Maternal health

department of reproductive health

by Woynareg Kassa(MPH,RH)

03/15/2024
 Learning objectives
 Define maternal health and safe motherhood
• Describe essential services for safe
motherhood
• Describe concepts and definitions of maternal death
• Identify direct and indirect causes of maternal
mortality.
• Describe some of the risk factors for maternal
mortality and morbidity.
• Discuss the three delay model

03/15/2024
 Definition.........

• Maternal health refers to the health of

women during pregnancy, childbirth and the
postpartum period.
- While motherhood is often a positive and
fulfilling experience, for too many women it is
associated with suffering, ill-health and even
death.

03/15/2024
 Definition.......
Motherhood should be a time of expectation and
joy for a woman, her family, and her
community.
- Improving maternal health and reducing
maternal mortality have been key concerns of
several international summits and conferences
since 1980s

03/15/2024
 SAFE MOTHERHOOD

• In 1987 the world bank, in collaboration with

WHO and UNFPA, sponsored a conference on
safe motherhood in Nairobi, Kenya to help
raise global awareness about the impact of
maternal mortality and morbidity.

03/15/2024
 SAFE MOTHERHOOD Cont…

• The conference launched the safe motherhood

Initiative(SMI), which issued an international
call to action to reduce maternal mortality and
morbidity by one half by the year 2000.
• The SMI’s target has subsequently been
adopted by most developing countries.

03/15/2024
 SAFE MOTHERHOOD CONT..
• Safe motherhood means ensuring that all
women receive the care they need to be safe
and healthy through pregnancy and child birth.
• Safe Motherhood means that no woman, fetus
or baby should die or be harmed by
pregnancy or birth.
• Maternal mortality in developing countries has
been described as a neglected tragedy in terms of
the magnitude of the problem.
• It is also a tragedy in terms of equity and social
justice.
03/15/2024
 What is the safe motherhood initiative

• The safe motherhood initiative is a global effort that

aims to reduce death and illness among women and
new born, especially in developing countries.

03/15/2024
 SAFE MOTHERHOOD CONT..

• Under the safe motherhood initiative, countries

have developing programs to reduce maternal
mortality and morbidity.
• How ever the strategies adopted to make
motherhood safe vary among countries.

03/15/2024
 Essential services of the safe motherhood
1. Community education on safe motherhood
2. Prenatal care and counseling, including the
promotion of maternal nutrition
3. Skilled assistance during childbirth
4. Care for obstetric complications, including
emergencies
5. Post partum care

03/15/2024
 Essential services of the safe motherhood
6. Post-abortion care and, where abortion is not
against the law, safe services for the
termination of pregnancy
7. Family planning counseling, information and
services
8. Reproductive health education and services
for adolescents

03/15/2024
 SAFE MOTHERHOOD CONT..

Four pillars of safe motherhood

http://helid.digicollection.org/en/d/Jwho36e/4.html

03/15/2024
 The Six Pillars of Safe Motherhood

03/15/2024
 The Six Pillars of Safe Motherhood
1. Family Planning-to ensure that individuals and couples have the
information and services to plan the timing, number, and
spacing of pregnancies.

2. Antenatal Care-to provide vitamin supplements, vaccinations,

and screen for risk factors in order to prevent complications
where possible, and to ensure that complications of pregnancy
are detected early and treated appropriately.

3. Obstetric Care-to ensure that all birth attendants have the

knowledge, skills, and equipment to perform a clean and safe
delivery, and to ensure that emergency care for high-risk
pregnancies and complications is made available to all women
who need it.
03/15/2024
 The Six Pillars of Safe Motherhood
4. Postnatal Care-to ensure that postpartum care is provided to
mother and baby, including lactation assistance, provision of
family planning services, and managing danger signs.

5. Post-abortion Care-to prevent complications where possible

and ensure that complications of abortion are detected early
and treated appropriately.

6. STD/HIV/AIDS Control-to screen, prevent, and manage

transmission to baby; to assess risk for future infection; to
provide voluntary counseling and testing; to encourage
prevention; and where appropriate to expand services to
address mother to child transmission.
03/15/2024
 Magnitude of Maternal Health Problems

03/15/2024
 Definitions
Definitions
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.
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
.

•
03/15/2024
 Definitions
Direct Maternal Death
• Direct maternal deaths are deaths that result from obstetric
complications of the pregnant state, which includes pregnancy,
labor and puerperium.
• Direct deaths can be caused by interventions, omissions,
incorrect treatment, or from a chain of events resulting from a
combination of these factors
Indirect Maternal Death
• Indirect maternal deaths are those deaths caused by conditions
or diseases that may exist before pregnancy, but are
aggravated by the physiologic effects of pregnancy.

03/15/2024
 Definitions
Pregnancy Related death: the death of a woman while
pregnant or with in 42 days of termination of
pregnancy, irrespective of the cause of death. It
includes both maternal death and co-incidental death
like trauma.
 This definition has importance when considering
deaths among pregnant women caused by conditions
such as domestic violence and suicide, that do not
meet the criteria of direct or indirect obstetric deaths.

03/15/2024
 Magnitude of maternal health problems
• Though the world has made steady progress in reducing
maternal mortality, an estimated global total of 10.7 million
women have died in the 25 years (between 1990 and 2015)
due to maternal causes.
• Every day at least 830 women die from the complications of
pregnancy and childbirth globally.
 Globally in 2015, 303,000 women at a minimum die each year
world wide .
 The risk of dying from pregnancy-related complications is
highest in sub- Saharan Africa and in South-Central Asia,
where in some countries the maternal mortality ratios are more
than 1,000 deaths per 100,000 live births.

03/15/2024
 Magnitude of maternal health problems
• Between 1990 and 2015, maternal mortality ratio worldwide
dropped nearly by half (44%), from the 1990 level of 385 (UI
359 to 427) to the 2015 level of 216 (UI 207 to 249).
• The overall MMR in developing regions is 239 (UI 229 to 275),
which is roughly 20 times higher than that of developed regions

• Sub-Saharan Africa has a very high MMR with a point-estimate of

546 (UI 511 to 652)
• The lifetime risk of maternal mortality is estimated at
- 1 in 36 in sub-Saharan Africa,
- 1 in 4900 in developed countries
• Though some progress has been made to reduce maternal mortality,
but maternal mortality is unacceptably high yet

• However, most could have been prevented

03/15/2024
03/15/2024
 Trend of maternal mortality ratio(1990 to 2015) in Ethiopia

Source:
 Maternal morbidity

03/15/2024
 Maternal morbidity

Maternal morbidity: Any deviation, subjective or objective, from

a state of physiological or psychological well being of women.
 WHO estimates that at least 15% of all pregnant women
require rapid and skilled obstetric care, without which they
will suffer serious, long-term morbidities .

03/15/2024
 Maternal morbidity
• Maternal morbidity is difficult to measure due to
variation in the definition and criteria to diagnose.
The risk factors for maternal morbidity include
prolonged labor,
• hemorrhage,
• infection,
preclampsia.

03/15/2024
 Maternal morbidity
• For every maternal death, there are approximately 20
other women who suffer pregnancy-related disability.
• That is equivalent to an estimated 10 million women
each year who survive pregnancy, yet experience
some type of severe negative health consequence.

03/15/2024
 Extent of Maternal Mortality, Morbidity and
Disabilities

03/15/2024 Source: Maternal Survival 5. The Lancet 2006; 368: 1535-41

 Maternal morbidity

The commonest long term complication of pregnancy and

child birth include:

A. Infection: There is high risk of infection of the

genital organs (cervix, uterus, tubes, ovaries and
peritoneum) after prolonged labor, when delivery
takes place in unclean settings, retained parts of
conception after unsafe abortion and delivery.
.

03/15/2024
 Maternal morbidity
B. Fistula: are holes in the birth canal that allow leakage
from the urethra, bladder or rectum into the vagina.
 The commonest cause in our country is obstructed labor as
opposed to surgery and cancer in the developed world
 Obstetric fistula is the most well-known of these
conditions, disabling tens of thousands of women in Africa
each year.

03/15/2024
 Maternal morbidity
C. Incontinence: is leakage of urine upon straining or standing.
D. Infertility: Unable to be pregnant for a year despite unprotected
sexual intercourse.
E. Uterine prolaps: the falling or sliding of the uterus from its normal
position into the vaginal canal. Commonest predisposing factors
include prolonged labor, heavy exercise, multiple childbirths, etc.

03/15/2024
 Maternal morbidity
F. Nerve Damage: As a result of prolonged labor, there may be
compression or damage of the nerves in the pelvis (Sciatic
nerve).
G. Psychosocial problems: maternal blues aggravated by other
conditions
H. Others, Include, pain during intercourse, anemia, etc.

03/15/2024
 Maternal mortality

03/15/2024
 Causes of maternal mortality

• Most maternal deaths occur between the third trimester and

the immediate postpartum period.
• There is evidence to suggest that direct effects of pregnancy
and childbirth are responsible for most maternal deaths in
developing countries.
• The major causes of maternal deaths are essentially the same
around the world.

03/15/2024
 causes of maternal death

Direct causes:
 Those resulting from obstetric complications of the pregnant

state (i.e. pregnancy, delivery and postpartum), interventions,

omissions, incorrect treatment, or a chain of events resulting

from any of the above

03/15/2024
 cont....

 Indirect causes:
• Indirect maternal deaths are those resulting from
previously existing diseases, or from diseases that
developed during pregnancy and that were not due to
direct obstetric causes but aggravated by
physiological effects of pregnancy:
- An existing cardiac or renal disease,
- HIV, Malaria,
- Anemia
03/15/2024
 cont......

 The major complications that account for nearly 75%

of all maternal deaths are:
 Haemorrhage (mostly bleeding after childbirth)
 High blood pressure during pregnancy (pre-

eclampsia and eclampsia)

 Infections (usually after childbirth)
• Obstructed labour
• Unsafe abortion.
03/15/2024
 Global causes of maternal deaths

Source:-source:
World
Causes ofHealth
maternalOrganization 2014;
death in the world Say L et al
by percentage
Say L et al global causes of maternal death, 2014
Global causes of maternal death

03/15/2024
 Global causes of maternal deaths

03/15/2024
 cont.....
• In Sub-Saharan Africa:
- Hemorrhage- 24·5%,
- Hypertension - 16·0%,
- Sepsis- 10·3%,
- Abortion- 9·6%,
- Obstructed labor and other direct causes- 9·0%,
- Embolism- 2 %, and
- Indirect causes- 28·6%
 The proportion of maternal death due to indirect obstetric
death is highest in southern Asia(29.3%) ,followed by
sub-Saharan Africa 28.6%,
 Indirect cause also accounts more than one forth of death
in developed region
03/15/2024
 cont.....

Figure: Direct causes of maternal mortality in Ethiopia

13%
19%
Obstructed/prolonged
labor
7%
Ruptured uterus
Haemorrhage
Severe pre eclampsia/
9% Eclampsia
Complications of abortion
18%
Post partum sepsis
Other

16%

18%

03/15/2024
 Trends of maternal death cause n Ethiopia

Source Ahmed abdela,2010

03/15/2024
 causes..........

 Most maternal deaths are preventable, as the health-care solutions

to prevent or manage complications are well known

 98% of maternal deaths are preventable through:

• Family planning to reduce unintended pregnancies

• Skilled attendance at deliveries

• Timely emergency care when obstetric complications

arise

• Timely management and treatment can make the difference

between life and death

03/15/2024
 causes..........

 Many of the top causes of maternal morbidity and mortality

—such as
• Haemorrhage,
• Sepsis,
• Unsafe abortion, and
• Eclampsia

—are largely preventable through low cost and highly effective

medicines like oxytocin, misoprostol, and magnesium
sulphate delivered by skilled providers.

03/15/2024
 Maternal Mortality in Context
• The three delays model
• The pathways framework for reproductive
health outcomes

03/15/2024
 The Three Delays
1. Delay in deciding to seek care
Failure to recognize signs of complications
Failure to perceive severity of illness
Cost consideration
Negative experience with health system
Transportation difficulties

03/15/2024
 Delays…

2. Delay in reaching care

 Lengthy distance to a facility
 Conditions of roads
 Lack of available transportation
 Transportation difficulties

3. Delay in receiving appropriate care

 Uncaring attitudes of providers
 Shortages of supplies and basic equipment
 Non-availability or poor skills of health personnel

03/15/2024
 The three delays model and its relationship to the right to health

03/15/2024
 Three delay model

• Maternity worldwide objective is address those delays,

through a strategy of:
– Enhancing availability and improving the quality and of
clinics and hospitals that offer basic/comprehensive
emergency obstetric and neonatal care
– Improving the quality and availability of professionally
trained skilled birth attendants

03/15/2024
 The three delay model
• Empowering women through improving their social status and
financial security and promoting women’s rights through a
network of income generating groups
• Empowering and mobilizing the local community through
reproductive health education and information

03/15/2024
 “Maternal Mortality”

03/15/2024
03/15/2024
 Risk Factors for Maternal Health
Maternal mortality is affected by many interrelated factors.
1. Socio-cultural factors:
 Like early marriage
 Early childbirth,

 girls aged 15 to 19 are two times more likely to

die during childbirth than women in their 20-30s,
while girls younger than 15 are five times more
likely to die.
 Harmful traditional practices including female genital
mutilation, etc.
03/15/2024
 Risk factor for maternal health

2. Economy: Socio economic status affects the women’s status

by affecting their
 decision making roles in the community
 educational status
 health coverage
 level of sexual abuse etc.

03/15/2024
Risk Factors for Maternal Health
3. Reproductive factors

– The risks posed by pregnancy for teenagers,

mothers over 40 years of age and mothers with
high parity are high
These groups are particularly exposed to complications
during pregnancy and delivery

03/15/2024
 Risk Factors for Maternal Health
4. Psychological factors:
 Fear of childbirth
 Too many pregnancies
 Death of other children in family.
 Women are at great risk of depression after sexual abuse,
divorce as a result of marriage with out consent and after
Vesico-Vaginal/Recto- Vaginal Fistula (VVF/RVF).

03/15/2024
 Risk Factors for Maternal Health
5. Health service factors

Lack of facilities for emergency transport

lack of or poor referral services with essential

obstetric function
Unavailability of blood transfusion, deficient
medical treatment of complications, lack of
essential supplies and trained personnel

03/15/2024
 Risk Factors for Maternal Health
 lack of access to maternity services, and lack of prenatal and
postnatal care are all crucial steps on the road to death
Unmet contraceptive need

•Currently estimated at 222 million women- has

impeded efforts to improve maternal health.
•There are 99 million unintended pregnancies each
year worldwide

03/15/2024
 Risk Factors for Maternal Health
 Quality of Care: The coverage and reach of maternal
health services have increased dramatically in some high-
burden countries, but the content and quality of those
services (both institutional and at the community level)
have not improved at the same space.

 Interaction with providers: Some health care

providers are unsympathetic and uncaring as they
do not respect women's cultural references.

03/15/2024
 Risk Factors for Maternal Health

E.g. privacy, birth position, or treatment by

women providers.
6. Health and nutrition services:
 The health status of women who are not getting adequate
amount of nutrients and proper reproductive health services
could be affected.

03/15/2024
 Risk Factors for Maternal Health
7. Gender Discrimination:

 Gender disparities: Deeply entrenched gender disparities

are common in many developing countries where maternal

mortality is high and health service utilization is low.

E.g. lack of women empowerment, giving more

attention to a male child.

03/15/2024
 challenges
• Measurement; Maternal mortality and morbidity are difficult
to measure for a variety of reasons.
- Under-reporting and misclassification of maternal deaths is all
too common.
• Morbidities: For every woman who dies of pregnancy-related
causes, approximately 20 others face serious or long-lasting
morbidities (e.g. anemia, maternal depression, infertility,
fistula, uterine rupture and scarring, uterine prolapse, chronic
infection, and perineal pain).
03/15/2024
 quize 1
1. Define maternal health and death?
2. List at least three factors of maternal Health?
3.What are three delay models of maternal mortality?
4.Discuss cause of maternal mortality?
5. List the three methods of maternal mortality
prevention?

03/15/2024