maternal n perinatal mortality - RADFORD.ppt

It's about maternal and perinatal mortality, the causes , the epidemiology nd the prevention

1. MATERNAL & PERINATAL MATERNAL & PERINATAL
MORTALITYMORTALITY
DR. HENRY XORSENYO KPELIDR. HENRY XORSENYO KPELI
BSc., MBCHB, Resident – OBGYN, GCPSBSc., MBCHB, Resident – OBGYN, GCPS
Part-time lecturer, OBGYN –RADFORD UNIVERSITYPart-time lecturer, OBGYN –RADFORD UNIVERSITY

2. OBJECTIVES
To define maternal and perinatal mortality.
To state the maternal and perinatal rates.
To identify the causes of maternal and perinatal mortality.
To outline preventive measures for maternal and perinatal
mortality.

3. MATERNAL MATERNAL
MORTALITYMORTALITY

4. MATERNAL MORTALITY
 For both mother and baby, childbirth can be the most dangerous
moment in life.
It is estimated that 585 000 maternal deaths occur per year with
99% in developing countries.
 The heaviest burden is in sub-Saharan Africa.
 Of the 20 countries with the highest maternal mortality ratios, 19 are in
sub-Saharan Africa.

5. DEFINITIONS
 Maternal death/MortalityMaternal death/Mortality
 This is death of a woman while pregnant or within 42
days of termination of pregnancy (regardless of the site
or duration of the pregnancy) from any cause related
to or aggravated by the pregnancy or its management
but NOT from accidental causes ( WHO )

6. DEFINITIONS
-----MATERNAL MORTALITY MATERNAL MORTALITY RATIORATIO
 Represents the obstetric risk associated with
each pregnancy
 it is the number of maternal deaths during a given
year per 100 000 live births during the same period.

7. • Globally, the maternal mortality ratio is 400 maternal deaths
per 100 000 live births.
• 1% of maternal deaths occur in the developed world.
• Maternal mortality ratios range from 830 per 100 000 live
births in African countries to 24 per 100 000 live births in
European countries.

8. DEFINITIONS
-----MATERNAL MORTALITY MATERNAL MORTALITY RATERATE
 Measures both the obstetric risk and the frequency
with which women are exposed to this risk.
 It is the number of maternal deaths in a given period
per 100 000 women of reproductive age ( usually 15 – 49).

9. MATERNAL MORBIDITY
•Maternal morbidity: The WHO Maternal
morbidity working group (2014):
“Any health condition attributed to and/or
complicating pregnancy and childbirth that has a
negative impact on the woman’s wellbeing and/or
functioning.”

10. MILLENNIUM DEVELOPMENT
GOALS
•Promote gender equality and empower women
•Reduce child mortality
•Improve maternal health

11. MDG GOAL 5: IMPROVE
MATERNAL HEALTH BY 2015
•Target 5 A: Reduce by three-quarters, between 1990 and
2015, the maternal mortality ratio
•Indicator 5.1 Maternal mortality ratio
•Indicator 5.2 Proportion of births attended by skilled health personnel
•Indicator 5.3 Contraceptive prevalence rate
•Indicator 5.4 Adolescent birth rate
•Indicator 5.5 Antenatal care coverage (at least one visit and at most
four visits)
•Indicator 5.6 Unmet need for family planning

12. HOW FAR DID WE GO IN ACHIEVING THE
MILLENIUM DEVELOPMENT GOAL 5
•As of 2015, the two regions with highest MMR were sub-
Saharan Africa (546) and Oceania (187).
•At the country level, Nigeria and India were estimated to
account for over one third of all maternal deaths worldwide in
2015, with an approximate 58 000 maternal deaths (19%) and
45 000 maternal deaths (15%), respectively

13. GLOBAL TREND FROM 2000-2017
•The global estimates for the year 2017 indicate that there were 295 000
maternal deaths; 35% lower than in 2000 when there were an estimated 451
000 maternal deaths.
•The global MMR in 2017 is estimated at maternal deaths per 100 000 live
births, representing a 38% reduction since 2000, when it was estimated at
342.
• The average annual rate of reduction (ARR) in global MMR during the
2000–2017 period was 2.9%; this means that, on average, the global MMR
declined by 2.9% every year between 2000 and 2017.

14. CAUSES OF MATERNAL
MORTALITY
Direct
Indirect
Underlying factors

15. CAUSES OF MATERNAL
MORTALITY
Direct causesDirect causes
Deaths resulting from obstetric complications of the
pregnant state, from interventions, omissions, incorrect
treatment or events resulting from any of these.
Egs haemorrhage, hypertensive disease and obstructed
labour.

16. CAUSES OF MATERNAL
MORTALITY
Indirect causesIndirect causes
Deaths from pre-existing disease arising during
pregnancy but without direct obstetric causes
and which were aggravated by the physiological
effects of pregnancy.
Egs malaria, anemia and sickle cell disease.

17. CAUSES OF MATERNAL
MORTALITY
Underlying factorsUnderlying factors
Poverty
Malnutrition
Ignorance
Illiteracy
High parity
Pregnancies at the extremes of reproductive age
Unhealthy customs and beliefs (child marriages, female genital
mutilation)

18. WHO GLOBAL CAUSES OF MATERNAL WHO GLOBAL CAUSES OF MATERNAL
DEATH (2003-2009)DEATH (2003-2009)
•Direct obstetric causes– 72.5%Direct obstetric causes– 72.5%
*Haemorrhage --27.1%
*Hypertensive disorders- 14.0%
*Sepsis—10.7%
*Abortion—7.9%
*Embolism—3.2%
*Others—9.6%
•Indirect causes—27.5%Indirect causes—27.5%

19. DIRECT CAUSES OF MATERNAL DEATH--2005
0
5
10
15
20
25
30
HYPERT HEMORRHAGE ABORTION SEPSIS
CAUSE OF DEATH
N
o
.

O
F

D
E
A
T
H
S
Series1

20. FIG. 1 DIRECT AND INDIRECT
CAUSES OF MATERNAL
MORTALITY FOR 2005

65,
63%
38,
37%
DIRECT
INDIRECT

21. CAUSES (CONT)
The 3 Delays Model
Delay in deciding to seek care
Delay in reaching a treatment facility
Delay in receiving adequate treatment at the facility
NB. Currently the delay in recognising the existence of a problem has been
added to the above.
The causes of maternal death are multifactorial hence a multidisciplinary
approach is needed to achieve prevention.

22. PREVENTION
Preconception care
Health education
Antenatal care
Supervised delivery
Postnatal care
Family planning
Post abortion care
Policy initiative
-poverty reduction strategies
-improving primary health care systems
-improving availability and access to emergency obstetric
care

23. PRECONCEPTION CARE
Purpose: to improve the prospects for safe motherhood.
Designed for non-pregnant women of reproductive age
before they become pregnant.
Aim: to detect and treat pre-existing medical conditions that
may

24. FACTORS PREDATING PREGNANCY
WITH POTENTIAL EFFECTS ON
PREGNANCY OUTCOME
•Modifiable factors
•1.Drug Abuse eg. Alcohol
•2.Medication
•3. Preexisting maternal disease
•4. Nutrition
•5. Physical exercise
•6. Psychosocial Problems
•7.Socio- economic class

25. •Unmodifiable Factors
•1.Maternal Age
•2. Maternal Parity
•3. Previous Obstetric History
•4. Maternal Parity

26. PREVENTION OF POST
PARTUM HAEMORRHAGE
ANC
-Early booking
-Identification of risk factors ( previous history of PPH,
anemia, grandmultip)
-Ensure that patient is not anemic throughout pregnancy
-Educate on good nutrition

27. INTRAPARTUM
Group and cross-match at least 2 units of blood in anticipation
Proper management of the 2
nd
stage of labour (right timing of administration of
oxytocin)
Active management of the 3
rd
stage of labour.
Repair of any perineal tears or suturing of any genital tract lacerations.
4
th
stage of labour – 20 IU oxytocin in IV infusion.
POST PARTUM
Regular monitoring of BP, pulse, temperature, urine output.
Examination of lochia.

28. HYPERTENSIVE DISORDERS
ANC
-Early booking
-Identify risk factors (nulliparity, extremes of
age, family history of eclampsia, chronic
hypertension, etc)
-Note booking BP
-Encourage regular ANC – check BP, urine
proteins
-Educate on warning signs (excessive vomiting
after 1
st
trimester, headaches, epigastric pain,
swollen legs)

29. INTRAPARTUM
-Prevent fits
-Control BP
-Delivery
POST-PARTUM
- Regular monitoring of BP, pulse, urine output

30. OBSTRUCTED LABOUR
•PRECONCEPTION CARE :
- Good nutrition for young girls or adolescents
•ANTENATAL CARE
•Early identification of risk factors
•Management by skilled practitioners
•Arrangement for elective C/S for high-risk pregnancies
•INTRAPARTUM
•Proper monitoring on partograph
•early recognition of slow progress of labour and prompt referral to a
tertiary unit.

31. UNSAFE ABORTIONS
PRECONCEPTION CARE
-Education on effective use of contraceptives
-Advice them on safe abortions
POST ABORTION CARE
Creating community awareness of the dangers and
complication of unsafe abortion
Community participation in the prevention of unsafe abortion
Treating the complications of the abortions – IVF, blood,
antibiotics, MVA or EOU, laparotomy etc
Post abortion contraception
linkage with other reproductive health services eg. Social
welfare, WAJU etc

32. PUERPERAL SEPSIS
•Aseptic techniques
•Identification of risk factors e.g. prolonged rupture of
membranes, retained products of conception.
•Give prophylactic antibiotics for women at risk of
chorioamnionitis
•ATB cover after operative delivery.

33. PREVENTION OF MATERNAL
MORTALITY
(3 DELAYS MODEL)
Improve primary health care systems
Improve availability and quality of emergency
obstetric care
-availability of drugs and supplies including blood
-upgrading essential life-saving facilitiesand equipment
-increasing staff coverage

34. PREVENTION OF MATERNAL MORTALITY
(3 DELAYS MODEL)
Improve access to health facilities
-transportation system
Socio-economic/ cultural factors
-development of poverty reduction strategies
-empowerment of women to enable them make
informed choices concerning their health
-tackling unhealthy customs and beliefs (child
marriages and FGM)

35. MATERNAL MATERNAL NEAR-MISSNEAR-MISS
•Maternal morbidity can be conceptualized as a spectrum
ranging, at its most severe, from a “maternal near miss” – to
non-life-threatening morbidity, which is more common by far.
•Maternal Near Miss is defined as “a woman who
nearly died but survived a complication that occurred
during pregnancy, childbirth or within 42 days of
termination of pregnancy) based on markers of organ
dysfunction”.

36. NEAR MISS APPROACH: INCLUSION
CRITERIA 1
Severe maternal complications
• Severe postpartum haemorrhage
• Severe pre-eclampsia
• Eclampsia
• Sepsis or severe systemic infection
• Ruptured uterus
• Severe complications of abortion

37. NEAR MISS APPROACH: INCLUSION
CRITERIA 2
Critical interventions or intensive care unit use
• Admission to intensive care unit
• Interventional radiology
• Laparotomy (includes hysterectomy, excludes
caesarean section)
• Use of blood products

38. NEAR MISS APPROACH:
INCLUSION CRITERIA 3
•Signs of organ dysfunction
•Respiratory
•Cardiovascular
•Renal
•Hematologic
•Hepatic
•Neurologic
•Uterine

39. NEAR MISS APPROACH
•The ultimate purpose of the near-miss approach is to
improve clinical practice and reduce prevent-able
morbidity and mortality through the use of best
evidence-based practices.

40. PERINATALPERINATAL
MORTALITYMORTALITY

41. PERINATAL MORTALITY
Pregnancy and childbirth can be regarded as a physiological
event in the majority of women both in the developed and
developing countries of the world.
However, in some pregnancies, conditions in the mother
and the environment appear to pose serious risks to the
fetus leading to growth restriction and in some cases
stillbirth.

42. DEFINITIONS
 Stillbirth
Any fetus born with no signs of life after 28
weeks gestation.
Early neonatal death
This denotes death in the first week after birth.
 Perinatal death
Denotes stillbirth greater than 28 weeks
gestation or death of a baby within 7 days of
birth.

43. PERINATAL MORTALITY RATE
Definition
The number of perinatal deaths per 1000 live births
and stillbirths.
In the developed world: < 10 per 1000 live births
Less developed world: 25 to 60 per 1000 live births
Korle bu: 98.7 per 1000 live births
N/B: The millennium development goal that pertains to
perinatal mortality is to reduce under 5yr mortality by
two-thirds

44. RISK FACTORS
 maternal age
-Less than 15 years (risk of obstructed labour and hypertensive disease)
-Greater than 35 and grandmultip (risk of APH, PPH and abnormal fetal lie
and presentation, chromosomal and congenital anomalies)
Multiple pregnancy
associated with preterm delivery, hypertensive disorders of pregnancy
Medical conditions in pregnancy (diabetes, malaria, hypertension)

45. RISK FACTORS
Smoking and alcohol or drug abuse
Poor obstetric history
-history of stillbirth or neonatal death
-history of operative delivery
-history of low birth weight infant
Pre-term labour in a previous pregnancy
Abnormal lie/presentation – difficult or traumatic deliveries

46. CAUSES OF PERINATAL DEATH
In one-third of cases of stillbirth, the cause of death cannot be established.
IN UTERO
-Congenital malformations
-Poorly managed maternal complications eg diabetes, hypertensive
disorders and sickle cell disease.
-maternal infections and infestations (toxoplasmosis, rubella, HIV/AIDS,
gonorrhea, Group B Streptococcus)
-rhesus factor disease
 INTRAPARTUM
Complicated deliveries eg vaginal breech delivery and shoulder dystocia leading
to:
-birth asphyxia
-birth injuries including intracranial haemorrhage, rupture of abdominal viscera
etc

47. CAUSES (CONT)
Early neonatal period
-prematurity (hypothermia, hypoglycemia, respiratory distress
syndrome, PDA, necrotizing enterocolitis etc)
-infections
-barriers to rapid transfer of the sick neonate to a health facility
-harmful home care practices – discarding of colostrum, application
of unclean substances to the umbilical cord stump and failure to
keep babies warm.
-sudden infant death (cause unknown)

48. (A study of the factors affecting the survival of the ‘at risk’ Newborn at KBTH –
J.Welbeck et al)
Disease conditionDisease condition
Total casesTotal cases
No.No.
%%
Total Total
deathsdeaths
%%
CFRCFR
PrematurityPrematurity
10861086 (44.2)(44.2)329329 (64.8)(64.8)36.136.1
Long gestationLong gestation
152152 (6.2)(6.2)11 (0.2)(0.2)0.70.7
Birth asphyxiaBirth asphyxia
442442 (18.0)(18.0)114114 (18.8)(18.8)25.825.8
Respiratory distressRespiratory distress
415415 (16.9)(16.9)5959 (9.8)(9.8)14.214.2
Bacterial sepsisBacterial sepsis
1818 (0.7)(0.7)44 (0.7)(0.7)22.222.2
Neonatal haemorrhageNeonatal haemorrhage2222 (0.9)(0.9)55 (0.8)(0.8)22.722.7
Neonatal jaundiceNeonatal jaundice
7979 (3.2)(3.2)22 (0.3)(0.3)2.52.5
Pulm haemorrhagePulm haemorrhage 1010 (0.4)(0.4)11 (0.2)(0.2)10.010.0

49. Disease conditionDisease condition
Total Total
casescases
No.No.
%%
Total Total
deathsdeaths
No.No.
%%
CFRCFR
Congenital Congenital
abnormalitiesabnormalities
3737 (1.5)(1.5)88 (1.3)(1.3)21.621.6
other circulatory other circulatory
problemsproblems
2626 (1.1)(1.1)44 (0.7)(0.7)15.415.4
twitchingtwitching 1111 (0.4)(0.4)00 -- --
Pyrexia of unknown Pyrexia of unknown
originorigin
1010 (0.4)(0.4)00 -- --
othersothers 151151 (6.1)(6.1)2424 (4.0)(4.0)15.915.9
totaltotal 24592459

50. PREVENTION OF PERINATAL
MORTALITY
Health education
Preconception care
Antenatal care
Supervised delivery
Neonatal care

51. HEALTH EDUCATION
•Promote community awareness of the need for good nutrition especially in
adolescents and in pregnancy.
•Encourage patronage of maternal health services and early registration for
antenatal care.
•Family planning.

52. PRECONCEPTION CARE
-check for pre-existing medical conditions eg
anemia, diabetes and hypertension.
-Screen for nutritional deficiencies and provide
supplementation; folic acid, iron and vitamins.
-Check HBsAg and rubella antibody titres and
immunize if necessary.
-Counsel on psychosocial risk factors such as
smoking, alcohol and substance abuse and
exposure to teratogens.

53. ANTENATAL CARE
Identification of risk factors and proper management of both
high- and low-risk mothers
history-taking: establish parity, obstetric history, presence of
medical conditions, previous incidence of APH, PPH
Accuracy in pregnancy dating – will help in the diagnosis of
IUGR, reduction of post-term pregnancy and in the management
of premature labour (tocolysis and steroid therapy)
Physical examination - general assessment : pallor, short stature
(<150cm)

54. ANTENATAL CARE
Screening tests –
blood (Hb, blood group, rhesus typing),
urine, stool;
serological tests for syphilis, rubella, HIV.
Frequency of visits depending on presence of any
complication or medical condition.
Proper fetal monitoring – serial USS if indicated
Birth plan – mode of delivery & time of admission.

55. SUPERVISED DELIVERY
•Anticipatory care for high-risk mothers
•Proper monitoring on partograph
•Adequate fetal monitoring – CTG
•Presence of a paediatrician at delivery to assist with resuscitation
in high-risk deliveries

56. NEONATAL CARE
Education of mothers on breastfeeding
- timing & frequency
Avoid discarding of colostrum
Care of the umbilical cord stump
Preventing hypothermia by keeping babies warm
Avoid delay in transferring the sick neonate to a health
facility

57. At the special care unit (health facility)
-Increased vigilance of neonates
-Appropriate and adequate antibiotic therapy
-Aseptic techniques
-Oxygen therapy
-(face masks, nasal prongs, intermittent ambu bagging)
-Fluid and electrolyte support
-Nutritional support

58. REFERENCES
www.who.org
Comprehensive textbook of Obstetrics in the tropics.
Publication on perinatal mortality by J. Wellbeck et al.
Diagrams and Graphs courtesy of Dr. Damale

59. THANK
YOU.