Maternal health in
Emergencies and Beyond
Deepti Thomas-Paulose MD, MPH
Global Health Division
St. Luke’s Roosevelt Hospital Center
http://www.youtube.com/watch?v=oHjwc4a57Vo
http://www.youtube.com/watch?v=5g0vzs8bC8s
Outline
Definitions
 Some sobering numbers
 Direct and Indirect Causes
 EmOC
 Crisis
 Post-Emergency Phase
 References

Definitions

Maternal Mortality – death of a woman
while she is pregnant, or within 42 days of
termination of pregnancy regardless of the
site or duration of the pregnancy.
Definitions

Maternal Mortality Ratio – the number of
maternal deaths per 100,000 live births
per year. The numerator includes deaths
to women during their pregnancy or in the
first six weeks after delivery.
Definitions

Maternal Mortality Rate – the number of
maternal deaths per 100,000 women of
reproductive age (15-49). This measures
the impact of maternal deaths on the
population of women as a whole but is
generally not used in public health since
not all women are at risk for maternal
mortality—only those that are pregnant.
Definitions

Lifetime Risk of Maternal Death – the
probability of dying as a result of
pregnancy cumulative across pregnancies
in a woman's life

Obtaining accurate maternal death data is
challenging in the developing world because
accurate vital statistics are not available in many
areas (particularly rural areas), and because the
majority of births take place outside of health
facilities. Instead of using vital statistics to track
pregnancy related deaths, survey data is used
instead. Thus, these data significantly
underestimate the actual number of pregnancyassociated deaths.
Recent 2008 data estimated 342,900
maternal deaths worldwide in 2008
down from 536,000 in 2005.
They estimate that more than 50% of all
maternal deaths in 2008 occurred in six
countries: India, Nigeria, Pakistan,
Afghanistan, Ethiopia, and the Democratic
Republic of the Congo
Sobering facts
Based on 2005 data, the
average lifetime risk of a woman in a
least developed country dying from
complications related to pregnancy
or childbirth is more than 300 times
greater than for a woman living in
an industrialized country. No other
mortality rate is so unequal.
Beyond Pregnancy and
Childbirth
For every
woman who dies from causes related
to pregnancy or childbirth, it is estimated
that there are 20 others who
suffer pregnancy-related illness or
experience other severe consequences.
An estimated
10 million women annually who survive
their pregnancies experience
such adverse outcomes.
Beyond Pregnancy and
Childbirth
Almost 40 per cent of under-five deaths – or 3.7
million in 2004, according to the
latest World Health Organization
estimates – occur in the first 28
days of life. Three quarters of
neonatal deaths take place in the
first seven days, the early neonatal
period; most of these are also
preventable.
Beyond Pregnancy and
Childbirth
Lowering a mother’s risk of
mortality and morbidity directly
improves a child’s prospects for
survival. In a study
conducted in Afghanistan, 74
per cent of infants born alive to
mothers who died of maternal
causes also subsequently died.
Quality of Health Systems
Maternal mortality ratios strongly
reflect the overall effectiveness of
health systems, which in many low income
developing countries suffer
from weak administrative, technical
and logistical capacity, inadequate
financial investment and a lack of
skilled health personnel.
Top Ten Failed States 2010*
1.
2.
3.
4.
5.
Somalia
Chad
Sudan
Zimbabwe
Dem. Rep. of the
Congo
6. Afghanistan
7. Iraq
8. Central African
Republic
9. Guinea
10. Pakistan
*http://www.foreignpolicy.com/articles/2009/06/22/2009_failed_states_ind
ex_interactive_map_and_rankings
Source-UNFPA
Maternal health – as epitomized
by the risk of death or disability
from causes related to pregnancy and
childbirth – has scarcely advanced in
decades is the result of multiple underlying
causes.
The root cause may lie
in women’s disadvantaged position
in many countries and cultures, and in
the lack of attention to, and accountability
for women’s rights.
A human rights-based approach to
improving maternal and neonatal
health focuses on enhancing healthcare
provision, addressing gender discrimination
and inequities in society
through cultural, social and behavioral
changes, among other means,
and targeting those countries and
communities most at risk.
MDG 5

The reduction of maternal mortality is a
leading Millennium Development Goal
(MDG), which calls for a 75% reduction in
maternal mortality by the year 2015.

http://www.youtube.com/watch?v=mW20V
fDz6rE
Causes of Maternal Mortality
Direct Causes are those related to
obstetric complications of pregnancy, labor
and delivery, and the post-partum periods.
Direct causes account for 80% of maternal
death.
 Indirect causes are those relating to preexisting medical conditions that may be
aggravated by the physiologic demands of
pregnancy.

Direct Causes

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Hemorrhage
Accounts for approximately 25% of maternal
deaths and is the single most serious risk to
maternal health.
Blood loss during pregnancy, labor, or postpartum.
Can rapidly lead to death without medical
intervention.
Can be treated with blood transfusions,
oxytocics and/or manual removal of the
placenta.
Direct Causes

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Sepsis
Accounts for approximately 15% of maternal
deaths.
Related to poor hygiene and infection control
during delivery or to the presence of untreated
sexually transmitted infections during pregnancy.
Can be prevented or managed with high
standards for infection control, appropriate
prenatal testing and treatment of maternal
infection, and appropriate use of intravenous or
intramuscular antibiotics during labor and postpartum period.
Direct Causes
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Hypertensive Disorders
Accounts for approximately 12% of maternal deaths
Pre-eclampsia is characterized by hypertension,
proteinurea general edema, and sudden weight gain. If
left untreated, can lead to eclampsia.
Eclampsia is characterized by kidney failure, seizures,
and coma during pregnancy or post-partum. Can lead to
maternal and/or infant death.
Pre-eclampsia can be identified in the prenatal period by
monitoring blood pressure, screening urine for protein,
and through physical assessment.
Treatment available during childbirth includes the use of
sedative or anti-convulsant drugs.
Treatment of Hypertension in
Pregnancy
Unclear benefit in mild to moderate HTN
 In severe HTN, use any anti-HTN drug
available
 Load with 4 grams of IV magnesium then
1-2 grams per hour to prevent eclampsia
and also to treat seizures

Magnesium overdose

Cardiac arrest

Increased urinary calcium

Pulmonary edema (lungs
fill with fluid; can be fatal)

Visual disturbances

Decreased bone density

Respiratory depression
(difficulty breathing)

Muscular hyperexcitability

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Chest pain
Cardiac conduction
defects
Low blood pressure
Low calcium
Direct Causes

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Prolonged or Obstructed Labor
Accounts for 8% of maternal deaths.
Caused by cephalopelvic disproportion (CPD), a
disproportion between the size of the fetal head and the
maternal pelvis; or by the position of the fetus at the time
of delivery.
Increased incidence among women with poor nutritional
status
Use of assisted vaginal delivery methods such as
forceps, vacuum extractor, or performing a Caesarean
Section can prevent adverse outcomes.
CPD is the leading cause of obstetrical fistula
Direct Causes
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Unsafe Abortion
Accounts for approximately 13% of maternal
deaths.
In some parts of the world unsafe abortion
accounts for 1/3 of maternal deaths.
Approximately 67,000 cases of abortion related
deaths occur each year.
Can be prevented by providing safe abortion,
quality family planning services, and competent
post-abortion care.
Indirect Causes
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Accounts for approximately 20% of maternal
deaths.
Pre-existing medical conditions such as anemia,
malaria, hepatitis, heart disease, and HIV/AIDS
can increase the risk of maternal death.
Risk of adverse outcomes can be reduced
through prenatal identification and treatment as
well as the availability of appropriate basic
emergency obstetric care (EmOC) at the time of
delivery.
EmOC
Reproductive Health in Crisis
There are multiple competing health
priorities in an emergency, such as
addressing diarrhea, measles, acute
respiratory infections, malaria and
malnutrition
 Reproductive health needs should not be
ignored

Reproductive Health in Crisis
In any displaced population, approximately
4 percent of the total population will be
pregnant at a given time.*
 Of these pregnant women, 15 percent will
experience an unpredictable obstetric
complication, such as obstructed or
prolonged labor, pre-eclampsia or
eclampsia, sepsis, ruptured uterus, ectopic
pregnancy or complications of abortion.*

*UNFPA, UNICEF, WHO
What causes women to die from
obstetric complications?
delay in deciding to seek care;
 delay in reaching care due to
transportation difficulties; and
 delay in having appropriate care available
at the facility once reached.

The Minimum Initial Service
Package (MISP)

A series of actions needed to respond to the
reproductive health needs of populations in the
early phase of a refugee situation (which may or
may not be an emergency). The MISP is not just
kits of equipment and supplies; it is a set of
activities that must be implemented in a
coordinated manner by appropriately trained
staff. It can be implemented without any new
needs assessment since documented evidence
already justifies its use.
MISP

Prevents excess neonatal and maternal
morbidity and mortality, reduces HIV
transmission, prevents and manages the
consequences of sexual violence, and
includes planning for the provision of
comprehensive reproductive health
services integrated into the primary health
program in place.
MISP objectives and activities

1. Identify an organization(s) and
individual(s) to facilitate the coordination
and implementation of the MISP by:
ensuring the overall RH Coordinator is in
place and functioning under the health
coordination team; ensuring RH focal
points in camps and implementing
agencies are in place; making available
material for implementing the MISP and
ensuring its use.
MISP objectives and activities

2. Prevent sexual violence and provide
appropriate assistance to survivors by:
ensuring systems are in place to protect
displaced populations, particularly women
and girls, from sexual violence; ensuring
medical services, including psychosocial
support, are available for survivors of
sexual violence.
MISP objectives and activities

3. Reduce the transmission of HIV by:
enforcing respect for universal
precautions; guaranteeing the availability
of free condoms; ensuring that blood for
transfusion is safe.
MISP objectives and activities

4. Prevent excess maternal and
neonatal mortality and morbidity by:
providing clean delivery kits to all visibly
pregnant women and birth attendants to
promote clean home deliveries; providing
midwife delivery kits (UNICEF or
equivalent) to facilitate clean and safe
deliveries at the health facility; initiating
the establishment of a referral system to
manage obstetric emergencies.
The New Emergency Health Kit

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The kit provides the drugs and medical supplies
for 10,000 people for approximately 3 months. It
is designed to meet the primary health care
needs of a displaced population without medical
facilities, or a population with disrupted medical
facilities in the immediate aftermath of a disaster.
The kit includes supplies for professional
midwifery care and emergency contraception.
Clean Delivery Kits

Clean Delivery Kits consist of a square
meter of plastic sheet, a bar of soap, a
razor blade, a length of string, and a
pictorial instruction sheet
MISP objectives and activities

5. Plan for the provision of
comprehensive reproductive health
services, integrated into primary health
care (PHC), as the situation permits by:
collecting basic background information
identifying sites for future delivery of
comprehensive RH services; assessing
staff and identifying training protocols;
identifying procurement channels and
assessing monthly drug consumption.
Post-Emergency Phase
The main methods of reducing maternal
and newborn mortality and morbidity are
well established and understood.
Post-Emergency Phase
Quality antenatal care providing a
comprehensive package of health
and nutrition services.
 Preventing mother-to-child transmission
of HIV and offering antiretroviral
treatment for women in need.

Post-Emergency Phase
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Basic preventive and curative
interventions, including immunization
against neonatal tetanus for pregnant
women, routine immunization, distribution
of insecticide treated mosquito nets and
oral rehydration salts, among others.
Post-Emergency Phase

Access to improved water and sanitation,
and adoption of improved hygiene
practices, especially at delivery. Clean
water for hygiene and drinking is essential
for safe delivery
Post-Emergency Phase
Access to skilled health personnel
–a doctor, nurse or midwife – at
delivery.
A strong referral system, skilled health workers and well equipped facilities
are pivotal to reducing maternal and newborn deaths resulting from
complications during childbirth.
Health workers treat babies in the Sick Newborn Care Unit, India.
Post-Emergency Phase
Basic emergency obstetric care at
a minimum of four facilities per 500,000
population – adapted to each country’s
circumstances – for women who
experience some complication.
 Comprehensive emergency obstetric care
at a minimum of one facility in every
district or
one per 500,000 population.

Post-Emergency Phase

A post-natal visit for every mother and
newborn as soon as possible after
delivery, ideally within 24 hours, with
additional visits towards the end of the first
week and at four to six weeks.
Post-Emergency Phase
Knowledge and life skills for pregnant
women and families on the danger signs
of maternal and newborn health and about
referral systems.
 Maternal nutrition counseling and
supplementation as needed as part of
routine antenatal, post-natal and neonatal
care.
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Post-Emergency Phase

Essential care for all newborns, including
initiation of breastfeeding within the first
hour of birth, exclusive breastfeeding,
infection control, warmth provision and
avoidance of bathing during the first 24
hours.
Household to Hospital Continuum
of Care
 Closely
linking the household with
community health workers, peripheral
health facilities and hospitals to
promote essential maternal and
newborn care (EMNC)
 Accredited Social Health Activist
(ASHA) program in India
Summary
Maternal mortality reflective of quality of
health systems
 Key interventions save lives
 Access to skilled care of utmost
importance

Mumtaz Mahal
References
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UNICEF State of the World’s Children 2009
http://misp.rhrc.org/content/view/22/36/lang,engli
sh/
http://whqlibdoc.who.int/hq/2001/WHO_RHR_00
.13.pdf
http://www.who.int/whosis/whostat/EN_WHS09_
Table2.pdf
Refugee Health- An approach to emergency
situations
Averting Maternal Death and Disability