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Maternal & SRHR - Coggle Diagram

- - - - Maternal Mortality Rates / Estimates
        
        Childbirth mortality = >300K
        --> 20-40x more life threatening maternal diseases, injuries, & disabilities
        :flag-dk: <1 : 10K
        :flag-tz: 1:45
        :flag-sl: 1 : 20
        
        Child mortality / stunting (1 month-5 years) = 3.2M
        --> >1M neonates survive w/ l-t neurodvlptl impairment
        
        Newborn mortality (1 month) = 2.7M
        
        Stillbirth mortality = 2.6 M (w/ 1.3M at birth)
        --> how can this not be a goal when it concerns 2.6M lives?!?!*
        ==> Slower progress for last 2
        
        LICs Complex Clinical Mngt
        
        Human res (pro competencies)
        
        Delays to reaching health facilities
        
        Diff. co-morbidities (obstetric transition to complex double GBDs)
        
        Values & policies (competing discourses based on diff. values)
        
        :!:: Time matters: onset of major obstetric complications & death in the absence of medical interventions
        
        Haemorrhage
        
        Postpartum = 2h
        
        Antepartum = 12h
        
        Ruptured uterus = 1 day
        
        Eclampsia = 2 days
        
        Obstructed labor = 3 days
        
        Infection = 6 days
        
        :warning: 3 delays model (Thaddeus & Maine)
        
        Deciding to seek care
        
        Reaching the facility
        
        Receiving adquate treatment
        
        "Maternal deaths in areas far from health clinics are comparable w/ maternal deaths like in New York where a woman might live next to the hospital, but still dies due to poverty & its effect on her decision-making"
      - Maternal mortality in :flag-us: >>> other industrialized / devlpd regions
        
        :flag-us: 23.8 : 100K live births
        
        :flag-fr: 8.7 : 100K
        
        :flag-ca: 8.6 : 100K
        
        :flag-gb: 6.5 : 100K
        --> & on the rise
    - - Influenced by external shocks
        
        Urbanization = mega maternity units
        
        Disease outbreaks = eg Covid
        --> MSc thesis = Experiences of (dis)respectful care during covid among women suffering a stillbirth in Italy
        --> UNICEF - Do No Harm: Maternal, Newborn & Infant Care during Covid-19
        
        Conflicts
        
        Extreme weather
        
        Changing pol envs
        
        :flag-tz:
        
        Maternal mortality
        
        2000 = 854 : 100K
        
        2017 = 524 : 100K
        
        Child mortality (<5)
        
        2000 = 128.8 : 1K
        
        2019 = 50.3 : 1K
        
        Urban pop growth (5% annually)
        => A growing disadvantage to being born in urban areas
        A significant difference in neonatal mortality rates
        
        Urban = 40% (2015)
        
        Rural = 20% (2015) More stable for rural
        --> more stable line from 1991-2015
        
        Mixed politics
        :heavy_minus_sign:
        
        President against birth control
        
        Plans to track & arrest LGBT people
        
        Cervical cancer most commonly diagnosed cancer in TZ
        
        :heavy_plus_sign:
        
        Newly named a MIC
        
        1st female president urging for unity
        
        Reports to "create health cities in TZ"
        
        :flag-ph: Urban mega maternity unit
        One of the busiest maternity wards in the world
        (~ 60 births / day)
    - - Oxytocin
        = the "love hormone" that acts on organs in the body (incl breast & uterus)
        Commonly used in modern obstetric practice for labor induction, to increase uterine activity (make it contract), in cases where the labor process has failed, with the aim to enable it to progress to a vaginal delivery.
        
        BUT in LIC no access to same technology & res as in HIC
        
        :flag-eg: :flag-in: = incredibly common practice to augment oxytocin during L (51-100%)
        :flag-tz: :flag-ng: 31-50%
        
        :flag-tz: How time factors influence re-negotiated care practices in a busy maternity unit in TZ
        
        Shifts & ward rounds (+ care reduces during the night)
        
        Other emergencies (beds fill-up & hands are full)
        
        Actual care
        Oxytocin given despite normal L progression to free up beds & hands & ensure flow
        
        Partograph not used
        
        Care practices when using oxytocin not followed
        
        --> How can 1 midewife manage to stay w/ every mothre 10min to count contractions while others are pushing?
        
        Evidence of using Oxytocin
        --> :!!: All studies from HIC
        
        Decrease by 2h of labor duration
        
        Increased risk of fetal heart rate (FHR) changes
        
        No diff. in intensive care unit admission + Agpar score (1-10, 10 as best, to assess overall health of the newborn)
        
        Unknown diff. for CS rate + perinatal deaths
        
        ==> CONCLUSION: Safe to use in experienced hands
        
        :bookmark: Guidelines for oxytocin augmentation
        
        Follow evolution of pregnancy on partograph = a labor monitoring tool used worldwide to enable early detection of complications, so that referral, action or closer observations can ensure.
        
        Alert line = starts at 4 cm of cervical dilatation and it travels diagonally upwards to the point of expected full dilatation (10 cm) at the rate of 1 cm per hour.
        
        Action line = allows unambiguous diagnosis of prolonged labour, enabling the timing of intervention to be based on the rate of cervical dilatation.
        
        If monitoring "crosses the alert line" = must start an unidentified interval of watchful expectancy before confirming delay in progress & initiate augmentation
        
        Dosage for labour induction = 2.5 IU in 500 mL of detrose (or normal saline) at 10 drops per minute (~2.5 mIU per minute)
        
        Requires one-to-one care & assessment every 30min:
        
        Titration
        
        Foetal heart rate
        
        Contractions
        
        Trends from PartoMa guidelines
        
        Uncomplicated progress (grp A) = 1,830 women (57.7%) = L did not cross the alert line
        
        Early detection of potentially slow L (grp B) = 915 women (29.8%) = L duration between the Alert & Action line (4 hours)
        
        Poor progress (grp C) = 322 somen (10.5%) = L cross the action line
        
        Injustice of unfit clinical practice guidelines in low-res realities
        How to bridge the gap?
        From the frontline, local leadership, researchers, global community?
        
        :flag-tz: Zanzibar Case for the dvlpt of maternal & neonatal health prog
        --> 2 year initiative to work with maternity ward in tertiary hospital
        
        Local Context:
        
        Pop ~1.5M
        
        Total fertility rate = 5.1
        
        30% below poverty line
        
        First antenatal care visit = 80%
        
        Facility birth rate = 55%
        
        Maternity Unit context:
        
        ~12k births / year
        
        Lack of supplies
        
        2 women per bed
        
        1 health provider per 3-6 laboring women
        
        High teaching obligation
        
        High staff turnover (low knowledge, skills & experience)
        
        Two years later, 80% of doctors & 60% of nurse-midwives had left the department
        
        70% of doctors at the maternity unit had <3 years of experience
        
        35% of nurse-midwives had <3 months of experience
        
        Desired outputs
        
        Which key outcome indicator to target?
        
        What type of activity should the org invest in?
        
        How will you ensure sustainability after 2 years of external support ends?
        
        :tada: The PartoMa Guidelines: A Pocket Guide for Best Possible Safe & Respectful Childborth Care
        --> "Local adaptation of intrapartum clinical guidelines in TZ"
        
        A partograph-based decision support for intrapartum care
        
        Foetal heart surveillance
        
        Surveillance of labour progress
        
        Surveillance of maternal vital signs
        
        The PartoMa Seminars:
        
        Low-dose, high-frequency training
        
        Reoccuring every 3 months, after working hours, repeated twice
        
        No per diems / allowances
        
        Case-based
        
        Multidisci grps
        
        Results:
        
        Stillbirths from 59:1k to 39:1k
        
        Agpar score 1-5 from 52:1k to 28:1k
        
        Is it ethical to provide best possible care?
        CONTEXT IS KING, CONTEXT IS GOD!
- - - - Mortality & Morbidity from Unsafe Abortions
        
        Maternal mortality due to abortion, miscarriage & ectopic pregnancy = 8-10%
        --> +22K women die / year from complications of unsafe abortions w/ Ms more injured
        
        Morbidity from unsafe abortions:
        
        Haemorrhage
        
        Infection & sepsis
        
        Peritonitis
        
        Trauma to the cervix, vagina, uterus & abdominal organs
        
        Infertility
        
        Chronic pain
        
        Potential l-t risks of ecotopic prgnancy, premature delivery & spontaneous abortion in subsquent pregnancies
        
        ==> :!: 50% of hospital budgets for OB/GYM in LICs spent treating complications of unsafe abortion
        
        Magnitutde of abortion
        
        :warning: 25% of all pregnancies end in induced abortion (2010-14)
        
        56M / year
        
        35 abortions : 1K women (15-44)
        
        LMIC women likelihood > HIC (w/ good family planning services) = 36 VS 27 : 1K women (15-44)
        
        225 M women in LMIC have an unmet need for Modern Contraception
        
        86% of abortions take place in LMIC
        --> esp. in countries with highly restrictive abortion laws
        
        Competing discourses based on different values
        When does personhood begin?
        
        Inter. Human Rights (Maputo Protocol):
        
        Rights of the mother
        
        Rights of the unborne baby
        
        Religious: the holy nature of life & sin of killing (bible/quran)
        
        Ethics: "do no harm" (Hippocrate)
        
        PH (SDGs)
        
        Abortion laws
        
        Prohibited altogether
        
        To save the women's life
        
        To preserve health
        
        Broad socio-econ grounds
        
        On request (gestational limits vary)
        
        :green_book: Abortion Laws in :flag-tz:, Zambia :flag-zm: & :flag-et:
        
        :flag-zm: = Liberal
        
        Abortion legal to save life / preserve phy & mental health + socio-econ ground
        
        BUT requirement of 3 doc signatures
        
        85% of indiced abortions = unsafe
        
        :flag-et: = Semi-Liberal
        
        Abortion legal to save life / preseve phy health (in cases of underage, rape, incest)
        
        Word of woman sufficent to justify
        
        47% induced abortions = unsafe
        
        :flag-tz: = Restrictive
        
        Abortion severely restricted (only legal to save life)
        
        1 health worder decides in woman eligible
        
        No estimates; nearly all abortions = unsafe BUT misoprosol available in urban centers
        
        Limited access to res
        :flag-tz: study of health facilities in 3 districts
        
        Only 24% had MVA kits in stock
        
        Only 1 in 5 hospitals had both misoprostol (medicine used in inducing birth or causing abortion)
        
        1 more item...
        
        :flag-zm: Silent politics & Unknown numbers: Rural health bureaucrats & ZM Abortion policy"
        
        Very Christian nation
        
        Supporting abortion policy = morally controversial BUT silencing the policy = morally safe (not counting abortions)
        
        No district rural hospital offering abortion care (only doc who could sign = against it)
        
        :flag-et: When the law makes doors slightly open
        
        The word of the woman is enough
        
        The slightly open (closed) door is defined by the health worker
        
        Judges the eligibility
        
        Finds reasons acceptable or not
        
        Personal religious beliefs & norms VS saving a mother
        
        "Making abortion illegal does not stop it -- it just forces women to obtain clandestine & unsafe procedures"
        :flag-us: Roe v. Wade
        :flag-pl: Top court bans almost all terminantions
        :flag-ro: Resitricting access to safe abortion = dramatic increase in maternal mortality (due to usafe abortion-related deaths)
        --> Increased access to modern contraception = reduced need for women to resort to abortion
        
        Unmet need of contraception
        
        1 in 4 adolescents
        
        32% of married women (15-49) = using modern method of family planning
        
        If the need for family planning was fully met in SSA maternal mortality would decrease by 29% + unintended preganncies by 78% (from 19M to 4M)
        
        :!: The access paradox: deriving full benefit of the law
        Individual
        
        Women's knowledge of the law & how to get access
        
        Practitioners knowledge of the law & right to conscientious objection due to moral/ religious belief
        
        Resource-based
        
        Availability of services & equip for abortion / contra
        
        Training & guidelines to health workers
        
        Social
        
        Stigma & anti-abortion / contra sentiments
        
        Role of market & media (i.e. access & availability of misoprostol)
        
        Abortion suffers from gross underreporting
        
        Esp. where illegal
        
        Few countries have complete reporting
        --> Even in :flag-us: no requirement to report
        
        Non-judgmental Post-Abortion Care
        --> Accepted by all countries
        
        Emergency treatment
        
        Empty the uterus w/ a manual vacuum aspiration (MVA) kit
        --> A life saving tool BUT not easily available
        
        Antibiotics
        
        Tetanus booster
        
        Before discharge:
        
        STI evaluation & treatment
        
        Contra counseling
        
        Community involvement
- - - - :green_book: Cultural sensitivities - a wedding in Afghanistan bw 40 yo man & 11 yo girl
  - - - :warning: MUST MAKE ABORTIONS SAFER
        By making Misoprostol more easily accessible
        --> As effective as surgical techniques
        Can be used to:
        
        Induce 1st & 2nd trimester abortions (93-95% effective during 1st tri)
        
        Assist in prevention & treating post-partum bleeding