A Review of Maternal Mortality Globally and Nationally

A Review of Maternal Mortality Globally and Nationally (in Nigeria and specifically, Ondo State) by Olutunde Philips

1. MATERNAL MORTALITY Olutunde Philips Owoyemi MB;BS (ILORIN) Department of Obstetrics and Gynaecology FMC, OWO Supervisor: Dr A de deji A.B

2. OUTLINE INTRODUCTION EPIDEMIOLOGY MATERNAL MORTALITY INDICATORS MATERNAL MORTALITY CAUSES THE THREE DELAYS MODEL MILLENNIUM DEVELOPMENT GOALS SUSTAINABLE DEVELOPMENT GOALS EPMM S TRATEGIES LATEST UPDATES INTERVENTION STRATEGIES CONCLUSION REFERENCES

3. INTRODUCTION Childbirth is a universal event , and i t brings joy many a times to the mother and her relatives. This is often the situation in many developed countries. In developing countries, this is not entirely so , as the journey is a perilous one , littered with many maternal deaths , and sadly, most of these are preventable. Maternal mortality is influenced by the social economic and political context of the health-care system, so as the cultural beliefs and biological realities of the women seeking care.

4. INTRODUCTION Maternal mortality is defined as 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 cause. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, (ICD-10, WHO) This definition allows identification of the cause of a maternal death, either a direct or indirect maternal cause.

5. INTRO CONT'D... Direct maternal deaths (or direct obstetric deaths) are those “resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), and from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above” . For instance, deaths due to obstetric haemorrhages, hypertensive disorders in pregnancy, or those due to complications of anaesthesia or caesarean section are classified as direct maternal deaths.

6. INTRO CONT'D... Indirect maternal deaths (or indirect obstetric deaths) are those maternal deaths “resulting from previously existing diseases or diseases that developed during pregnancy and not due to direct obstetric causes, but were aggravated by the physiologic effects of pregnancy”. For example, deaths due to aggravation (by pregnancy) of an existing cardiac or renal disease are considered indirect maternal deaths.

7. INTRO CONT'D... A late maternal death is “the death of a woman from direct or indirect obstetric causes, more than 42 days but less than one year after termination of pregnancy”. M aternal near-miss i s defined as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”.

8. EPIDEMIOLOGY From 2000-2020 , global Maternal Mortality Ratio (MMR) declined by 34% - from 339 deaths to 223 deaths per 100,000 live births according to UN Inter-agency estimates . Despite this, almost 800 women still die each day from the complications in pregnancy and childbirth. This is equivalent to 1 death in every 2 minutes . The global estimate of maternal deaths for 2017 is 295,000 with 94% (277,300) occurring in low resource countries. Sub-Saharan accounted for 66% (196,000), Nigeria accounted for 23% (67,000).

9. EPIDEMIOLOGY CONT'D In 2020, West and Central Africa have the highest MMR in the world, with 724 maternal deaths per 100,000 live births. Countries with extremely high maternal mortality ratio in 2020 are South Sudan with 1,223 deaths, followed by Chad with 1,063 deaths and Nigeria with 1,047 deaths per 100,000 live births. The lifetime risk of death from pregnancy is 1 in 49 in low income countries compared with 1 in 5,300 in high income countries.

10. Lifetime risk of death from pregnancy

11. The Sunshine State...

12. The Sunshine State... A comparative analysis of the Confidential Enquiries into Maternal Deaths in Ondo State ( CEMDOS ) over 3 year period (1st June, 2012-30th May, 2015) revealed;

13. The Sunshine State... Maternal deaths (and maternal mortality ratios) were 114 (253 per 100,000 births), 89 (192) and 81 (170), respectively per year, indicating a 33% reduction in maternal mortality ratio. Maternal Deaths in Owo LGA were 25 (21.9 % ) , 6 (6.7 % ) , 13 (16.0 % ) , respectively per year, with 44 (15.5 % ) in total. These achievements could be attributed to the multi-pronged “ Abiye ” (safe motherhood) programme instituted by the State Government between 2009 and 2015.

14. The Sunshine State... Postpartum haemorrhage, Eclampsia and Septicaemia were the leading causes of deaths.

15. MATERNAL MORTALITY INDICATORS The number of maternal deaths in a population during a specified time period reflects two factors: ( i ) the risk of mortality associated with a single pregnancy or birth (whether live or still birth); and (ii) the fertility level (i.e. the number of pregnancies or births that are experienced by women of reproductive age, i.e. age 15–49 years). The Maternal Mortality Ratio (MMR) is defined as the number of maternal deaths during a given time period per 100,000 live births during the same time period; thus, it quantifies the risk of maternal death relative to the number of live births, and essentially captures the first factor mentioned above .

16. MATERNAL MORTALITY INDICATORS By contrast, the Maternal Mortality Rate ( MMRate ) is defined as the number of maternal deaths in a given period per 100,000 women of reproductive age group (15-49 yrs) during the same period. The Maternal Mortality Rate captures both the risk of maternal death per pregnancy or per birth (whether live birth or stillbirth), and the level of fertility in the population (i.e. both factors mentioned above ).

17. MATERNAL MORTALITY CAUSES Largely preventable and broadly divided into 4 groups: Medical factors Socio-cultural factors Health service factors Reproductive factors

18. M edical F actors Haemorrhage: APH, PPH (commonest cause) Infection: P uerperal sepsis Toxaemia: PE/Eclampsia (Hypertensive disorder of pregnancy ) Labour: P rolonged/ O bstructed Abortion: C omplications of unsafe abortion Abnormal pregnancy implantation ( E ctopic) Anaesthetic procedures

19. Socio-cultural F actors Poverty Low status of women Ignorance/illiteracy Poor nutrition [in childhood, adolescence and adulthood] Religious beliefs [that act as barriers to utilization of available health services] Harmful traditional practices [e . g . Northern norm of first delivery at home, teenage marriages]

20. Health Service Causes Too numerous to enumerate: Lack of access to essential obstetric care . Lack of access to family planning [ FP ] counselling and service . Lack of drugs, blood, equipment, essential materials, instruments, consumables e . t . c in hospital . Non-availability of health workers on essential duties . Deficient transportation, communication and utility (power, water e . t . c) facilities.

21. Reproductive Health Causes A number of studies have shown that certain groups of women are at increased risk of maternal mortality. They include: Too young [<18 years] Too old [> 35 years] Too many [having 5 or more deliveries] Too frequent [having spacing of their deliveries less than 2 years apart] Too sick [pregnancies contraindicated or at very high risk to life]

22. Direct Causes of Maternal Deaths These account for about 75-80% Haemorrhage Infection/Sepsis Eclampsia/high blood pressur e Unsafe abortion Prolonged/o bstructed labour Others Haemorrhage remains the leading cause of maternal mortality accounting for over one quarter (~29%) of maternal deaths in developing countries.

23. Indirect Causes of Maternal Deaths These account for about 20-25% Malaria HIV/AIDS Hepatitis Diabetes A naemia Others Malaria is the leading indirect cause of maternal mortality in Sub- saharan Africa.

24. THE THREE-DELAY MODEL These distinguished three phases of delay have been associated with maternal mortality. 1st DELAY : This is the delay at home and community It is the delay to seek for help. It is due to lack of information about pregnancy and labour complication signals. Economic and financial means to afford cost of transportation and health care. Cultural barrier.

25. 2nd DELAY : Delay in getting to the health care facility. Poor siting of health facility. Poor road and communication network. Poor community support. Non-availability/scarcity of transport means. Inability to afford means of transport. 3rd DELAY : Institutional delay, between arrival and accessing services at the health facility. Absence of relevant health workers. Negligence of health workers. Inadequate skilled attendants. Inadequate supply of equipment and drugs. Inability to pay hospital bills.

26. THE THREE-DELAY MODEL

27. MILLENNIUM DEVELOPMENT GOALS The eight MDGs were the international development goals for the year 2015 that had been established following the millennium summit of the United Nations in 2000. Goal 5; improve maternal health Target 5a ; reduce by ¾ , between 1990 and 2015, the maternal mortality ratio Target 5b; achieve, by 2015, universal access to reproductive health

28. Success with the MDG 5 Although the MDG of reducing maternal mortality by 75% globally was not achieved, a 45% global reduction was achieved over 15 years. Ondo State is the only state in Nigeria that met the MDG indicators of reducing maternal death in the country, surpassing the goal with a 75 percent reduction. By 2016, the State 's MMR had been reduced by 84.9 % ; from 745 per 100,000 live births in 2009 to 112 per 100,000 live births in 2016 through the Abiye Initiative .

29. SUSTAINABLE DEVELOPMENT GOALS The SDGS were created by the United Nations and they are more ambitious than their predecessors. They were introduced in 2015 to consolidate on the gains made in the era of the MDGS and address lapses. There are 17 SDGS and a total of 169 targets aimed at 2030. SDG 3 : “ensure healthy lives and promote well living at all ages”

30. SDGs CONT'D... Target 3.1 : Maternal mortality; reduce to less than 70 per 100,000 live births

31. SDG Target In order to achieve this, WHO published “strategies toward ending preventable maternal mortality” ( EPMM strategies ), a direction-setting report outlining global targets and strategies for reducing maternal mortality under the SDG. The strategies aim towards a global reduction of MMR to less than 70 per 100,000, while countries should aim for an MMR not greater than 140 per 100,000 by 2030.

32. EPMM S TRATEGIES

33. EPMM Targets

34. LATEST UPDATES The global MMR in 2020 was 223 per 100,000 live births, requiring an annual rate of reduction of 11.6% to achieve the target of below 70 by 2030. In the African Region where MMR was 531 per 100,000 live births, MMR needs to be reduced by at least 20.3% each year from 2020, to reach the SDG target by 2030. In 2017, Nigeria’s maternal mortality rate was estimated at 917 per 100 , 000 live births; it increased by nearly 14% in 2020 to reach 1 , 047 deaths .

35. LATEST UPDATES CONT'D...

36. LATEST UPDATES CONT'D...

37. INTERVENTION STRATEGIES TO REDUCING MATERNAL MORTALITY Tackling the 1st DELAY through; Raising awareness in communities about the danger signs of life-threatening complications, and educating them about when and where to seek care. Encouraging families and communities to develop plans of action in case of obstetric emergencies. Raising women’s status so that they are empowered to make critical health decisions. Improving relationship between traditional birth attendants and skilled health care providers. Improving the interpersonal skills of health care providers.

38. INTERVENTION STRATEGIES CONT'D... Tackling the 2nd DELAY through; Encouraging communities to create emergency transportation plans; Upgrading roads and other transportation systems between communities and health care providers. Enhancing referral systems between communities and health care providers. Establishing maternity waiting homes.

39. INTERVENTION STRATEGIES CONT'D... Tackling the 3rd DELAY through; Upgrading the quality of care at health facilities, including improving providers’ technical and interpersonal skills, motivation, and performance. Establishing national protocols for treating obstetric complications. Training health facility staffs to recognize and admit patients with life-threatening complications. Providing 24-hour service at facilities that provide emergency obstetric care.

40. INTERVENTION STRATEGIES CONT'D... Ensuring adequate and sustainable supplies of emergency medicines, essential equipment, blood, and staffing levels at health facilities. Improving communication between the units that provide care in order to enhance care. Other interventional strategies includes; Family P lanning Improved Antenatal Care Essential Obs tetric Care Human R ight A dvocacy Free Health/ Insurance Plan for Mother & Child

41. CONCLUSION Reducing maternal deaths requires well-coordinated and sustained efforts. Sub-saharan Africa, Nigeria in particular still contributes a huge portion of the burden of the world’s m aternal mortality. Ultimately, the critical need may be one of generating sufficient political, and social will at international and national levels to overcome this avoidable tragedy, and to make motherhood safer.

42. The journey to safe motherhood.. Together, we can make it better!

43. REFERENCES Analytical Fact Sheet, by Integrated African Health Observatory. World Health Organization, March 2023. https:// aho.afro.who.int Oyeneyin, L., van den Akker, T., Durojaiye, O. et al. Confidential enquiries into maternal deaths in Ondo State, Nigeria – a comparative analysis. BMC Pregnancy Childbirth 19, 514 (2019). https://doi.org/10.1186/s12884-019-2659-y The Millennium Development Goals report. The United Nations, 2015

44. The Sustainable Development Goals report. The United Nations, 2016 Trends in maternal mortality 2000 to 2020. WHO, UNICEF, UNFPA, World Bank Group, and United Nations population Division. Geneva, World Health Organization, 2023. Strategies toward ending preventable maternal mortality (EPMM). World Health Organization, February 2015 http://www.who.int/reproductivehealth/topics/maternal_perinatal/epmm/en/

45. Cooke, Jennifer G., and Farha Tahir. "Maternal health in Nigeria." Center for Strategic & International Studies (2013). Abiye, Safe Motherhood Project. Wikipedia, 2024 https://en.m.wikipedia.org/wiki/Abiye_(Safe_Motherhood)_Project Professor. A.P. A boyeji Notes on Maternal Mortality & Morbidity: Breaking The Cycle .