dr. paramjothi. p (frcog) senior consultant...

MATERNAL MORTALITYIssues, Challenges & The Way

Forward

By

DR. PARAMJOTHI. P (FRCOG)Senior Consultant Obstetrician &

GynaecologistHospital Selayang

1

STATES 2009 2010 2011 (Jan. – June)

Perlis 1 3 0

Kedah 20 20 4

P. Pinang 11 13 3

Perak 18 14 8

Selangor 52 40 19

F. T KL 10 9 2

F. T Putrajaya 0 0 1

N. Sembilan 4 10 5

Melaka 3 4 7

Johor 37 25 16

Pahang 12 18 9

Terengganu 12 14 3

Kelantan 20 18 9

Sabah 67 56 32

Labuan 0 1 0

Sarawak 27 28 12

MALAYSIA 294 273 142

NUMBER OF MATERNAL DEATHS NOTIFIED TO MOH, 2009-2011 (J-J)

Maternal Deaths by Ethnic Specific

MMR in Others, Other Bumiputera, Malay & Indian are double the rate among Chinese

Source: CEMD, MoH

7

MATERNAL MORTALITY CHALLENGE

MDG 5 : IMPROVE MATERNAL HEALTH

Target 5A :

Reduce by three-quarters between 1990 and 2015, the maternal mortality ratio

Indicators :-Maternal mortality ratio-Proportion of birth attended by skilled health

8


MDG 5 : IMPROVE MATERNAL HEALTH

Target 5B :

Universal access to reproductive health by 2015

Indicators :-Contraceptive prevalence rate-Adolescent birth rate-Antenatal care coverage (1st visit & 4th visit)-Unmet need for family planning

MATERNAL MORTALITY ISSUES

HIGH RISK GROUPS

Remote communities

Orang Asli

Illegal immigrants

High Risk Pregnancies

Previous Near Misses

10

Special AttentionClose monitoring

11


HOME DELIVERIES

Low Risk..??

Screening – M.O

Tragedies Maternal Deaths

Trained / Untrained birth attendants

12


ALL DELIVERIES AT:

Hospitals

Low Risk Centres

Birth Centres

MATERNAL MORTALITY MALAYSIA

Per 100,000 live births

•1950 - 530

•1970 - 148

•1990 - 20

*Confidential enquiries started 1991

•1991 - 44.0

•1992 - 47.9

•1993 - 45.8

•1994 - 39.0

•2008 - 25.013

MATERNAL MORTALITY MALAYSIA

1992 – 1993

Place of Delivery

Home - 53.4 per 100,000

Government Hospitals - 36.1 per 100,000

Private Institutions - 20.7 per 100,000

*Home deliveries ~ 5 x more risk.

14

POSTPARTUM HAEMORRHAGE - Mx

Obstetric haemorrhage is one of leading causes of

deaths in pregnancy.

Prevention of mortality from haemorrhage mainly

depends on

PROMPT TREATMENT

of its cause to prevent further bleeding and

REPLACEMENT of BLOOD LOSS

to maintain the

CIRCULATION

16

POSTPARTUM HAEMORRHAGE - Mx

CAESAREAN SECTION

17

POSTPARTUM HAEMORRHAGE – Mx

4 Components undertaken SIMULTANEOUSLY

1. Communication

2. Resuscitation

3. Monitoring and Investigation

4. Arresting the bleeding

18


Treat the Cause:

Atonic uterus - 80%

Injuries - Genital Tract

Retained placenta

Placenta Accreta / percreta

Inversion of uterus

Rupture uterus

Disseminated Intravascular Coagulation (DIVC)

19


Atony - Hysterectomy20


Uterus - Repaired

21

SM08.222

23

ILLEGAL IMMIGRANTS

Major contributor-MM

No antenatal visits

Refuse Hospital Mx

Brought in TOO LATE

Arrested

Charged first class fees


Laws – charged

24


HEART DISEASE

One of leading causes

Mortality high Severe cases

Cyanotic Heart disease

Pre-pregnancy Counselling

BTL / Vasectomy

Adoption Fast track

25

POSTNATAL HOME VISITS

Fulfilled Quantity

Quality poor

Hospitals = Public Health

Well trained staff

Early pickup Hospitals

Family aware


26

HOSPITALS WITHOUT SPECIALISTS -1

Emergencies poorly Mx

Delays, indecisions

No specialist involment

No facilities eg: O.T


27

HOSPITALS WITHOUT SPECIALISTS -2

Upgrade

Post Obstetricians – enough being trained

Direct contact with Tertiary Centre

O.T facilities / Trained staff

Resusciate Transfer

Specialist Hospital


28

POSTMORTEMS - 1

Confidential Enquries – U.K - Success

Diagnosis / Cause of death - unknown

Home deaths / Dead on arrival

Medico - Legal

Clinicians / Forensic Pathologist

Police

Consent


29

POSTMORTEMS - 2

Compulsory

Coroner’s case

Immediately done


30


PATIENT FACTORS

Unbooked cases

Non – compliance to advice

Non – compliance to admission

Non – compliance to therapy

Ignorant; not educated

Migration

31


PATIENT FACTORS

Improve Patient Education

Patient Education to Effective care

Empower patients

Improve awareness

Tab on migrations

Compulsory Antenatal Care

32


REMEDIABLE CLINICAL FACTORS

Failure to inform seniors

Failure of combined care (Team)

Failure of communication

Failure to diagnose

Failure to appreciate severity

Inadequate, inappropriate or delayed therapy

33

OBSTETRICIANS

Resident

NHS Consultant in Labour SuiteShifts

Preform Difficult LSCS

Consultant involvement early / called-in

Obstetric Hysterectomies

MATERNAL MORTALITY RECOMMENDATIONS

34

MORBIDITY REDUCTION

No statistics

Numerous near misses

Need investigations

To reduce MMR


SeriousMorbidity

Mortality

35

RED ALERT SYSTEM

High power team - Obstetrician- Anaesthetist- Paediatrician- Blood bank- Haematologist

Alerted immediately

Every Hospital - Compulsory

PA system / Operators


36

OBSTETRIC FLYING SQUAD

High Quality Team (with Doctor)

Immediate response

Resusciate

Transport to Hospital

Helicopters – remote areas


37

MATERNAL MORTALITY PROGRESS

MDG 5 : IMPROVING MATERNAL HEALTH

MMR decline from 44 deaths per 100,000 LB (1991) to 27.3 (2008) and plateau

Contraceptive prevalence rate 52% (1984) decline to 51.9% (2004)

Proportion of births attended by skilled health personnel increased from 74.2% (1990) to 98.6% (2009)

Adolescent birth rate 28 births per 1,000 adolescents age 15-19 years (1991) to 13 (2007)

Antenatal care coverage at first visits 78% (1990) to 93.7% (2008)

PPH as a cause of maternal death (projected), 1991 - 2015

39

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Postpartum Haemorrhage 61 52 58 58 60 44 31 35 28 31 27 21 16 25 17 24 24 27 20 16 11 8 5 1 0

0

10

20

30

40

50

60

70

To

tal

Year

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Hypertensive Disorders in Pregnancy

46 29 39 37 31 30 24 32 24 13 18 18 18 12 20 22 25 14 10 8 7 5 3 1 0

0

5

10

15

20

25

30

35

40

45

50

To

tal

Year

HDP as a cause of maternal death (projected), 1991 - 2015

40

41


QUALITY MATERNAL CARE

To formulate a structured credentialing and privileging process

- for nurses and doctors who manage pregnant women in health centres & district Hospital without specialist

Advanced Diploma in Midwifery

To improve the manpower norms for MO’s and Specialist in O&G in all Hospitals

42


PRE-PREGNANCY CLINICS

To start a pre-pregnancy clinic for high risk mothers in hospitals and health centres

Establishing and running of pre-pregnancy clinics in every specialist hospital and major health centres

43


OBSTETRIC MEDICINE PHYSICIAN

To train more physicians in Obstetric Medicine and get more obstetrician in maternal medicine

Starting a sub-specialty in Obstetric Medicine and giving emphasis in maternal medicine among maternal fetal medicine specialists

44


CONTRACEPTION

Make available contraceptive methods in hospitals, beside health clinics.

Budget to allocate for contraceptive methods in hospitals

Enforce/increase promotion of FP in daily practice – out & in patient setting

Provision of health educator to promote FP-hospital & health clinic

Increase patient awareness and empowerment

Utilize patient information leaflets / checklist to enhance health education / patient empowerment

Increase HO awareness in FP

Include MEC as one of the ‘must read’ materials for O&G Houseofficerinclude this topic in O&G HO assessment

45

CONFIDENTIAL INQUIRIES - UK

1. Pre-Pregnancy Counselling

2. Professional interpretation services

3. Communications and referrals

4. Women with potentially serious Medical Condition require immediate and appropriate multidisciplinary specialists care

5. Clinical skills and training


46

CONFIDENTIAL INQUIRIES - UK

6. Specialist clinical care: identifying and managing very sick women.

7. Systolic hypertension requires treatment.

8. Genital tract infections / sepsis

9. Serious Incident Reporting and Maternal Deaths

10. Pathology


47

MATERNAL MORTALITY DIRECTIVES

DG’s EXPECTATIONS...WE MUST

There should not be more than 45 maternal deaths nationwide.....By 2015

All midwifery trained staff will be placed in O&G facilities both in the hospital and health side.....By end of 2011

Contraception is to be made available to all women of reproductive age without unnecessary hassle or questions.....By end of 2011

48



Be competent in knowledge and skills

Be community motivators and leaders

Promote practices that are beneficial to mothers and their newborns

Be able to supervise and monitor

49



Reaching the MDG 5 targets will require a clear commitment from “US”

We have the power to make profound impact

Women, families and the nation is counting on us to DELIVER on time

ACTIVITIES AND TARGET

NO. ACTIVITY INDICATOR TARGET 2011

1. Antenatal care i. % coverage new antenatal mothers

ii. % coverage antenatal mothers at 36 POG

>90.0%

2. ANC at 1st visit % of antenatal mothers seen<12 wks POG

>70.0%

3. Screening for HIV & Syphilis % antenatal mothers screened 100% (MOH)

4. ATT immunisation (MOH) % coverage ATT >80.0%

5. Anemia in pregnancy % pregnant mothers with Hb <11 gm% at 36 wks POG

<19.5%

6. SRH status of PLKN trainee % of trainee detected pregnant and referred to health clinic

100.0%

7. Surveillance of pregnant adolescents

% pregnant adolescents among new antenatal cases

Monthly report

50

CONT….NO. ACTIVITY INDICATOR TARGET 2011

8. Safe deliveries % deliveries conducted by trained personnels

> 99.0%

9. Safe deliveries among pregnant adolescents

% registered pregnant adolescents delivered by trained personnel

100.0%

10. Home visits/nursing of postnatal mothers by health staff (hospital/home)

% postnatal mothers visited on the 2nd or 3rd day after delivery

100.0%

11. Maternal mortality (KPI) Maternal mortality ratio < 25/100,000

12. Maternal mortality surveillance Notify within 48 hrs 100.0%

13. Review and follow-up maternal deaths (PPH, HDP , Hrt Dis)

Report In one month

14. Death among pregnant single mother

No. of death No death

51

STRATEGIES TO ACHIEVE MDG 5

No. Strategy

1.

2.

3.

4.

5.

6.

Strengthen referral, feedback and retrieval systems

Skills training of health care providers

Advocacy on health to women in reproductive age

groups

Family planning for high risk mothers

Implementing pre-pregnancy care

Strengthening access to sexual and reproductive

health information and services for the under

privileged groups

52

53

THANK YOU

dr. paramjothi. p (frcog) senior consultant...

Documents