Maternal mortality in ethiopia — Presentation Transcript

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• 1. Maternal Mortality Trend in Ethiopia Ahmed Abdella MD, MSc (PHDC) Obstetrics & Gynecology Department Addis Ababa University
• 2. Magnitude of the problem Causes of maternal death in Africa Percentage • Global Maternal Deaths: 585,000 Haemorrhage 33.9 • In Africa five direct obstetric cause Other indirect 16.7 account for 60.7% of MD: causes of deaths Sepsis 9.7 • Hemorrhage Hypertensive 9.1 • Infection disorders • Unsafe abortion HIV/AIDS 6.2 Unclassified 5.4 • Hypertensive disorders of deaths pregnancy Other direct 4.9 causes of deaths • Obstructed labor Obstructed labour 4.1 • Most of the direct causes of MD Abortion 3.9 are unpredictable and occur intra- Anaemia 3.7 partum & in early postpartum. Embolism 2.0 Ectopic pregnancy 0.5 12 May 2009 Maternal Mortality Trend in Ethiopia 2
• 3. Magnitude of the problem (cont) 14% of pregnancies suffer serious or long term complications from pregnancy-related health problems and disabilities including anemia, uterine prolapse, fistula, PID, and infertility. The poor health and nutrition of women and the lack of care also compromise the health and survival of the infants and children they leave behind 12 May 2009 Maternal Mortality Trend in Ethiopia 3
• 4. Underlying factors The underlying factors of maternal deaths and disability contribute to women’s health and nutritional problems before, during, and after pregnancy, and are integrally linked to women’s low utilization of available health services. The factors are a range of social, economic, and cultural factors include education, low social status, and lack of income and employment opportunities. Almost 90% of the maternal deaths occur in sub-Saharan Africa and Asia, making maternal mortality the health statistic with the largest discrepancy between developed and developing countries. Risk of MD: North Europe: 1:4,000 Africa 1:16. 12 May 2009 Maternal Mortality Trend in Ethiopia 4
• 5. The tragedy Most of these women die during the normal, life-enhancing process of procreation that could be prevented if adequate care were available. Maternal death is an indicator of disparity and inequity between men and women and its extent is a sign of women’s place in society and their access to social, health, and nutrition services and to economic opportunities. 12 May 2009 Maternal Mortality Trend in Ethiopia 5
• 6. Data sources Review of published and unpublished Analysis of data to generate required proportion if available such as case fatality Note: Use of total deliveries Vs live births Mid-year use if a study covers more than one year Review of maternal deaths at TAH and GMH from 2007-2009 (unpublished) 12 May 2009 Maternal Mortality Trend in Ethiopia 6
• 7. Maternal mortality and morbidity in Ethiopia Maternal Deaths: 25 000/ year Maternal Morbidity: 500, 000/ year Serious complications such as fistula, infertility, chronic pain 12 May 2009 Maternal Mortality Trend in Ethiopia 7
• 8. MMR Trend in 'Community' Studies DHS00 DHS05 2000 M M R p er 100,000 L B 1500 1000 500 0 1980 1985 1990 1995 2000 2005 2010 Years Data source: 4 10 12 13 16 26 27 28 31 12 May 2009 Maternal Mortality Trend in Ethiopia 8
• 9. Trend of Maternal Mortality Ratio in Hospitals 3000 M MR per 100,000 LB 2500 2000 1500 1000 500 0 1970 1975 1980 1985 1990 1995 2000 2005 2010 Years Data sources: 2 3 6 9 10 18 22 25 32 33 12 May 2009 Maternal Mortality Trend in Ethiopia 9
• 10. Causes of maternal deaths in Ethiopia Major causes of maternal deaths in Ethiopia are similar to most developing countries: infection, hemorrhage, obstructed labor, Abortion Hypertensive disease in pregnancy Two major changes noted: Proportions of MD ascribed to major direct obstetric causes Appearance of HIV and disappearance of infectious hepatitis in recent years 12 May 2009 Maternal Mortality Trend in Ethiopia 10
• 11. Trends in Proportion of 5 Major Causes of Direct Maternal Deaths (Hospital Data) 60.0 % of all Maternal 50.0 40.0 Deaths 30.0 20.0 10.0 0.0 1982 1983 1991 2001 2003 2008 Years Abortion sepsis Rubtured uterus & OL Hemorrhage Eclampsia & SPE 12 May 2009 Maternal Mortality Trend in Ethiopia 11
• 12. Abortion Proportion of Maternal death due to abortion shows a declining trend Earlier hospital and community studies: 20-50% of all MD deaths TAH & GMH: 2007-2009: 3 abortion deaths among 42 MD deaths (7%) 1981-82: 37 abortion deaths (26.6%) Jimma Hospital: 1980s: 40% of all the maternal death 1990s: 26.8% Case fatality rate of abortion ranges between 0.9 to 1.9% Exceptional high from TAH of 4.9% Public hospitals mainly provide PAC and little safe abortion 12 May 2009 Maternal Mortality Trend in Ethiopia 12
• 13. Eclampsia-preeclampsia Trend of proportion of eclampsia/ preeclampsia related deaths is increasing TAH & GMH: 2007-2009: 15 eclampsia-SPE deaths (35.7%) 1981-1983: 9 deaths (6.5%) Prevalence of eclampsia: 1.2% to 7.1% In most studies about 3% CFR of eclampsia generally shows an increasing trend. 12 May 2009 Maternal Mortality Trend in Ethiopia 13
• 14. Case Fatality Rate of Abortion, Ruptured Uterus and Eclampsia/SPE 40 30 % C FR 20 10 0 68 76 90 90 91 91 95 97 98 98 00 01 02 19 19 19 19 19 19 19 19 19 19 20 20 20 Years Abortion Ruptured uterus Eclampsia/SPE 12 May 2009 Maternal Mortality Trend in Ethiopia 14
• 15. Ruptured Uterus No trend change in proportion of deaths due to uterine rupture/ obstructed labor (10-34%) High than some African reports (4.1%) Underreporting due to classification of ruptured uterus-obstructed labor to hemorrhage or sepsis Case fatality rate: increasing trend From 3 to14% Similar to findings in Africa 1–13% 12 May 2009 Maternal Mortality Trend in Ethiopia 15
• 16. Hemorrhage Increasing trend in the proportion: From less than 10% to 17% (Ambo H) and 21% (TAH/GMH). 12 May 2009 Maternal Mortality Trend in Ethiopia 16
• 17. Sepsis Proportion: slight decline Infection complications are common in most of the MD classified under other causes: For example, among 24 maternal deaths in the last 2 years at TAH, 12 (50%) of them had infection complications such as pneumonia, postpartum PID, HIV, TB. 12 May 2009 Maternal Mortality Trend in Ethiopia 17
• 18. Hepatitis, HIV, Malaria Causes of Maternal Deaths in Hospitals Causes of MD in Regional & Community study 100.0 50.0 % o f a ll M a t e rn a l D e a t h s 90.0 80.0 40.0 % o f all M atern al death s 70.0 30.0 60.0 50.0 20.0 40.0 30.0 10.0 20.0 10.0 0.0 0.0 1982 1983 1991 2001 2003 2008 1982 2000 Years Years Abortion Sepsis Abortion Sepsis Ruptured uterus/OL Ruptured U & Obstructed L. Hemorrhage Hemorrhge Eclampsia-PE Other Direct OC eclampsia & PE Other DO Hepatitis Other Indirec OC Malaria Hepatitis Other IDO Malaria HIV HIV Accidental 12 May 2009 Maternal Mortality Trend in Ethiopia 18
• 19. Factors Affecting Use of Health Facilities Economic status, Delay I: Lack of information & Inadequate Educational status, knowledge about danger signals during Women’s status, Women’ pregnancy and labor Denial of pregnancy, Cultural/ traditional practices that restrict women from seeking health care Cultural factors, Lack of money Perception of illness Delay II: Out of reach of health facilities Distance Poor road & communication network Roads Poor community support mechanisms Transport Cost Delay III: Inadequate skilled attendants Quality of care Poorly motivated staff Inadequate equipment and supplies Weak referral system, procedural guides 12 May 2009 Maternal Mortality Trend in Ethiopia 19
• 20. Example: Effect of Distance Presentation in shock (TAH, 28 MD) Addis Ababa: 0.0% Out of Addis Ababa: 70% Case fatality rate of abortion Outside Jimma town: 3.6% Jimma town: 1.2% Average duration of labor among women with (Adigrat Hospital): All ruptured uterus: 60 hours, Rupture uterus and died: 80 hours 12 May 2009 Maternal Mortality Trend in Ethiopia 20
• 21. Examples: Effect of Distance (cont) Tigray community study: 80% of the maternal deaths took place at home Obstacles in more than 50% of the deaths was “Poor health seeking behaviors” and lack of transportation MD from outside of AA: 2/3 of abortion deaths 75% of ruptured uterus 8% eclampsia 29% Hemorrhage 12 May 2009 Maternal Mortality Trend in Ethiopia 21
• 22. Conclusions Though the MMR in Ethiopia might be declining, the MMR is still high: To achieve a three-fourth decline in MMR by 2015, efforts has to be strengthen 12 May 2009 Maternal Mortality Trend in Ethiopia 22
• 23. Conclusions & Recommendations: Specific issues Proportion of MD due to eclampsia/ SPE: increasing Availing magnesium sulfate for treatment of eclampsia is essential Proportion of MD due to abortion: declining The distance factor and access issue in hospital statistics may lead to underestimation Earlier studies showed that “secondary school and out of marriage” were common reasons for unsafe abortion: Expect increase with more girls going to secondary school and age marriage raising to 18 years Strengthening adolescent RH intervention: delaying sexual debut, FP, safe abortion services (legality permitted for <18 age) … PPH: Misopristol use at community level 12 May 2009 Maternal Mortality Trend in Ethiopia 23
• 24. Recommendation (cont) Ensuring skilled birth attendance at delivery Delaying marriage and first birth Prevention of unwanted pregnancy and unsafe abortion Recognize that every pregnancy faces risk and improve access to good quality maternal health services Addressing barriers to access Measure progress Maternal death review to understand the slippery road of maternal death and to enhance quality of services: strong governmental support. 12 May 2009 Maternal Mortality Trend in Ethiopia 24
• 25. Recommendations (cont) Reducing maternal mortality requires coordinated long-term efforts. Interventions are required: with families & communities, in society as a whole, in health system, and at the level of national legislation & policy. 12 May 2009 Maternal Mortality Trend in Ethiopia 25
• 26. Recommendations (cont) Addressing the causes of maternal mortality requires a well-functioning health system that encompasses all levels – from the community to referral facilities – and provides accessible good quality care. Adequate supplies, skilled personnel, and an effective system for referral and transport are particularly important for managing obstetric emergencies, which can arise suddenly and without warning. Efforts addressing underlying factors are also important to improve maternal health in the long term. 12 May 2009 Maternal Mortality Trend in Ethiopia 26