Epidemiology of Maternal and
Neonatal Mortality in Malawi
Dr. Chisale Mhango FRCOG
NPC Training in MNH
1
MATERNAL MORTALITY IN LOW RESOURCE
COUNTRIES: How to accelerated reduction
Objectives:
• Understand the issues relating to
MMR
• Review Global and Local Progress on
Reduction of MMR
– Key article from The Lancet
• Discuss effective strategies
Outline of presentation
1.
2.
3.
4.
Definitions of terms
Global and Local Trends in MMR and NNM
Causes of maternal and neonatal mortality
Current data on place of delivery in
Malawi
5. Coverage for Skilled Birth Attendants in
Malawi
6. Rationale for new roles for TBAs
NPC Training in MNH
3
Statistical measurements..
Definitions
Maternal Mortality Number of
Ratio
maternal deaths
during a given
period per 100,000
live births during
the same timeperiod
Maternal Mortality
Rate
Adult life time risk
of maternal death
Number of
maternal deaths in
a given period per
100,000 women of
reproductive age
during the same
time-period
The probability of
dying from a
maternal cause
during a woman’s
reproductive
lifespan.
Alternative definition of MD in ICD10 (1992)
Pregnancy-related
death
The death of a woman
while pregnant or within
42 days of termination of
pregnancy, irrespective
of the duration or the
site of the pregnancy,
from any cause related to
or aggravated by the
pregnancy or its
management but not
from accidental or
incidental causes.
Late maternal death
The death of a woman
from direct or indirect
obstetric causes, more
than 42 days but less
than one year after
termination of pregnancy.
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Definitions cont…
Neonatal mortality
rate
Number of deaths
within 28 days of life
per 1,000 live births
Early neonatal mortality
rate
Number of deaths
within 7 days of life per
1,000 live births
Infant mortality rate
The difference
between infant and
neonatal mortality
Number of deaths
within the first 12
months of life per 1,000
live births
Under-5 mortality rate
The probability of
dying between
birth and the fifth
birthday
Number of deaths
within the first five years
of life per 1,000 live
births
Child mortality rate
Number of deaths
within the first five years
of life per 1,000 children
surviving to 12 months
5
of age.
Definitions and Statistical measurements..
Neonatal mortality The probability of
dying within the
first month of life
Infant mortality
Post-neonatal
mortality
Under-5 mortality
Child mortality
The probability of
dying before the
first birthday
The probability of
dying between the
first and fifth
birthday
Methods of defining
Maternal Mortality
Millennium Development Goal 5: Improve
Maternal Health
 Target 5.A:
 Reduce by 3/4, between
1990 and 2015, the
maternal mortality ratio
 Indicators:
 Maternal mortality ratio
 Proportion of births
attended by skilled health
personnel
 Target 5.B:
 Achieve, by 2015, universal
access to reproductive
health
 Indicators:
 Contraceptive prevalence
rate
 Adolescent birth rate
 Antenatal care coverage
 Unmet need for family
planning
Millennium Development Goal 4:
Reduce Child Mortality
Target 4:
 Reduce by 2/3, between 1990 and 2015, the child mortality rate
Indicators:
 Under-five mortality rate
 Infant mortality rate
 Proportion of 1 year-old children immunized against
measles
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The Lancet Article
Maternal mortality for
181 countries, 1980–
2008:a systematic
analysis of progress
towards Millennium
Development Goal 5
Margaret C Hogan, Kyle J Foreman, Mohsen
Naghavi, Stephanie Y Ahn, Mengru Wang, Susanna
M Makela, Alan D Lopez, Rafael Lozano, Christopher
J L Murray
Volume 375 May 8, 2010, pp. 1609-1623.
Map of Priority Countries
Global Situation
• 180-210 million pregnancies annually
• 80 million unwanted pregnancies
• 50 million induced abortions
• 20 million unsafe abortions
• 68,000 deaths from unsafe abortion
• 20 million women suffer from maternal morbidity
• Estimated 350,000 to 450,000 maternal deaths
• 3million babies are born dead
• Almost 10 million children under age of 5 die
• Of which 3 million newborns die within the first week
• 500,000 infants are infected with HIV
Every Single minute…
…380 women become pregnant
…190 women face an unplanned
or unwanted pregnancy
…110 women experience
pregnancy-related complications
…40 women have an unsafe abortion
…1 woman dies
MM WHO estimates
MM WHO… Estimates
Maternal Mortality:
The latest data
• For the first time, new data indicate that we are seeing real progress in
reducing maternal mortality worldwide.
• A new study published in The Lancet in May 2010 revealed that the
number of women dying from pregnancy-related causes has declined
from 526,300 in 1980 to 342,900 in 2008.
• The finding contradict previous research which showed very little
change in reducing maternal mortality, and represent a powerful
opportunity to show that investments to reduce maternal mortality
actually work.
“These numbers should now act as a catalyst, not a brake, for
accelerated action on MDG-5, including scaled-up resource
commitments. Investment incontrovertibly saves the lives of women
during pregnancy.” Richard Horton
Source: Hogan MC et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium
Development Goal 5. The Lancet 2010: published online April 12. doi:10.1016/S0140-6736(10)60518-1.
Current Situation
6 Countries Account for 50%
of Maternal Mortality
- India
- Afghanistan
- Nigeria
- Ethiopia
- Pakistan
- Democratic Republic of
the Congo
Countdown to 2015
Trends in MMR in Malawi
1200
1120
984
Deaths/100,000 live births
1000
800
675
620
600
400
200
0
1992'
2000'
2004'
2010'
2015'
Yr. of DHS Study
NPC Training in MNH
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Trends in Maternal Mortality in Malawi:
UN Estimates with extrapolation to 2015
1000
910
900
830
770
800
Maternal Mortality Ratio
700
620
600
510
500
400
300
200
100
0
1990'
NPC Training in MNH
1995'
2000'
2005'
2008'
2015'
19
Trends in Under-5 Mortality Rate (top line) and
Infant Mortality Rate (lower line) in Malawi
250
234
200
150
189
134
133
122
112
104
100
79
72
66
50
0
1992'
2000'
2004'
2006'
2010'
2015'
20
Neonatal Mortality Rate in Malawi
Trends in NNMR in Malawi
35
33
31
30
27
Deaths/1000 live births
25
20
15
10
5
0
2000'
2004'
2010'
Yr. of DHS survey
NPC Training in MNH
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Causes of Maternal Mortality
Main direct causes of maternal deaths
in Malawi
1.
2.
3.
4.
Haemorrhage after childbirth (27%)
Sepsis after childbirth (23%)
Hypertension of Pregnancy (17%)
Complications of unsafe abortion (16%)
ALL THESE CONDITIONS ARE COMMONEST WITH
CHILDBIRTH OR ABORTION OUTSIDE HEALTH
FACILITIES
NPC Training in MNH
Source: MDHS2010
23
Main causes of neonatal deaths
1. Birth asphyxia
–lack of resuscitation skills at birth
2. Low birth weight
–Prematurity leading to
• Cold injury
• RDS
–HIV
3. Severe infections
–Home births
NPC Training in MNH
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Time of Death
Key strategies
to reduce maternal mortality
Access to
contraceptives, to
avoid unintended
pregnancies
Access to skilled
care at the time of
birth
Timely access to
emergency obstetric
care in the event of
complications
What factors are driving
maternal mortality in Malawi?
Not only medical issues, but also a social,
economic, political and human rights issues
•
Poverty
– No food security
•
Low female literacy rates
– Cultural factors
•
High fertility rate
•
Poor functioning health infrastructure
– Contraceptive services
–
–
–
–
•
Insufficient focus on quality of care
Inadequate number of skilled health workers.
Physical infrastructure
Basic tools of the trade
Slow adoption of evidence based policy
“I am going to fetch a baby.
The journey is dangerous
and I may not return …”
Maternal Mortality:
The Link to Family Planning
• The Lancet study data indicate that the global decline in
fertility is a key contributing factor to the decline in maternal
mortality.
• Societies in which the total fertility rate has decreased are also those in
which maternal mortality has decreased.
Global decline in total fertility rate (TFR)
3.70
3.26
2.56
I__________________I_________________I
1980
1990
2008
Trends in CPR in Malawi
60
50
MMR/100,000 live births
42
40
30
26
28
20
10
7
0
1992'
2000'
2004'
2010'
2015'
Year of Study (DHS, MICS2006)
29
Skilled attendance at birth
saves mothers and babies
WHO
April 2005
Skilled attendance at childbirth
is the most effective intervention
Access to skilled birth attendants
About 35 % of pregnant women in
developing countries have no access
to, or contact with, health personnel
before delivery, and
only 57 % give birth with
a skilled attendant
present.
Access to emergency obstetric care
 42 % of all pregnancies everywhere experience a complication.
In 15 % of all pregnancies, the complications are life-
threatening.
 61 % of maternal deaths occur just before, during, or just after
delivery, often from complications that cannot
be
predicted and are difficult to prevent
 Therefore… it is critical that every woman have access to
emergency obstetric care











Why Women Do Not Access
Health Services?
Distance from health services
Lack of transportation
Cost
Multiple demands on women’s time
Lack of decision-making power within
the family
Attitude of health care providers
Limited access to education
Inadequate health care services
Discriminatory or inadequate laws or
health care policies
Culture
Community
Reasons for decrease
of maternal mortality
•
•
•
•
Global decrease in Total Fertility Rate (TFR)
Increase of income in low-income countries
Increase in maternal education
Increase in skilled birth attendants from approximately
25% to 45–55%
1. What Interventions Work?
Cause of Death
% of Deaths
Known Successful Interventions
Haemorrhage
24-35% of maternal
deaths
- Oxytocin and Misoprostol are medications that can prevent or stop bleeding
during and immediately following delivery.
- Controlled cord traction and uterine massage are known techniques to stop
postpartum bleeding.
- Skilled attendants are necessary to administer medication or perform techniques.
Unsafe Abortion 9-13% of maternal
deaths
- Family planning information and access to contraception and reproductive health
supplies are needed to prevent unintended and unplanned pregnancies.
- Where legal, effective reproductive services include the availability of safe
abortions conducted by trained healthcare providers using proper techniques
under sanitary conditions.
- Post-abortion care including emergency treatment for complications from
spontaneous or induced abortion, follow-up and referral to other reproductive
health services.
Infections (e.g.
Sepsis,
pneumonia,
tetnus)
8-15% of maternal
deaths, 29-36% of
newborn deaths,
46% of child deaths
- Antibiotics and immunizations are critical to treat infections in women and
children.
- Hygienic delivery and postpartum care in a health facility can prevent infections in
mothers and newborns.
- Treatment by a skilled health care provider near children’s homes.
Eclampsia &
Hypertensive
Disorders
12% of maternal
deaths
- Magnesium Sulphate can be administered by skilled attendants as an effective,
safe and inexpensive medication that reduces the risk of eclampsia and maternal
death caused by pregnancy-related hypertensive disorders.
2. What Interventions Work?
Cause of Death
% of Death
Known Successful Interventions
Obstructed
Labour
8% of maternal
deaths
- Caesarean section by trained, skilled attendants can perform this surgical
procedure to ensure safe childbirth when obstructed labour or other complications
make vaginal birth impossible or unsafe for the mother and baby.
- Access to proper nutrition can help prevent obstructed labour by ensuring proper
growth and development in women.
Asphyxia
23% of newborn
deaths
- Increasing maternal nutrition reduces the likelihood of low birth weight, a
significant factor in causing birth asphyxia.
- Presence of a skilled attendant to provide immediate care after delivery.
Diarrhoea
24% of child
deaths, 2.4% of
newborn deaths
- Treatment by a skilled health.
- Oral rehydration therapy using oral rehydration salts, home fluid and food intake
guidelines.
- Increased sanitation and access to clean water.
Malaria and
HIV/AIDS
15% of child
deaths
19% of women’s
deaths (AIDS)
- Treatment by a skilled health care provider.
- Use of insecticide-treated nets and region-specific antimalarial medicines.
- Preventing Maternal to Child Transmission (PMTCT) counseling and ARVs
-Treatment with ARVs for women
Nutrition-related
disorders
35% of child
deaths
- Access to proper, age appropriate nutrition sources.
- Encouraging breastfeeding from 1-hr after birth through 6 months of age.
- Vitamin A supplements.
3. What Interventions Work?
childbirth

Access to quality care
– - Antenatal care
for
pregnancy and childbirth
– - Skilled attendance at birth, including

- Antenatal
care and neonatal care
emergency obstetric
–
- Immediate
postnatal care for
- Skilled
attendance
atmothers
birth,
and newborns
including
emergency obstetric
and neonatal care
Access to family planning
-– Immediate
- Counseling postnatal care for
–
- Services and newborns
mothers
–
- Modern contraception
 Access to family planning
 Access to safe abortion (when legal)
- Counseling
- Services
- Modern contraception
 Access to safe abortion
(when legal)
 Strong health systems
– - Scaling-up critical health
interventions
– - Training health care
professionals
– - Training of mid-wives
 Accelerated access to life-saving,
interventions, medicines and
vaccines
– - Vaccines to target pneumonia,
tetanus, and diarrhea
– - Prevention, screening and
treatment of HIV and STIs
– - Treatment and prevention of
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malaria, pneumonia and diarrhea
COVERAGE FAILURES ACROSS
THE CONTINUUM OF CARE GLOBALLY
For some
interventions:
• Family planning
• Exclusive
breastfeeding
• Clinical care for
newborn and child
illnesses
In some
countries:
• Wide gaps in coverage
across countries
Coverage estimates for interventions across the continuum of care in the 68
priority countries (2000-2006).
Vertical bars indicate the range in coverage across countries.
Place of Delivery in Malawi
URBAN
1.
84% in health facilities
a.
85% had skilled attendance at
birth
2.
For all Malawi 72% delivered
in health facilities
3.
98% women with tertiary
education had skilled
attendance at childbirth
compared to 63% women
without education.
NPC Training in MNH
RURAL
1. 71% in health facilities
a.
70% had skilled attendance at
birth
2. For all Malawi, 73%
women had skilled
attendance at childbirth
Source: MDHS 2010
39
Which women and newborns were
dying the most in Malawi?
Mothers
• Women who delivered or
procured abortion outside
the health facilities,
especially when they
developed, PPH, PIH and
sepsis
– Women who developed these
complications while in health
facility, had treatment
initiated earlier and were less
likely to die.
NPC Training in MNH
Neonates
• Babies born without skilled
attendant present at birth.
– Suffered the most from birth
asphyxia, cold injury and
infection, especially if they
were under weight or
premature
40
Rationale for Change of TBA roles
1. International WHO and local studies revealed
that investment in TBAs did not contribute
significantly to reduction of maternal and
neonatal deaths
2. The option of TBA births prevented the scale
up of skilled attendance at child births
– As soon as the TBA option was removed in
Malawi, health facility births soared, distance of
health facility had been overestimated
NPC Training in MNH
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Trends in Skilled Attendance at Birth in Malawi
Institutional Birth Coverage in Malawi
80
75
72
70
66
67
62
%
c
o
v
e
r
a
g
e
60
55
55
1992*
2000*
57
59
50
40
30
20
10
0
Year of NSO
2004*2005'
study 2006' 2007' 2008' 2009'2010*
2015'
NPC Training in MNH
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There is no better time
to reduce maternal and child
death in Malawi - Commited
leadership critical
References/reading
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•
•
•
•
•
•
•
•
•
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•
•
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