Transcript GAPPS plenary - The National Academies

Reducing Maternal Mortality:
examples of health technologies
in Asia and Africa
Fifth Annual Meeting of the African Science
Academy Development Initiative (ASADI)
Ayo Ajayi,
November 10, 2009
What we know…
Africa
Asia
6.1%
12.5%
5.4%
16.7%
30.8%
33.9%
12.8%
3.7%
0.0%
6.2%
1.6%
9.1%
0.4%
4.9%
2.0%
9.1%
0.5%
9.7%
4.1%
3.9%
0.1%
9.4%
5.7%
11.6%
Haemorrhage
Hypertensive disorders
Sepsis/Infections
Abortion
Obstructed labour
Ectopic pregnancy
Embolism
Other direct causes of death
HIV/AIDS
Anaemia
Other indirect causes of death
Unclassified deaths
Country Rankings for Neonatal
and Maternal Deaths
Ranking for numbers
of neonatal deaths
Ranking for numbers
of maternal deaths
1
India
1
2
China
9
3
Pakistan
3
4
Nigeria
2
5
Bangladesh
8
6
Ethiopia
4
7
Dem. Rep. Congo
4
8
Indonesia
11
9
Afghanistan
7
10
Tanzania
6
WHO/UNICEF/UNFPA estimates of maternal mortality for 2000
Causes of Maternal Mortality in Asia
Hemorrhage is the leading cause of maternal mortality in Asia.
Hypertensive
disorder
9%
Obstructed
Labor
9%
Sepsis
12%
Anemia
13%
Hemorrhage
31%
Unsafe
Abortion
6%
Other Causes
20%
Other causes include embolism, ectopic pregnancy, anesthesia-related, include: malaria, heart disease.
Source:" WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, vol 367, April 1, 2006.
Postpartum Hemorrhage

14 million cases of postpartum
hemorrhage (PPH) per year

PPH causes up to 60% of all
maternal deaths in developing
countries

PPH often needs a quick response,
which is especially difficult if
delivery is at home, or in high
volume, low resource facilities
Case Study: Pakistan
Verbal Autopsy of Maternal Deaths in 2 Districts
Findings
Most of the deaths were:

in the lower socio-economic group

in the postpartum period (71%)

within 24 hours 40 %, mostly of PPH

in health facilities (Govt. 37, Pvt. 34)
(Sukkur & Malir districts 2004-2006)
Simple steps… a balanced
approach to PPH prevention
An evidence-based intervention for skilled
birth attendants (SBAs), combined with a
community-based strategy, can prevent 5060 % of PPH
Active management of the third stage of
labor for SBAs
 Community-based distribution of
misoprostol
Evidence Supporting Use of Oxytocin
in the Active Management of
the 3rd Stage of Labor (ATMSL)





Reduces incidence of PPH by 60%
Reduces the quantity of blood loss—thereby decreasing
incidence and severity of anemia
Reduce emergencies and related cost, transport
Reduces the use of blood transfusion
Routine use of 10 IU of oxytocin can reduce the incidence of
PPH, but it is difficult to ensure safe injection
Bristol Trial ‘88
Hinchingbrooke Trial ‘98
Active Management
50/846 (5.9%)
51/748 (6.8%)
Physiologic Management
152/849 (17.9%)
126/764 (16.5%)
OR and 95% CI
3.13 (2.3-4.2)
2.42 (1.78-3.3)
For Births That Occur Without Skilled Care
Community-based distribution
of misoprostol is an effective
strategy
Why?

We cannot predict PPH on the
basis of risk factors.

In many countries very few
deliveries are attended by a
skilled attendant.

Once severe PPH occurs, death
follows very rapidly

Timely referral and transport to
facilities is not always available
or affordable

Availability of EOC services is
grossly limited.
Eclampsia and pre-eclampsia in Kano State

In Kano state, eclampsia was the
commonest cause of maternal deaths and
contributed 46.3% of all the deaths in one
study[i] and 31.3% in another[ii].
[i] Society of Gynaecology and Obstetrics of Nigeria (SOGON). Status of emergency obstetric service
in six states of Nigeria- A needs assessment report. June 2004
[ii] Adamu YM, Salihu HM, Sathiakumar N and Alexander R. Maternal mortality in Northern Nigeria: a
population based study. Eur J Obs Gynae Rep Biol 2003; 109(2): 153-159
Patient Data
Biichi General Hospital
Danbatta General Hospital
Doguwa General Hospital
Gwarzo General Hospital
Minjibir General Hospital
Murtala Mohammed specialist
Hospital
Rano General Hospital
Rogo General Hospital
Tudun Wada general Hospital
Wudil General Hospital
Total
79
5%
8%
3%
5%
4%
799
43%
153
115
110
194
1846
8%
6%
6%
11%
100%
95
152
58
91

On the basis of the available evidence, The
World Health Organisation (WHO) has
recommended MgSO4 as the most
effective, safe and low cost drug for the
treatment of severe pre-eclampsia and
eclampsia
Provider acceptability




Whereas 77.5% of the participants have
heard of MgSO4, only 28.4% have ever
administered it
83.4% knew the drug was used for
treatment of severe
preeclampsia/eclampsia
10.7% have heard of Magpie trial
Common sources of information:
colleagues, journals and clinical instructors
Age distribution among patients treated
Highest formal education attained by the patients treated
Case Outcomes
Maternal
Alive
1643
Dead
77
89%
4.2%
Missing
6.8%
135
7.3%
1846 100%
1846
100%
Total
126
Peri-Natal
1472 79.7%
239 12.9%
MMR and attributable deaths from eclampsia comparison



Facility based MMR pre intervention (2007)
was 3195/ 100 000 live births while post
intervention (2008) was 2146/ 100 000
live births
This demonstrated a reduction in MMR of
32.8% over the one year period of the
intervention
Maternal attributable deaths from
eclampsia fell by 66% across the 10 health
facilities
Value Chain for Public Health Impact
Financial commitment and political leadership
Research
Research
Product
Regulatory
development processes
processes
Introduction
strategies
Scaled up
Effective
effective
use
use
Engagement of affected communities
Impact
Conclusion – What does this all mean?

If public health impact is our goal, we must keep the entire
value chain in mind as we identify and introduce new
interventions

Even in the world’s most remote regions, simple and
appropriate health technologies can be used to save the
lives of mothers and children

Innovation plays an important role in meeting the needs of
the most vulnerable, not just innovation in technology, but
processes and behavior change.
Acknowlegements
1. Deborah Ambruster, PATH - POPPHI Project, DC
2. Jamil Tukur & Andrew Karlyn, Population Council, Abuja
Ayo Ajayi, MD, MPH
Vice president – Field Programs
[email protected]
206.285.3500
www.path.org