoule, 500 mg/ml in a 10-ml ampoule
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  Medical causes ofdeath and treatment (WHO, 2011) • Maternal sepsis – Infection can follow an abortion or childbirth and is a major cause of death. – Sepsis not related to unsafe abortion accounts for up to 15% of maternal deaths in developing countries. – Medicines • Ampicillin: powder for injection 500 mg; 1 g (as a sodium salt) in vial • Gentamicin: injection 10 mg; 40 mg /ml in a 2-ml vial • Metronidazole: injection 500 mg in a 100-ml vial • Misoprostol: tablet 200 μg
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  Medical causes ofdeath and treatment (WHO, 2011) • Sexually transmitted infections – Nearly a million people acquire a sexually transmitted infection, including HIV, every day. – The results of infection include acute symptoms, chronic infection, and serious delayed consequences such as infertility, ectopic pregnancy, cervical cancer, and the untimely deaths of infants and adults. – Medicines • Uncomplicated genital chlamydial infections: Azithromycin: capsule 250 mg; 500 mg or oral liquid 200 mg/5 ml • Gonococcal infection – uncomplicated anogenital infection: Cefixime: capsule 400 mg • Syphilis: Benzathine benzylpenicillin: powder for injection 900 mg benzylpenicillin in a 5-ml vial; 1.44 g benzylpenicillin in a 5-ml vial
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  Maternal Death Review 18deaths in 82 LGUs (9 audited cases) Top causes of maternal deaths Placenta Previa/PPH Eclampsia Sepsis others 56% 22% 11% 11% Gravida Status Gravida Percentage Prima Gravida 11% 2 – 4 33% Multi Gravida 53% Interventions: Preventive measures: 1. Map catchment areas 2. Augment human resources (competency & number) / health facilities /equipment 3. Implement well-coordinated referral and return referral systems, including transportation to and from home to facility 4. Improve access to medicines for obstetric emergencies like anti-hypertensive meds 1. Pregnancy Tracking System, early detection of high-risk patients 2. Birthing plans for high-risk patients 3. Skills Training (BEMONC, Life-saving Skills) for birth attendants 4. FP counselling and access to FP commodities Referral Hospital 44% RHU/ BHS 12% Home 44% SBA=67% vs Hilot=33% Hilots now referring pregnant women albeit usually late Maternal Deaths
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  Systems Approach toaddressing Maternal Mortality • 6 Building Blocks (Technical) – Governance, Human Resource, Financing, Medicines, Health Info, Service Delivery. (WHO) • Local leadership is the key to changing systems and innovating programs that lead to better health outcomes (ZFF, 2012) – Focused on Mayors and MHOs who decide to change the health system, through meaningful engagements and new arrangements with other stakeholders.
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  Road Map • Away to analyze the health situation in municipalities including gaps and challenges • A road map to weigh options and set priorities • A scorecard to measure accomplishment. Intervention on Health Systems Transformation: Municipal Basic Health System’s Technical Roadmap Leadership & Governance Health Financing Health Human Resource Access to Medicine & Technology Health information System Health Service Delivery MunicipalHealthGovernance Municipal Health Action Plan HealthResourceGenerationand Management LGU Budget for Health (15% IRA) RHUandBHSResourcemanagement Health Human Resource Adequacy at the RHU (MD 1:20,000) (Nurse 1:20,000) DrugManagementSystem Presence of Essential Medicine at the RHU (Stock Basis) DataCollection,UtilizationandInformationDissemination Accomplished Baseline Data Collection BarangayHealth Infrastructure Presence of Barangay Health Stations (1 BHS:1 Braangay or 1 BHS per Catchment) Maintenance and Operations Utilization Actual budget Utilization (95% Utilization) RHU HHR Competency Available Transportation for Emergency Regular Data Gathering and Recording MaternalandChildCare Sustainable Maternal Health Care Initiatives Pre-Natal Services (at least 80%) Full Implementation of Magna Carta for Public Health WorkersExpanded and Functional Local Health Board Facility-Based Devleiries (85%) BLGU Health Budget (5% of Barangay IRA) Skilled Birth Attendants (85%) Installed Performance Management System Sustainable Breastfeedi ng Initiatives Exclusive Breastfeeding for Infants (70%) RHU Medicine Tracking and Inventory System Maternal/Infant Death Review Newborns Initiated Breastfeeding (85%) BarangayHealthGovernance Functional Barangay Health Governance Body (with functional CHT) LocalPhilhealthAdministration 4-in-1 Accreditation Sustainable Essential Intrapartum and Newborn Care Initiatives Health Human Resource Adequacy in BHS (1 Midwife: 1 Brgy; with consideration to GIDA) (BHW to HH 1:20HH) Sustainable Infant and Child Care Initiatives Fully Immunized Child (95%) Regular IEC for Enrolled Indigent (for Q1 and Q2) Monthly Updated Health Data Board Under-5 Malnutrition Prevalence Rate (Below 17.3%) BHS HHR Competency (Basic BHW Training Course and CHT Training) Accomplishment, Utilization and Dissemination of the DILG, DOH LGU Scorecards ReproductiveHealth Sustainable Adolescent Reproductive Health Initiatives Reimbursement Filing (PCB, MCP, TB- DOTS) Sustainable Family Planning Initiatives Provision of FP Commodities and Services (RHU) Implemented and Integrated Barangay Health Plan Contraceptive Prevalence Rate (63%) System for BHW Recruitment and Retention Mechanisms Creation of Citizen’s Chrater Ordinance and System for Claims Disposition and Utilization Monitoring Ratio of Community- Based Pharmaccy (1 BNB/CBP catchment or 1 BNB per barangay) Unmet Needs (50% under NHTS) WaSH Sanitary Toilets (86%) Ordnance and Timely Provision of BHW Honorarium Access to Safe Water (87% of HH)
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  Progress of LGUsvis-a-vis building blocks Leadership & Governance Majority have reactivated and expanded membership of their local health boards Activating barangay health boards a work in progress in most LGUs Human Resources Most have hired additional personnel but ideal ratios have yet to be met Financing 33 of 82 (40%) LGUs have 4-in-1 Philhealth accreditation Non-ARMM LGUs have increased health budgets to 10% or above Still working on having barangays raise their health budgets to 5% Continuous & close coordination with DOH-ARMM & Philhealth led to release of much-needed reimbursements to LGUs in the region
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  Medicines Procurement and inventorysystems have been fixed at the RHU but availability of medicines in barangay health stations needs to improve in cohorts that have ended the 2-year partnership Accessibility, procurement & inventory systems are being improved in other LGUs Service Delivery LGUs have created their own innovative programs to address issues Information systems Systems of reporting & recording have improved Need to improve ability to analyze data Need to strengthen mortality audit system Progress of LGUs vis-a-vis building blocks
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  Health Outcomes (SLAM,Cohort 3) 207 73 153 106 70 212 0 50 100 150 200 250 '08 '09 '10 '11 '12 '13 SLAM and Cohort 3 MMR Cohort 3 SLAM 141 68 41 0 Cohort 3 Sources: FHSIS for ZFF ARMM municipalities
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  Working on HealthSeeking Behavior 2.47 5.30 5.94 16.96 22.12 16.52 14.91 33.62 2.47 5.30 12.99 15.59 29.44 0 5 10 15 20 25 30 35 40 '08 '09 '10 '11 '12 Facility Based Deliveries Trend (ARMM) Cohort 1 Cohort 3 ARMM Cohort 51.44 49.12 39.74 41.88 34.21 73.41 69.53 72.41 51.44 49.12 62.18 60.31 59.68 0 10 20 30 40 50 60 70 80 '08 '09 '10 '11 '12 Deliveries Attended by Skilled Birth Attendants (ARMM) Cohort 1 Cohort 3 ARMM Cohort Sources: FHSIS for ZFF ARMM municipalities
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  Conclusions • Medical andsocial factors are important to be understood. • There is a technical solution that can be implemented – medical response, strengthening the health system (6BB) • Leadership will ensure that more stakeholders gain ownership of the issue.
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  No mother shoulddie giving life...