Understanding Maternal Mortality using the medical and social contexts. In explaining the social contexts, the presentation will present a case of the Zuellig Family Foundation on Maternal Death Reviews.

1. Maternal Mortality
Understanding the Biological and
Social Contexts
Jeromeo Jose
11382333
Biological and Social Foundations of Health
MAHESOS

2. The great divide of Maternal Mortality
Everyday, 800 women die
from pregnancy and
childbirth
Developing countries
Developed Countries
99%
• Who are the most
susceptible?
– Women living in rural
areas and poor
communities
– Young adolescents
– Women who do not
receive care (pre, during
and post)

3. The Philippine Context
162
221
0
50
100
150
200
250
'08 '09 '10 '11
Philippines Maternal Mortality
RP MDG
Source: Department of Health

4. What do we mean by maternal death?
• a 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 (ICD-10)

5. Medical causes of death and
treatment (WHO, 2011)
• Post partum hemorrhage
– World’s leading cause of maternal mortality
– 127,000 maternal deaths annually
– may cause up to 50% percent of all maternal
deaths in developing countries
– Medicines
• Oxytocin: 10 IU in 1-ml ampoule
• Sodium chloride: injectable solution 0.9% isotonic
or Sodium lactate compound solution – injectable
(Ringer’s lactate)

6. Medical causes of death and
treatment (WHO, 2011)
• Severe Pre-eclampsia and Eclampsia
– Major health problems in developing countries.
– Every year, eclampsia is associated with an
estimated 50 000 maternal deaths worldwide.
– Medicines
• Calcium gluconate injection (for treatment of
magnesium toxicity): 100 mg/ml in a 10-ml
ampoule
• Magnesium sulfate: injection 500 mg/ml in a 2-ml
ampoule, 500 mg/ml in a 10-ml ampoule

7. Medical causes of death and
treatment (WHO, 2011)
• Maternal sepsis
– Infection can follow an abortion or childbirth and is a
major cause of death.
– Sepsis not related to unsafe abortion accounts for up
to 15% of maternal deaths in developing countries.
– Medicines
• Ampicillin: powder for injection 500 mg; 1 g (as a
sodium salt) in vial
• Gentamicin: injection 10 mg; 40 mg /ml in a 2-ml vial
• Metronidazole: injection 500 mg in a 100-ml vial
• Misoprostol: tablet 200 μg

8. Medical causes of death and
treatment (WHO, 2011)
• Sexually transmitted infections
– Nearly a million people acquire a sexually transmitted
infection, including HIV, every day.
– The results of infection include acute symptoms, chronic
infection, and serious delayed consequences such as
infertility, ectopic pregnancy, cervical cancer, and the untimely
deaths of infants and adults.
– Medicines
• Uncomplicated genital chlamydial infections: Azithromycin:
capsule 250 mg; 500 mg or oral liquid 200 mg/5 ml
• Gonococcal infection – uncomplicated anogenital infection:
Cefixime: capsule 400 mg
• Syphilis: Benzathine benzylpenicillin: powder for injection
900 mg benzylpenicillin in a 5-ml vial; 1.44 g benzylpenicillin in a
5-ml vial

9. Maternal Death Review
18 deaths in 82 LGUs (9 audited cases)
Top causes of
maternal
deaths
Placenta Previa/PPH
Eclampsia
Sepsis
others
56%
22%
11%
11%
Gravida
Status
Gravida Percentage
Prima Gravida 11%
2 – 4 33%
Multi Gravida 53%
Interventions: Preventive measures:
1. Map catchment areas
2. Augment human resources (competency & number) / health
facilities /equipment
3. Implement well-coordinated referral and return referral
systems, including transportation to and from home to facility
4. Improve access to medicines for obstetric emergencies like
anti-hypertensive meds
1. Pregnancy Tracking System, early
detection of high-risk patients
2. Birthing plans for high-risk patients
3. Skills Training (BEMONC, Life-saving
Skills) for birth attendants
4. FP counselling and access to FP
commodities
Referral
Hospital
44%
RHU/
BHS
12%
Home
44%
SBA=67% vs Hilot=33%
Hilots now referring pregnant
women albeit usually late
Maternal Deaths

10. Systems Approach to addressing
Maternal Mortality
• 6 Building Blocks (Technical)
– Governance, Human
Resource, Financing, Medicines, Health
Info, Service Delivery. (WHO)
• Local leadership is the key to changing
systems and innovating programs that lead to
better health outcomes (ZFF, 2012)
– Focused on Mayors and MHOs who decide to
change the health system, through meaningful
engagements and new arrangements with other
stakeholders.

11. Road Map
• A way to analyze the health situation in
municipalities including gaps and challenges
• A road map to weigh options and set priorities
• A scorecard to measure accomplishment.
Intervention on Health Systems Transformation: Municipal Basic Health System’s Technical Roadmap
Leadership &
Governance Health Financing Health Human
Resource
Access to
Medicine &
Technology
Health
information
System
Health Service Delivery
MunicipalHealthGovernance
Municipal
Health Action
Plan
HealthResourceGenerationand
Management
LGU Budget for
Health
(15% IRA)
RHUandBHSResourcemanagement
Health Human
Resource Adequacy at
the RHU
(MD 1:20,000)
(Nurse 1:20,000)
DrugManagementSystem
Presence of
Essential
Medicine at the
RHU
(Stock Basis)
DataCollection,UtilizationandInformationDissemination
Accomplished
Baseline Data
Collection
BarangayHealth
Infrastructure
Presence of Barangay Health Stations
(1 BHS:1 Braangay or 1 BHS per
Catchment)
Maintenance and Operations
Utilization
Actual budget
Utilization
(95% Utilization)
RHU HHR
Competency
Available Transportation for Emergency
Regular Data
Gathering and
Recording
MaternalandChildCare
Sustainable
Maternal
Health
Care
Initiatives
Pre-Natal Services
(at least 80%)
Full Implementation
of Magna Carta for
Public Health WorkersExpanded and
Functional
Local Health
Board
Facility-Based Devleiries
(85%)
BLGU Health
Budget
(5% of Barangay
IRA)
Skilled Birth Attendants
(85%)
Installed Performance
Management System Sustainable
Breastfeedi
ng
Initiatives
Exclusive Breastfeeding for
Infants (70%)
RHU Medicine
Tracking and
Inventory
System
Maternal/Infant
Death Review
Newborns Initiated
Breastfeeding (85%)
BarangayHealthGovernance
Functional
Barangay
Health
Governance
Body
(with functional
CHT)
LocalPhilhealthAdministration
4-in-1
Accreditation
Sustainable Essential
Intrapartum and Newborn
Care Initiatives
Health Human
Resource Adequacy in
BHS
(1 Midwife: 1 Brgy;
with consideration to
GIDA)
(BHW to HH 1:20HH)
Sustainable
Infant and
Child Care
Initiatives
Fully Immunized Child
(95%)
Regular IEC for
Enrolled Indigent
(for Q1 and Q2)
Monthly Updated
Health Data
Board
Under-5 Malnutrition
Prevalence Rate
(Below 17.3%)
BHS HHR Competency
(Basic BHW Training
Course and CHT
Training)
Accomplishment,
Utilization and
Dissemination of
the DILG, DOH
LGU Scorecards
ReproductiveHealth
Sustainable Adolescent Reproductive
Health Initiatives
Reimbursement
Filing
(PCB, MCP, TB-
DOTS) Sustainable
Family
Planning
Initiatives
Provision of FP
Commodities and Services
(RHU)
Implemented
and Integrated
Barangay
Health Plan
Contraceptive Prevalence
Rate (63%)
System for BHW
Recruitment and
Retention
Mechanisms Creation of
Citizen’s Chrater
Ordinance and
System for Claims
Disposition and
Utilization
Monitoring
Ratio of
Community-
Based
Pharmaccy
(1 BNB/CBP
catchment or 1
BNB per
barangay)
Unmet Needs
(50% under NHTS)
WaSH
Sanitary Toilets
(86%)
Ordnance and Timely
Provision of BHW
Honorarium
Access to Safe Water
(87% of HH)

12. Progress of LGUs vis-a-vis building blocks
Leadership &
Governance
Majority have reactivated and expanded membership of their local
health boards
Activating barangay health boards a work in progress in most LGUs
Human Resources
Most have hired additional personnel but ideal ratios have yet to be
met
Financing
33 of 82 (40%) LGUs have 4-in-1 Philhealth accreditation
Non-ARMM LGUs have increased health budgets to 10% or above
Still working on having barangays raise their health budgets to 5%
Continuous & close coordination with DOH-ARMM & Philhealth led
to release of much-needed reimbursements to LGUs in the region

13. Medicines
Procurement and inventory systems have been fixed at
the RHU but availability of medicines in barangay health
stations needs to improve in cohorts that have ended
the 2-year partnership
Accessibility, procurement & inventory systems are
being improved in other LGUs
Service Delivery
LGUs have created their own innovative programs to
address issues
Information systems
Systems of reporting & recording have improved
Need to improve ability to analyze data
Need to strengthen mortality audit system
Progress of LGUs vis-a-vis building blocks

14. Health Outcomes (SLAM, Cohort 3)
207
73
153
106
70
212
0
50
100
150
200
250
'08 '09 '10 '11 '12 '13
SLAM and Cohort 3 MMR
Cohort 3 SLAM
141
68
41
0
Cohort 3
Sources: FHSIS for ZFF ARMM municipalities

15. Working on Health Seeking Behavior
2.47
5.30 5.94 16.96 22.12
16.52 14.91 33.62
2.47
5.30
12.99
15.59
29.44
0
5
10
15
20
25
30
35
40
'08 '09 '10 '11 '12
Facility Based Deliveries Trend
(ARMM)
Cohort 1 Cohort 3 ARMM Cohort
51.44 49.12 39.74 41.88 34.21
73.41 69.53 72.41
51.44
49.12
62.18 60.31 59.68
0
10
20
30
40
50
60
70
80
'08 '09 '10 '11 '12
Deliveries Attended by Skilled Birth
Attendants (ARMM)
Cohort 1 Cohort 3 ARMM Cohort
Sources: FHSIS for ZFF ARMM municipalities

16. Conclusions
• Medical and social factors are important to be
understood.
• There is a technical solution that can be
implemented – medical
response, strengthening the health system
(6BB)
• Leadership will ensure that more stakeholders
gain ownership of the issue.

17. No mother should die giving life...