Maternal Mortality in Jordan
Content
Maternal Mortality in Jordan 2007-2008
Professor Zouhair Amarin
Jordan University of Science and Technology
Worldwide, childbearing carries a major risk to the life of women
Measures of maternal mortality
Maternal mortality rate Maternal mortality ratio Lifetime risk of maternal death
“Ratio” and “Rate” are often used interchangeably It is essential to specify the denominator used
Maternal mortality rate
Is the number of maternal deaths in a given period per 100 000 women of reproductive age
Maternal mortality ratio Is the number of maternal deaths during a given year per 100 000 live births during the same period
The Millennium Development Goals (MDGs are eight international development goals 192 United Nations member states and 23 international organizations have agreed to achieve those goals by the year 2015
Reducing maternal mortality by three quarters between 1990 and 2015 is a specific part of Goal 5 (Improving Maternal Health) of the eight MDGs
At global level, maternal mortality has decreased less than 1% annually between 1990 and 2005
This is far below the 5.5% annual decline, which is necessary to achieve the fifth MDG
WHO UNICEF and UNFPA 2003 MMR The world average 400 Developed regions 20
Developing regions 440
Approaches for measuring maternal mortality
Civil Registration Systems Routine recording of deaths is not complete
The woman’s pregnancy status may not be known and the death would not be reported as a maternal death
Medical certification of death is deficient, accurate attribution of deaths as maternal death is difficult
In the UK, the Confidential Enquiry into Maternal Deaths (2000–2002) identified 44% more maternal deaths than was reported in the routine Civil Registration System Studies have shown that the true number of maternal deaths could be almost 200% higher
In the absence of complete and accurate civil registration systems, MMRs are based upon: Household surveys Sisterhood methods
Reproductive-age mortality studies (RAMOS)
Verbal autopsies Censuses
2007 - 2008
Study
Objectives
1. Determine maternal mortality ratio among Jordanian women
2. Identify the direct and indirect causes of maternal mortality
3. Determine the extent to which maternal deaths are preventable 4. Assess hospital medical and vital records for completeness
Step 1
Civil Registry, 1164 names were obtained for dead married women, 15-49 years of age
Step 2
From the MOH, 848 names were obtained
Step 3
Both lists were pooled to contain only married women in the age group 15-49 years
1177 names
Step 4
229 names from hospital registries 1177 + 229 = 1406 dead women of reproductive age
All hospitals and forensic departments were visited to search for maternal deaths
112 pregnancy related maternal deaths
Number of maternal deaths, number of live births, total fertility rate, and measures of maternal mortality in 2007-2008 Number of maternal deaths in 20072008 (95% CI) 76 deaths (60-95)
Number of live births
Total fertility rate in 2007 Maternal Mortality Ratio (95% CI)
397588 live births
3.6 19.1 (14.3-26.5)
Maternal Mortality Rate
Lifetime risk of maternal death (The probability that a 15-year-old female will die from a maternal cause)
2.0
0.0007 (1 in 1428)
Sociodemographic and health characteristics of study population (N=76) Age 15-29 30-39 40-49 Region Middle (62.3% of population) Northern (28.1% of population) Southern (9.3% of population) Family size 2-3 4-6 ≥7 (average family size 5.75) 17 24 17 41 10 29.3 41.4 29.3 80.4 19.6 45 19 12 59.2 25 15.8 n 31 27 18 % 40.8 35.5 23.7
Income in Jordanian Dinar
≤350 >350
Gravidity 1-3
n 28
% 43.1
4-6 ≥7 Parity 0-1 2-4 ≥5 Gestational age ≤27 28-36 ≥37
21 16
23 26
32.3 24.6
34.8 39.4
17
18
25.8
24.0
17 40
22.7 53.3
Causes of maternal deaths
Direct Causes Haemorrhage Uterine rupture Uterine atony Placental abruption DIC Ruptured ectopic pregnancy Thrombosis and thromboembolism (n=5) (n=5) (n=3) (n=4) (n=2)
n
56 19
%
73.7 25.0
18
23.7
Sepsis Hypertensive disorders of pregnancy
Amniotic fluid embolism
6 5
4
7.9 6.6
5.3
Anesthesia
Hyperemesis gravidarum
3
1
3.9
1.3
Causes of maternal deaths Indirect Causes Cardiac disease Diseases of the CNS CVA Epilepsy (n=4) (n=2)
n 20 8 6
% 26.3 10.5 7.9
Infectious diseases Hepatobiliary peritonitis (n=2) Pancreatic perotonitis (n=1) Pulmonary infection (n=1) Chronic anemia Renal failure
4
5.2
1 1
1.3 1.3
Avoidable deaths
Variable
n
%
Avoidable deaths
41
54
75% of cardiac deaths were associated with some degree of substandard care
Antenatal care (N = 54*) Antenatal attendance Received antenatal care n 45 % 83.3 16.7
No antenatal care
Total
*22 women had no details of ANC
9
54
100
Antenatal care (N = 45)
Booking and # visits 1st trimester booking visit 2nd or 3rd trimester booking Total Number of visits 1-3 ≥4 Total n 41 4 45 15 30 45 % 91 9 100 33.3 66.7 100
Frequency distribution of maternal deaths by period of pregnancy, type of hospital and autopsy status (N=76)
Period of pregnancy n %
During pregnancy Intrapartum Postpartum
Type of hospital Dead on arrival Maternity Peripheral
28 5 43
13 2 35
36.8 6.6 56.6
17.1 2.6 46.1
Referral
Autopsy status Dead on arrival - Autopsy
26
13
34.2
17.1
Hospital death - Autopsy
Brought-in dead - No Autopsy Hospital death - No Autopsy
9
3 51
11.8
3.9 67.1
Frequency distribution of maternal deaths by delivery (N=76)
Type of delivery Total
No delivery
Abortion
24
5
(31.5 %)
(6.5 %)
Spontaneous vaginal
Induced vaginal Ventouse Forceps Vaginal breech
15
1 1 3 0
(19.7 %)
(1.3 %) (1.3 %) (3.9 %) (0.0 %)
Caesarean section
Emergency Elective Perimortem Postmortem
27
20 5 1 1
(35.5 %)
(26.3 %) (6.5 %) (1.3 %) ( 1.3 %)
Of all 76 maternal deaths, the details of family planning were not available for 25 (32.9%) women
Frequency distribution by contraceptive practices Ever use of contraception n %
Yes
No Planned pregnancy Yes
15
36
29.4
70.6
39
51.3
Delays
Delays and standards of care n Transport delay 3 % 4.0
Delay in seeking care
Lack of prompt care Substandard management
42
37 40
55.3
48.7 52.6
Suboptimal facilities
4
5.3
Frequency distribution of accidental and incidental deaths by cause Cause of death Road traffic accident CO poisoning Lymphoma or Leukemia Homicide n 11 4 3 2
Burn
Electric shock Meningitis Pancreatic cancer
1
2 1 1
Breast cancer
Ruptured aneurism Colon cancer Bowel obstruction Cardio-vascular accident Dog bite Fall Drowning Total
1
1 1 2 3 1 1 1 36
Out of 72 files on maternal deaths (4 files could not be located), only 12 (16.6%) were well structured and had complete details about events in their respective hospitals Substandard quality was evident in all other medical case notes that were reviewed
1995/6
MMR Direct 1 Direct 2 Direct 3 Indirect 1 Indirect 2 Indirect 3 41.4 Hypertension Haemorrhage Thrombotic events Cardiac Malignancy Diabetes
2007-2008
19.1 Haemorrhage Thrombotic events Sepsis Cardiac CNS events Infectious diseases
This report should reassure the public that maternal deaths in Jordan are rare and declining. Overall, 76 women had a maternal death out of the 397588 mothers who gave live birth during 2007-2008 The MMR for both direct and indirect causes of death showed a remarkable decrease as compared with the last Report of 19951996 A reduction of 53.9% achieved in 12 years (4.5% annual reduction) goes well with the 75% reduction as recommended by the MDG 5 At global level, maternal mortality had decreased at an average of < 1% annually between 1990 and 2005. This is far below the 5.5% annual decline recommended by the MDG 5
MMR (Per 100,000 live births)
1000
1200
200
400
600
800
0 0
UAE KUW SA JOR BAH OMA LIB QAT PAL TUN SYR EGY IRQ ALG MOR YEM COM DJI MAU SOM SUD
84 32 35 37 58 59 2 15 19 19 23 27
Country
AVR 08
180 227 365 380 546 750 1107 1044 329
RECOMMENDATIONS
General
Recognition of maternal health as a priority issue Reallocation of human and financial resources to the relevant interventions
Scale up the implementation of the strategies and plans of action related to Making Pregnancy Safer
Upgrade recording and reporting systems
Develop national surveillance systems to identify epidemiological patterns and maternal mortality trends
Implementation of community-based interventions related to maternal health Early recognition of the danger signs of sickness and also on preventive measures to promote maternal health
Introduce maternal health guidelines into the teaching curricula of medical and paramedical schools
Haemorrhage A forum of experts at a national level is recommended to develop a multidisciplinary massive haemorrhage protocol that should be updated and rehearsed regularly in conjunction with blood banks All grades of staff should participate in drills on site and consultant haematologists should be involved Women at high risk of bleeding should be delivered in centres with facilities for blood transfusion and ICU
Thromboembolism Acute symptoms suggestive of thromboembolism in known high-risk women are an emergency and anticoagulation may be indicated before the diagnosis is clear Attention should be paid to the up-to-date guidance on dosages A thrombophilic risk profile protocol should be developed and implemented in all maternity hospitals
Sepsis Hospitals should have an antibiotic policy for cases of sepsis to control infection and prevent the development of DIC and organ failure
Advice from a microbiologist must be sought early to ensure appropriate antibiotic therapy
Cardiac disease Women with known cardiac disease should receive prepregnancy counseling All medical and nursing staff should be trained in basic, intermediate and advanced life support
Emergency drills for maternal resuscitation should be regularly practiced, and should include the identification of the equipment required
Preconception counseling and antenatal care
Health Education
Communication and collaboration
Continuous professional development
Policies and protocols
Accreditation
Multidisciplinary support
Documentation
Death notification
Finally
“the act of getting pregnant should not be a death sentence”
BBC reporter on maternal mortality in Malawi, where 1 in 10 dies during childbirth 26th October 2009
Thank you
Professor Zouhair Amarin
Jordan University of Science and Technology
Worldwide, childbearing carries a major risk to the life of women
Measures of maternal mortality
Maternal mortality rate Maternal mortality ratio Lifetime risk of maternal death
“Ratio” and “Rate” are often used interchangeably It is essential to specify the denominator used
Maternal mortality rate
Is the number of maternal deaths in a given period per 100 000 women of reproductive age
Maternal mortality ratio Is the number of maternal deaths during a given year per 100 000 live births during the same period
The Millennium Development Goals (MDGs are eight international development goals 192 United Nations member states and 23 international organizations have agreed to achieve those goals by the year 2015
Reducing maternal mortality by three quarters between 1990 and 2015 is a specific part of Goal 5 (Improving Maternal Health) of the eight MDGs
At global level, maternal mortality has decreased less than 1% annually between 1990 and 2005
This is far below the 5.5% annual decline, which is necessary to achieve the fifth MDG
WHO UNICEF and UNFPA 2003 MMR The world average 400 Developed regions 20
Developing regions 440
Approaches for measuring maternal mortality
Civil Registration Systems Routine recording of deaths is not complete
The woman’s pregnancy status may not be known and the death would not be reported as a maternal death
Medical certification of death is deficient, accurate attribution of deaths as maternal death is difficult
In the UK, the Confidential Enquiry into Maternal Deaths (2000–2002) identified 44% more maternal deaths than was reported in the routine Civil Registration System Studies have shown that the true number of maternal deaths could be almost 200% higher
In the absence of complete and accurate civil registration systems, MMRs are based upon: Household surveys Sisterhood methods
Reproductive-age mortality studies (RAMOS)
Verbal autopsies Censuses
2007 - 2008
Study
Objectives
1. Determine maternal mortality ratio among Jordanian women
2. Identify the direct and indirect causes of maternal mortality
3. Determine the extent to which maternal deaths are preventable 4. Assess hospital medical and vital records for completeness
Step 1
Civil Registry, 1164 names were obtained for dead married women, 15-49 years of age
Step 2
From the MOH, 848 names were obtained
Step 3
Both lists were pooled to contain only married women in the age group 15-49 years
1177 names
Step 4
229 names from hospital registries 1177 + 229 = 1406 dead women of reproductive age
All hospitals and forensic departments were visited to search for maternal deaths
112 pregnancy related maternal deaths
Number of maternal deaths, number of live births, total fertility rate, and measures of maternal mortality in 2007-2008 Number of maternal deaths in 20072008 (95% CI) 76 deaths (60-95)
Number of live births
Total fertility rate in 2007 Maternal Mortality Ratio (95% CI)
397588 live births
3.6 19.1 (14.3-26.5)
Maternal Mortality Rate
Lifetime risk of maternal death (The probability that a 15-year-old female will die from a maternal cause)
2.0
0.0007 (1 in 1428)
Sociodemographic and health characteristics of study population (N=76) Age 15-29 30-39 40-49 Region Middle (62.3% of population) Northern (28.1% of population) Southern (9.3% of population) Family size 2-3 4-6 ≥7 (average family size 5.75) 17 24 17 41 10 29.3 41.4 29.3 80.4 19.6 45 19 12 59.2 25 15.8 n 31 27 18 % 40.8 35.5 23.7
Income in Jordanian Dinar
≤350 >350
Gravidity 1-3
n 28
% 43.1
4-6 ≥7 Parity 0-1 2-4 ≥5 Gestational age ≤27 28-36 ≥37
21 16
23 26
32.3 24.6
34.8 39.4
17
18
25.8
24.0
17 40
22.7 53.3
Causes of maternal deaths
Direct Causes Haemorrhage Uterine rupture Uterine atony Placental abruption DIC Ruptured ectopic pregnancy Thrombosis and thromboembolism (n=5) (n=5) (n=3) (n=4) (n=2)
n
56 19
%
73.7 25.0
18
23.7
Sepsis Hypertensive disorders of pregnancy
Amniotic fluid embolism
6 5
4
7.9 6.6
5.3
Anesthesia
Hyperemesis gravidarum
3
1
3.9
1.3
Causes of maternal deaths Indirect Causes Cardiac disease Diseases of the CNS CVA Epilepsy (n=4) (n=2)
n 20 8 6
% 26.3 10.5 7.9
Infectious diseases Hepatobiliary peritonitis (n=2) Pancreatic perotonitis (n=1) Pulmonary infection (n=1) Chronic anemia Renal failure
4
5.2
1 1
1.3 1.3
Avoidable deaths
Variable
n
%
Avoidable deaths
41
54
75% of cardiac deaths were associated with some degree of substandard care
Antenatal care (N = 54*) Antenatal attendance Received antenatal care n 45 % 83.3 16.7
No antenatal care
Total
*22 women had no details of ANC
9
54
100
Antenatal care (N = 45)
Booking and # visits 1st trimester booking visit 2nd or 3rd trimester booking Total Number of visits 1-3 ≥4 Total n 41 4 45 15 30 45 % 91 9 100 33.3 66.7 100
Frequency distribution of maternal deaths by period of pregnancy, type of hospital and autopsy status (N=76)
Period of pregnancy n %
During pregnancy Intrapartum Postpartum
Type of hospital Dead on arrival Maternity Peripheral
28 5 43
13 2 35
36.8 6.6 56.6
17.1 2.6 46.1
Referral
Autopsy status Dead on arrival - Autopsy
26
13
34.2
17.1
Hospital death - Autopsy
Brought-in dead - No Autopsy Hospital death - No Autopsy
9
3 51
11.8
3.9 67.1
Frequency distribution of maternal deaths by delivery (N=76)
Type of delivery Total
No delivery
Abortion
24
5
(31.5 %)
(6.5 %)
Spontaneous vaginal
Induced vaginal Ventouse Forceps Vaginal breech
15
1 1 3 0
(19.7 %)
(1.3 %) (1.3 %) (3.9 %) (0.0 %)
Caesarean section
Emergency Elective Perimortem Postmortem
27
20 5 1 1
(35.5 %)
(26.3 %) (6.5 %) (1.3 %) ( 1.3 %)
Of all 76 maternal deaths, the details of family planning were not available for 25 (32.9%) women
Frequency distribution by contraceptive practices Ever use of contraception n %
Yes
No Planned pregnancy Yes
15
36
29.4
70.6
39
51.3
Delays
Delays and standards of care n Transport delay 3 % 4.0
Delay in seeking care
Lack of prompt care Substandard management
42
37 40
55.3
48.7 52.6
Suboptimal facilities
4
5.3
Frequency distribution of accidental and incidental deaths by cause Cause of death Road traffic accident CO poisoning Lymphoma or Leukemia Homicide n 11 4 3 2
Burn
Electric shock Meningitis Pancreatic cancer
1
2 1 1
Breast cancer
Ruptured aneurism Colon cancer Bowel obstruction Cardio-vascular accident Dog bite Fall Drowning Total
1
1 1 2 3 1 1 1 36
Out of 72 files on maternal deaths (4 files could not be located), only 12 (16.6%) were well structured and had complete details about events in their respective hospitals Substandard quality was evident in all other medical case notes that were reviewed
1995/6
MMR Direct 1 Direct 2 Direct 3 Indirect 1 Indirect 2 Indirect 3 41.4 Hypertension Haemorrhage Thrombotic events Cardiac Malignancy Diabetes
2007-2008
19.1 Haemorrhage Thrombotic events Sepsis Cardiac CNS events Infectious diseases
This report should reassure the public that maternal deaths in Jordan are rare and declining. Overall, 76 women had a maternal death out of the 397588 mothers who gave live birth during 2007-2008 The MMR for both direct and indirect causes of death showed a remarkable decrease as compared with the last Report of 19951996 A reduction of 53.9% achieved in 12 years (4.5% annual reduction) goes well with the 75% reduction as recommended by the MDG 5 At global level, maternal mortality had decreased at an average of < 1% annually between 1990 and 2005. This is far below the 5.5% annual decline recommended by the MDG 5
MMR (Per 100,000 live births)
1000
1200
200
400
600
800
0 0
UAE KUW SA JOR BAH OMA LIB QAT PAL TUN SYR EGY IRQ ALG MOR YEM COM DJI MAU SOM SUD
84 32 35 37 58 59 2 15 19 19 23 27
Country
AVR 08
180 227 365 380 546 750 1107 1044 329
RECOMMENDATIONS
General
Recognition of maternal health as a priority issue Reallocation of human and financial resources to the relevant interventions
Scale up the implementation of the strategies and plans of action related to Making Pregnancy Safer
Upgrade recording and reporting systems
Develop national surveillance systems to identify epidemiological patterns and maternal mortality trends
Implementation of community-based interventions related to maternal health Early recognition of the danger signs of sickness and also on preventive measures to promote maternal health
Introduce maternal health guidelines into the teaching curricula of medical and paramedical schools
Haemorrhage A forum of experts at a national level is recommended to develop a multidisciplinary massive haemorrhage protocol that should be updated and rehearsed regularly in conjunction with blood banks All grades of staff should participate in drills on site and consultant haematologists should be involved Women at high risk of bleeding should be delivered in centres with facilities for blood transfusion and ICU
Thromboembolism Acute symptoms suggestive of thromboembolism in known high-risk women are an emergency and anticoagulation may be indicated before the diagnosis is clear Attention should be paid to the up-to-date guidance on dosages A thrombophilic risk profile protocol should be developed and implemented in all maternity hospitals
Sepsis Hospitals should have an antibiotic policy for cases of sepsis to control infection and prevent the development of DIC and organ failure
Advice from a microbiologist must be sought early to ensure appropriate antibiotic therapy
Cardiac disease Women with known cardiac disease should receive prepregnancy counseling All medical and nursing staff should be trained in basic, intermediate and advanced life support
Emergency drills for maternal resuscitation should be regularly practiced, and should include the identification of the equipment required
Preconception counseling and antenatal care
Health Education
Communication and collaboration
Continuous professional development
Policies and protocols
Accreditation
Multidisciplinary support
Documentation
Death notification
Finally
“the act of getting pregnant should not be a death sentence”
BBC reporter on maternal mortality in Malawi, where 1 in 10 dies during childbirth 26th October 2009
Thank you
