dr. paramjothi. p (frcog) senior consultant .malaysia 294 273 142 ... -antenatal care coverage (1st

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  • 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

    MATERNAL MORTALITY CHALLENGE

    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

    MATERNAL MORTALITY ISSUES

    HOME DELIVERIES

    Low Risk..??

    Screening M.O

    Tragedies Maternal Deaths

    Trained / Untrained birth attendants

  • 12

    MATERNAL MORTALITY CHALLENGE

    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

  • 15

  • 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

  • POSTPARTUM HAEMORRHAGE Mx

    Treat the Cause:

    Atonic uterus - 80%

    Injuries - Genital Tract

    Retained placenta

    Placenta Accreta / percreta

    Inversion of uterus

    Rupture uterus

    Disseminated Intravascular Coagulation (DIVC)

    19

  • POSTPARTUM HAEMORRHAGE Mx

    Atony - Hysterectomy20

  • POSTPARTUM HAEMORRHAGE Mx

    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

    MATERNAL MORTALITY ISSUES

    Laws charged

  • 24

    MATERNAL MORTALITY ISSUES

    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

    MATERNAL MORTALITY ISSUES

  • 26

    HOSPITALS WITHOUT SPECIALISTS -1

    Emergencies poorly Mx

    Delays, indecisions

    No specialist involment

    No facilities eg: O.T

    MATERNAL MORTALITY ISSUES

  • 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

    MATERNAL MORTALITY CHALLENGE

  • 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

    MATERNAL MORTALITY ISSUES

  • 29

    POSTMORTEMS - 2

    Compulsory

    Coroners case

    Immediately done

    MATERNAL MORTALITY CHALLENGE

  • 30

    MATERNAL MORTALITY ISSUES

    PATIENT FACTORS

    Unbooked cases

    Non compliance to advice

    Non compliance to admission

    Non compliance to therapy

    Ignorant; not educated

    Migration

  • 31

    MATERNAL MORTALITY CHALLENGE

    PATIENT FACTORS

    Improve Patient Education

    Patient Education to Effective care

    Empower patients

    Improve awareness

    Tab on migrations

    Compulsory Antenatal Care

  • 32

    MATERNAL MORTALITY ISSUES

    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

    MATERNAL MORTALITY CHALLENGE

    SeriousMorbidity

    Mortality

  • 35

    RED ALERT SYSTEM

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

    Alerted immediately

    Every Hospital - Compulsory

    PA system / Operators

    MATERNAL MORTALITY CHALLENGE

  • 36

    OBSTETRIC FLYING SQUAD

    High Quality Team (with Doctor)

    Immediate response

    Resusciate

    Transport to Hospital

    Helicopters remote areas

    MATERNAL MORTALITY CHALLENGE

  • 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

    MATERNAL MORTALITY CHALLENGE

    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 MOs and Specialist in O&G in all Hospitals

  • 42

    MATERNAL MORTALITY CHALLENGE

    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

    MATERNAL MORTALITY CHALLENGE

    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

    MATERNAL MORTALITY CHALLENGE

    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 aware

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