Maternal & SRHR

Maternal Mortality Rates / Estimates

• Childbirth mortality = >300K
  --> 20-40x more life threatening maternal diseases, injuries, & disabilities
  🇩🇰 <1 : 10K
  🇹🇿 1:45
  🇸🇱 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

1. Human res (pro competencies)

2. Delays to reaching health facilities

   
   

3. Diff. co-morbidities (obstetric transition to complex double GBDs)

4. 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

Influenced by external shocks

1. Urbanization = mega maternity units
2. 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
3. Conflicts
4. Extreme weather
5. Changing pol envs

⚠ 3 delays model (Thaddeus & Maine)

1. Deciding to seek care
2. Reaching the facility
3. 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"

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

• ⚠ 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 in 🇹🇿, Zambia 🇿🇲 & 🇪🇹

• 🇿🇲 = Liberal
  
  • Abortion legal to save life / preserve phy & mental health + socio-econ ground
  • BUT requirement of 3 doc signatures
  • 85% of indiced abortions = unsafe
• 🇪🇹 = 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
• 🇹🇿 = 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
🇹🇿 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)

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)

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

🔖 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

1. Uncomplicated progress (grp A) = 1,830 women (57.7%) = L did not cross the alert line
2. Early detection of potentially slow L (grp B) = 915 women (29.8%) = L duration between the Alert & Action line (4 hours)
3. Poor progress (grp C) = 322 somen (10.5%) = L cross the action line

🇪🇬 🇮🇳 = incredibly common practice to augment oxytocin during L (51-100%)
🇹🇿 🇳🇬 31-50%

🇹🇿 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?

🇹🇿 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

🎉 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