Disclosure “IMANA is committed to providing CME activities that are fair, balanced, and free of bias. Full and specific disclosure information is provided in your handouts.” I have no relevant financial relationship(s) with any commercial interests.
Increasing a Comprehensive Awareness of Maternal Mortality Adrienne Strong, M.A. Washington University in St. Louis, Department of Anthropology Universiteit van Amsterdam
Outline of the presentation Overview of maternal mortality globally Past successes Current challenges Maternal mortality in Tanzania Research on non-clinical causes of maternal death in the health facility setting Directions for improvement and further research Conclusions
Maternal Mortality: A Global Problem
Graphic from worldmapper.org
Definition of Maternal Death WHO definition of maternal death: “Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. To facilitate the identification of maternal deaths in circumstances in which cause of death attribution is inadequate, a new category has been introduce: pregancy-related death is defined as the death of a woman while pregnant or within 42 days of the termination of pregnancy, irrespective of the cause of death.”
Direct and Indirect Causes Direct causes: "direct complication from pregnancy, birth, or postpartum related to things that were done or should have been done" major causes include--> hemorrhage, infection, eclampsia and hypertensive disorders, unsafe abortion, obstructed labor (leading to ruptured uterus), embolism, and anesthetic complications
Indirect causes: "due to a disease or condition that is exacerbated or caused by the pregnancy" i.e. heart conditions, renal disease, HIV, malaria
Past Successes
Progress has been made since the 1985 launch of the Safe Motherhood Initiative but there is much work still to be done and we must still consider the effects of severe morbidity sustained during pregnancy, birth, and the post-partum
Safe Motherhood Timeline
Safe motherhood Initiative Launched
Millennium Development Goals Adopted
• 1985
• 2000
Endpoint of MDGs • 2015
Changing Strategies Shifting policy focus since 1985 Emphasis on training local birth attendants Encouraging access to prenatal care Incorporating a rights-based approach Emphasis on skilled attendance at birth Emphasizing access to Basic Emergency Obstetric Care (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC) Evidence based interventions and policies (including capacity building for BEmOC and CEmOC)
BEmOC and CEmOC Requirements BEmOC Parenteral antibiotics Oxytocic drugs Anti-convulsants Manual removal of placenta Assisted vaginal delivery CEmOC All of the above plus safe blood transfusions and ability to perform surgery
WHO Notes General Successes Leadership and partnership Evidence and innovation Dual long- and short-term strategies Adaptation to change for sustained progress Improvements in strategies related to gender, neonatal health, nutrition, and safer motherhood Improved efforts to conduct death reviews
Continuing Challenges
Continuing Challenges In Communities Data collection Distribution of supplies and funds On-going presence of traditional/indigenous birth attendants
In Health Facilities Data collection Communication Continuing education Connection between all levels of the health care system
Continuing Challenges In Communities
In Health Facilities Blood supplies
Male involvement Transportation Skilled providers and support for them Sensitization
Improving provider skill levels Management and leadership Consistent and reliable supply of equipment and medications
Data Collection Lack of documentation Incomplete civil registery systems Lack of death certificates Misunderstanding of how to document or code deaths Misdiagnosis or incorrect attribution of cause of death
Estimates from different organizations all different Biases and purposeful withholding of data Approaching MDGs endpoint in 2015 Desire for projects to look like they are working Desire to avoid litigation Desire or need to cover-up pregnancy state, cases of unwanted pregnancies or abortions
Estimates
Estimating Maternal Mortality Rates As per the WHO document “Trends in Maternal Mortality: 1990-2013”
Overall Challenges Political will Funds and budgeting for maternal and child health care Reaching people in less densely populated areas Corruption and bureaucratic procedures Quality of prenatal care and regular attendance “Cultural” barriers
The 3 Delays Model
Delay in reaching care Delay in deciding to seek care
Delay in receiving care
Maternal Death Thaddeus and Maine, 1994
Bad experience, decides not to return
Pregnancy Ba rrie
r rr ie Ba
r
Desire for Care
Care
ri e Bar
r
Barrier
Unable to find transport
Reach Hospital
Barrier
Does not receive care
Doesn’t seek care
Seek transportation
Denied permission, no place to go
The Poverty Factor
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Poverty sets women up for many pregnancyrelated complications and puts her at risk for all three delays
The Status of Women
Other Clinical Conditions Classified as indirect causes of maternal death, may be exacerbated by the pregnancy but not directly caused by it Particularly HIV/AIDS Malaria Anemia Renal conditions Cardiovascular conditions
Maternal Mortality in Tanzania
White Ribbon Alliance Tanzania
Wajibika Mama Aishi
Political Commitment Advocating for political commitment to the promise that 50% of government health centers (secondary level of care) will provide CEmOC services Increasing per capita spending on health care Building dispensaries and health centers in every village throughout Tanzania Increasing number of health professionals who graduate from training programs each year
Social and Institutional Environments of Health Facilities
An Institutional Environment is Comprised of… Formally stated goals and mission of an organization Organization of staff, bureaucratic procedures Hierarchy Leadership Communication Involvement of staff in larger, organization-level decision making Opportunities for education and career advancement Supplies/equipment- quality and availability Budget Connection to outside organizations, the government
How Does This Affect Care? Level of provider training Supportive supervision Budget for staff, supplies, and maintenance of infrastructure Poor leadership and communication can lead to conflict between staff members Routines are hard to change Lack of creative problem solving No consistent recognition of jobs well done Difficult disciplinary procedures with few immediate effects
Examples Small but important problems Illegible handwriting, especially clinicians leads to delays, repeat tests, communication issues No lab tests done when ordered or answers not retrieved ANC clinics and inpatient
Opportunities for leadership and problem solving Interactions and communication with patients Should keep in mind disempowered populations i.e. very young, older grand multiparous women, women from villages, uneducated, etc. Patient education Basic physiological explanations of how the body works and what to expect during pregnancy and birth (i.e. what does “bado sana” mean while in labor)
Examples cont. Timely, honest, and comprehensive reviews of deaths, near misses, and cases of mismanagement What went wrong? What can we do better next time? What kinds of systems do we have to implement to make our work more efficient and effective? Follow up at all levels, including districts, to find this information Routes for asking for and addressing patient complaints Is there a transparent and easily accessible way for patients and their family members to express concerns or ask questions about the care they received? How are their concerns used to improve care?
From the Data Focus Group Discussion (n=19) What can cause a pregnant woman to die during, pregnancy, birth, or in the post-partum period? Other questions: What are the biggest difficulties at the hospital? What problems do women have when seeking care at the maternal child health clinic and during labor and birth?
WANAUME, HAWANA ELIMU NDANI YA NYUMBA MILA- (KUPENDELEA KUJIFUNGUA NYUMBANI) MAMA MJAMZITO HAJAWAHI KWENDA HOSPITALI/ GO EARLY MAMA MJAMZITO HAJAENDA KLINIKI/AMEACHA KWENDA KLINIKI KUZAA MARA KWA MARA KUTUMIA MADAWA YA KULEYVA KUTUMIA MADAWA YA KIENYEJI KUTOPELEKWA HOSPITALI KUKOSA USAFIRI KUJIFUNGULIA NJIANI KUHITAJI KUNUNUA MAHITAJI YOTE KUFANYA KAZI NGUMU UKIWA MJAMZITO/MAISHA MAGUMU UNYANYASAJI WA MANESI UKALI WA MANESI RUSHWA , MANESI WANATAKA RUSHWA MANESI KUTOKUJALI MGONJWA MANESI KUANGALIA HALI YA NDUGU MANESI KUANGALIA HALI YA MTU MWENYE PESA MANESI HUTOA MAJIBU YA KASHIFA KWA WAJAWAZITO MAMA AMEKAA MUDA MREFU MAPOKEZI, BILA KUINGIA LABOR [ROOM] KUTOKANA NA UZEMBE WA MANESI KULETA WANAFUNZI WODI YA WAZAZI/ MANESI BILA UTAALUM WA UZAZI KUKOSA HUDUMA MAPEMA KUJIFUNGUA HOSPITALINI BILA NESI
UKIMWI MALARIA MAGONJWA YA ZINAA KUVUJA DAMU NYINGI KUTOKUWA NA UZAZI WA MPANGO KUTOKANA NA UPUNGUFU WA DAMU
0
1
2
3
4
5
6
7
8
9
10
ReasonsPregnant Woman Develop Problems/ Complica ons
13%
42%
Clinical Condi ons Personal Behavior Hospital Staff 45%
Interpersonal Interactions Conflicts between providers Poor leadership skills Not collaborative; accusatory style Lack of initiative to generate new ideas and solutions Unable to effectively get genuine input from subordinates
Lack of cohesive vision for the care and services provided As generated by staff members themselves, not imposed from outside or a higher level
Results of Interpersonal Relations Care Suffers!- lack of rigor and lack of communication leads to bad outcomes Ward or clinic staff unable to work effectively as a team New ideas are not encouraged and implemented Worker burnout and decrease in motivation Decreases in staff morale Women unhappy with services and do not return or come late
In the Village Setting Different problems Severe shortage of workers Low-levels of training Lack of supplies Lack of support from district health administration LACK OF KNOWLEDGE Long distances to referral centers Low levels of supervision
The Way Forward Improving integration of health systems at all levels Improving communication within and between facilities Being mindful of the influence of social interactions on patients’ likelihood to return for care Continuing capacity building for medical interventions Improved documentation and death surveillance Continuing efforts at improving health knowledge and community participation in maternal health
Future and Continuing Research  Need more information on the functioning of local health care administration and the challenges they face from a qualitative perspective  Integrating clinical and nonclinical causes within facilities in order to increase our understanding of the confluence of events leading to maternal death
References
Bazzano, A. N., Kirkwood, B., Tawaih-Agyemang, C., Owusu-Agyei, S., & Adongo, P. (2008). Social costs of skilled attendance at birth in rural Ghana. International Journal of Gynecology and Obstetrics (102), 91-94. doi: 10.1016/j.ijgo.2008.02.004
Campbell, O. M., & Graham, W. J. (2006). Maternal Survival 2: Strategies for reducing maternal mortality: getting on with what works. The Lancet (368), 1284-99. doi: 10.1016/S0140-6736(06)69381-2
Donnay, F. (2000). Maternal survival in developing countries: what has been done, what can be achieved in the next decade. International Journal of Gynecology & Obstetrics (70), 89-97.
Gage, A. J. (2007). Barriers to the utilization of maternal health care in rural Mali. Social Science & Medicine (65), 1666-1682.
Griffiths, P., & Stephenson, R. (2001). Understanding users' perspectives of barriers to maternal health care use in Maharashtra, India. Journal of Biosocial Science , 33, 339-359.
Koblinsky, M., Matthews, Z., Hussein, J., Mavalankar, D., Mridha, M. K., Anwar, I., et al. (2006). Maternal survival 3: going to scale with professional skilled care. The Lancet (368), 1377-86. doi: 10.1016/S01406736(06)69382-3
Kruk, M. E., Mbaruku, G., Rockers, P. C., & Galea, S. (2008). User fee exemptions are not enough: out-of-pocket payments for "free" delivery services in rural Tanzania. Tropical Medicine and International Health , 13 (12), 1442-1451.
Kyomuhendo, G. B. (2003). Low use of rural maternity services in Uganda: impact on women's status, traditional beliefs and limited resources. Reproductive Health Matters , 11 (21), 16-26.
Lubbock, L. A., & Stephenson, R. B. (2008). Utilization of maternal health care services in the department of Matagalpa, Nicaragua. Pan American Journal of Public Health , 24 (2), 75-84.
Ronsmans, C., & Graham, W. J. (2006). Maternal Survival 1: Maternal mortality: who, when, where, and why. The Lancet (368), 1189-200. doi: 10.1016/S0140-6736(06)69380-X
Thaddeus and Maine (1994) “Too far to walk: maternal mortality in context.” Social Science & Medicine 38 (8): 1091-110.
White Ribbon Alliance Tanzania [WRATZ] (2014). www.whiteribbonalliance.org/national-alliances/tanzania/
World Health Organization [WHO] (2014) “Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank, and the United Nations Population Division.” WHO: Geneva, Switzerland.
Disclosure “IMANA is committed to providing CME activities that are fair, balanced, and free of bias. Full and specific disclosure information is provided in your handouts.” I have no relevant financial relationship(s) with any commercial interests.