Maternal and neonatal morbidity and mortality

1. Maternal and Neonatal Morbidity and Mortality:
International/National Perspectives and
Complications During Pregnancy, Childbirth and
Postpartum Period Including Neonatal Problems
Presenter: Dipsikha Aryal
MPH 2nd Semester
BPKIHS

2. Contents:
1) Maternal health
2) Reproductive health
3) Maternal morbidity and mortality
4) International and national status
5) Neonatal health
6) Neonatal morbidity and mortality
7) International and national status
8) Three delays
9) Complication during pregnancy, childbirth and postpartum
10)Neonatal health problems
11)Policy and programs of Government of Nepal
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3. Introduction
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4. Maternal Health
Maternal health refers to the health of women during pregnancy, childbirth and
the postpartum period.
Each stage should be a positive experience, ensuring women and their babies
reach their full potential for health and well-being.
The most common direct causes of maternal injury and death are excessive blood
loss, infection, high blood pressure, unsafe abortion, and obstructed labour, as
well as indirect causes such as anemia, malaria, and heart disease.
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Ref: https://www.who.int/health-topics/maternal-health#tab=tab_1
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5. Maternal Health….contd
Most maternal deaths are preventable with timely management by a skilled
health professional working in a supportive environment.
Ending preventable maternal death must remain at the top of the global
agenda. At the same time, simply surviving pregnancy and childbirth can
never be the marker of successful maternal health care. It is critical to
expand efforts reducing maternal injury and disability to promote health and
well-being.
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6. Reproductive health
 Reproductive health is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity, in all matters relating to
the reproductive system and to its functions and processes.
 Reproductive cycle: It includes duration from birth of mother to birth of child.
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7. Eleven core indicators to assess the impact of maternal
health services (key progress indicators)
Impact indicators
 Maternal mortality ratio
 Under 5 mortality rate
 Prevalence of stunting in under 5 children
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8. Coverage indicators
 Met need for contraception
 Four or more ANC visit
 Anti retro viral therapy to HIV positive women to decrease maternal to child
transmission, ARV for pregnant women who are eligible
 Skilled birth attendant at birth
 Post natal check for mother and baby within two days of birth
 Exclusive breast feeding for six month
 Percentage of infant receiving three dose of DPT
 Antibiotics treatment for pneumonia 16:04
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9. WHO’s short list of reproductive health indicators for global
monitoring
 These 17 largely population-based indicators provide an overview of the reproductive health (RH)
situation at the global and national level, endorsed by the WHO and the United Nations Interagency
Working Group.
1. Total Fertility Rate (TFR): Total number of children a woman would have by the end of her
reproductive period if she experienced the currently prevailing age-specific fertility rates throughout
her childbearing life
2. Contraceptive Prevalence Rate (CPR): Percent of women of reproductive age (15-49) who are
using (or whose partner is using) a contraceptive method at a particular point in time
3. Maternal Mortality Ratio (MMR): Annual number of maternal deaths per 100,000 live births
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10. 4. Antenatal Care Coverage: Percent of women attended at least once during pregnancy, by
skilled health personnel (excluding trained or untrained traditional birth attendants), for
reasons relating to pregnancy
5. Percent of Births Attended by Skilled Health Personnel: Percent of births attended by
skilled health personnel (excluding trained or untrained traditional birth attendants)
6. Availability of Basic Essential Obstetric Care: Number of facilities with functioning
basic essential obstetric care per 500,000 population
7. Availability of Comprehensive Essential Obstetric Care: Number of facilities with
functioning comprehensive essential obstetric care per 500,000 population
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11. Indicators contd…
8. Perinatal Mortality Rate (PMR): Number of perinatal deaths per 1,000 total births
9. Low Birth Weight Prevalence: Percent of live births that weigh less than 2,500g
10. Positive Syphilis Serology Prevalence in Pregnant Women: Percent of pregnant women (15-
24) attending antenatal clinics, whose blood has been screened for syphilis, with positive serology
for syphilis
11. Prevalence of Anemia in Women: Percent of women of reproductive age (15-49) screened for
hemoglobin levels with levels 110g/l for pregnant women, and 120g/l for non-pregnant women
12. Percent of Obstetric and Gynecological Admissions Owing to Abortion: Percent of all cases
admitted to service delivery points providing in-patient obstetric and gynecological services, which
are due to abortion (spontaneous and induced, but excluding planned termination of pregnancy)
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12. Indicators contd…
13. Reported Prevalence of Women with FGC: Percent of women interviewed in a community survey reporting having
undergone FGC
14. Prevalence of Infertility in Women: Percent of women of reproductive age (15-49) at risk of pregnancy (not
pregnant, sexually active, non-contracepting, and non-lactating) who report trying for a pregnancy for two years or more
15. Reported Incidence of Urethritis in Men: Percent of men aged (15-49) interviewed in a community survey reporting
episodes of urethritis in the last 12 months
16. HIV Prevalence among Pregnant Women: Percent of pregnant women (15-24) attending antenatal clinics, whose
blood has been screened for HIV and who are sero-positive for HIV
17. Knowledge of HIV-related Prevention Practices: Percent of all respondents who correctly identify all three major
ways of preventing the sexual transmission of HIV and who reject three major misconceptions about HIV transmission or
prevention
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13. Maternal Morbidity
Maternal morbidity is defined as “ Any physical or mental illness or
disability directly related to pregnancy and/or childbirth.”
It can be conceptualized as a spectrum ranging, at its most severe form,
from a maternal near miss to non-life-threatening morbidity, which
is more common by far.
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14. Maternal Mortality
Maternal mortality is defined as “ The deaths of a female from any cause
related to or aggravated by pregnancy or its management (excluding
accidental or incidental causes) during pregnancy and childbirth or within
42 days of termination of pregnancy, irrespective of the duration and site
of the pregnancy.
- WHO
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Ref: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4622
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15. Maternal Mortality
Maternal mortality measurements have significant roles to play in
monitoring health status and well-being in Nepal.
The plan for development as a whole, and for the health sector
specifically, prioritizes mortality reduction as an indicator of the impact
of all socioeconomic development efforts.
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16. Maternal mortality reduction has also been a global, regional, and
national commitment, with a vital role to be played in the Agenda for
Sustainable Development.
A major target under Sustainable Development Goal 3 is to reduce the
global maternal mortality ratio to less than 70 per 100,000 live births.
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Ref: https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf
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17. Indicators of Maternal Mortality
 Maternal Mortality ratio (MMR) =
Number of maternal deaths in a given year *100000
Number of live births in same year
 Maternal Mortality rate=
Number of maternal deaths in a given period * 1000
Number of women aged 15-49 in the same period
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19. International Status
• Every day in 2017, approximately 810 women died from preventable causes related
to pregnancy and childbirth.
• Between 2000 and 2017, the maternal mortality ratio (MMR, number of maternal
deaths per 100,000 live births) dropped by about 38% worldwide.
• 94% of all maternal deaths occur in low and lower middle-income countries.
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Ref: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
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22. Asia
 The average maternal mortality rate in Asia-Pacific is extremely high, at 127 per 100,000
live births, compared to the developed-country average of just 12 per 100,000.
 In 2015, almost 92 per cent of all maternal deaths in the region – around 78,000 – occurred
in just 12 countries.
 Afghanistan, Bangladesh, Cambodia, India, Indonesia, Lao PDR, Myanmar, Nepal,
Pakistan, Papua New Guinea, the Philippines and Timor-Leste all have particularly high
maternal mortality rates, of over 100 deaths per 100,000 live births.
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Ref: https://asiapacific.unfpa.org/en/news/maternal-mortality-asia-pacific-5-key-facts
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23. Nepal
The maternal mortality rate for women age 15-49 is 0.20 deaths
per 1,000 women years of exposure.
The maternal mortality ratio for the period 2009-2016 is 239
deaths per 100,000 live births. The confidence interval ranges from
134 to 345.
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Ref: https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf
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24. MMR decline from 1996-2016 with targets to 2030
539
281
239
125 116 99
70
NDHS 1996 NDHS 2006 NDHS 2016 TARGET 2020 TARGET 2022 TARGET 2025 TARGET 2030 16:04
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25. Maternal Mortality / Institutional Delivery
25
539
281
259
125
116
99
70
0
100
200
300
400
500
600
NDHS
1996
NDHS
2006
NDHS
2016
Target
2020
Target
2022
Target
2025
Target
2030
Per
100,000
live
births
Maternal Mortality Ratio
(1996-2016)
0
10
20
30
40
50
60
70
80
90
NDHS
1996
NDHS
2001
NDHS
2006
NDHS
2011
NDHS
2016
Target
2020
Target
2022
Target
2025
Target
2030
Institutional Delivery
8 9
18
35
57
70
74
79
90
%
Institutional Delivery

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27. Brief explanation of major causes of maternal death
 Postpartum hemorrhage (also called PPH) is when a woman has heavy bleeding after
giving birth. It’s a serious but rare condition. It usually happens within 1 day of giving
birth, but it can happen up to 12 weeks after having a baby. About 1 to 5 in 100 women
who have a baby (1 to 5 percent) have PPH.
 Preeclampsia and eclampsia are pregnancy-related high blood pressure disorders.
Preeclampsia is a sudden spike in blood pressure. Eclampsia is more severe and can
include seizures or coma.
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28. Causes contd…
 Infection: Puerperal sepsis was defined as infection of the genital tract occurring
at any time between the onset of rupture of membranes or labour, and the 42nd day
postpartum in which two or more of the following are present: Fever (oral
temperature 38.5°C/101.3°F or higher on any occasion)
 Abortion: the deliberate termination of a human pregnancy, most often performed
during the first 28 weeks of pregnancy.
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29. Causes contd…
 Obstetric complication: Defined as an acute condition arising from a
direct cause of maternal death, such as antepartum or postpartum
hemorrhage, obstructed labor, postpartum sepsis, complications of
abortion, pre-eclampsia or eclampsia, ectopic pregnancy, and ruptured
uterus, or indirect causes such as anemia.
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30. Neonatal Health
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31. Definition
Neonate- A neonate is a baby who is 4 weeks old or younger.
Neonatal morbidity- A disease condition or state during first 28 days of
life. Includes hypoglycemia, hypocalcemia, hyperbilirubinemia,
polycythemia.
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32. Neonatal Mortality
Neonatal mortality: The death of a live-born baby within 28 days of life.
Sub-divided into two:
Early neonatal deaths: deaths between 0 and 7 completed days of birth.
Late neonatal deaths: deaths after 7 days to 28 completed days of birth.
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33. Indicators of Neonatal Mortality
 Neonatal mortality rate=
Number of neonatal deaths in a given year * 1000
Total number of live births in the same year
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34. INDICATORS
Infant mortality rate=
Number of deaths of children less than 1 year of * 1000
age in a year
Number of live births in the same year
Under 5 mortality rate=
Number of deaths of under 5 children in a year * 1000
Number of live births in the same year
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35. International status
• Although the global number of newborns deaths declined from 5 million in 1990 to
2.4 million in 2019, children face the greatest risk of death in their first 28 days.
• In 2019, 47% of all under-5 deaths occurred in the newborn period with about one
third dying on the day of birth and close to three quarters dying within the first
week of life.
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Ref: https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality
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36. International status …contd
 The average global neonatal mortality rate (NMR) in 2018 is 18 per 1000 live
births.
 Globally 2.5 million children died in the first month of life in 2018.
 Approximately 7000 newborn deaths every day with about one third dying on
the day of birth and close to three quarters dying within the first week of life.
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37. INTERNATIONAL STATUS OF NEONATAL
MORTALITY
Ref: https://www.who.int/gho/child_health/mortality/neonatal/en/
27.2 25.9
20.2
7.4
5.8 4.6
0
5
10
15
20
25
30
Africa Eastern Mediterranean South east Asia Americas Western Pacific Europe
Average Neonatal mortality rate per 1000 live births by WHO region
average Neonatal mortality rate per 1000 live births
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38. National Status
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39. National Status
 NMR is 21 deaths per 1,000 live births in the most recent 5-year period. (NDHS
2016)
 In 2015, approximately 600,000 babies were born in Nepal, or around 1,600 every
day.
 Approximately 34 babies will die each day before reaching their first month ; 28
stillbirths occur every day.
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40. National Status…contd
NMR in rural areas is 24 deaths per 1,000 live births and 15 deaths
per 1,000 live births in urban areas.
NMR among the poorest households is 32 deaths per 1,000 live births,
compared to 14 deaths per 1,000 live births among the richest
households.
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43. Targets and Indicators
Baseline
2015
Target
2019
Progress
2019
Target
2030
3.1. By 2030, reduce the global maternal mortality ratio
3.1.1 Maternal mortality ratio
258 125 239 70
3.1.2 Proportion of births attended by skilled health personnel
55.6 69 79.3 90
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age
3.2.1 Under-five mortality rate
38 28 28 20
3.2.2 Neonatal mortality rate
23 18 16 12
12/5/2021
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44. Three Delays
 The three delays model developed by Thaddeus and Maine 1994 is the most common
framework used to evaluate the circumstances surrounding a maternal death. The
"Three Delays" model proposes that pregnancy-related mortality is overwhelmingly
due to delays in:
(1) deciding to seek appropriate medical help for an obstetric emergency;
(2) reaching an appropriate obstetric facility; and
(3) receiving adequate care when a facility is reached.
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46. First delay
Related to:
 Low status of women
 Poor understanding of complications and risk factors in pregnancy and when to
seek medical help
 Previous poor experience of healthcare
 Acceptance of maternal death
 Financial implications
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47. Second delay
Related to:
 Distance to health centers and hospitals
 Availability of and cost of transportation
 Poor roads and infrastructure
 Geography eg mountain and rivers
 Types of transport and quality of roads
 Performance of referral system between facilities
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48. Third delay
Related to:
 Quality of care such as the number and training of staff members
 Availability of blood supplies and essential equipment
 Poor facilities and lack of medical supplies
 Poor motivated medical staff
 Inadequate sanitation
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49. Fourth delay
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53. Complications
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54. Complication during pregnancy
Pregnancy, while one of the most stressful and uncomfortable times of a
woman's life, is also one of the most exciting and remarkable times of a
woman's life with the heavy anticipation of delivering her baby.
Each trimester is outlined with what happens and what to expect, the
duration of each, what happens to the fetus and common complications
that may arise to be on the lookout for.
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55. First trimester
For mother
Bleeding, Miscarriage, hyperemesis gravidarum, ectopic pregnancy.
Hormonal changes due to which women may experience fatigue, tender,
swollen breasts, vomiting, mood swings, weight loss or gain.
For the baby
Blighted ovum, spontaneous abortion, chromosomal abnormalities.
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Ref: https://www.birthinjuryhelpcenter.org/complication-pregnant.html
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56. Second trimester
For Mother
Gestational diabetes, miscarriage, infections, incompetent cervix, placenta
abruptions
Other includes: Body aches, stretch marks, patches of dark skin, swelling
of ankles fingers and face
For baby
Genetic problems, spontaneous abortion, Intra uterine growth restriction. 16:04
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57. Third trimester
For Mother
Gestational diabetes, preeclampsia, preterm labor, preterm rupture of the
membrane, placenta previa, post term pregnancy, malpresentation.
For baby
Still birth, birth defect, intrauterine growth restriction.
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Ref: https://www.birthinjuryhelpcenter.org/complication-pregnant.html
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58. Complication during childbirth
• Prolonged and obstructed labour
• Perineal tears
• Problems with the umbilical cord
• Fetal distress
• Early rupture of the membrane
• Perinatal asphyxia
• Shoulder dystocia
• Meconium stain
• PPH
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Ref: https://www.nichd.nih.gov/health/topics/labor-delivery/topicinfo/complications
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59. Complication during postpartum period
• Cardiovascular diseases.
• Other medical conditions often reflecting pre-existing illnesses.
• Infection or sepsis.
• Excessive bleeding after giving birth (hemorrhage)
• Cardiomyopathy
• Stroke
• High blood pressure (hypertensive) disorders of pregnancy
• A rare but serious condition that occurs when amniotic fluid or fetal material, such as
fetal cells, enters the mother's bloodstream (amniotic fluid embolism)
• Post partum depression
• Anesthesia complications
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Ref: https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/postpartum-complications/art-20446702
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60. Neonatal Health Problems
• Prematurity
• Respiratory disorders
• Low blood sugar (glucose)
• Severe infections (for example, sepsis )
• Heart problems
• Metabolic disorders
• Hydrocephalus
• Birth defects.
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Ref: https://www.msdmanuals.com/home/children-s-health-issues/general-problems-in-newborns/overview-of-
general-problems-in-newborns
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61. Policy and programs of GoN to reduce maternal
and neonatal mortality:
 National Safe motherhood program
 Aama Surakshya Program
 Skilled birth attendant policy (2006)
 National blood transfusion policy (2006)
 Rural ultrasound program
 Expansion of quality improvement of delivery sites
 Safe abortion services
 Newborn care program
 Heli lifting
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62. Community level maternal and newborn health
care interventions:
 Jeevansurakshya package
 Matri surakshachakki (misoprostol)
 Free ambulance service provided by some rural municipalities
 Increasing allowance of staff by municipality/ rural municipality involved in
obstetric care
 Providing nutritious food to pregnant women
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Ref: *DoHS-Annual-Report-FY-2076-77-for-website.pdf
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63. References
1) National Institute of Health: https://www.nichd.nih.gov/health/topics/labor-delivery/topicinfo/complications
2) Birth Injury help center: https://www.birthinjuryhelpcenter.org/complication-pregnant.html
3) World health organization https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4622
4) Ministry of Health - MOH/Nepal, New ERA/Nepal, and ICF. 2017. Nepal Demographic and Health
Survey 2016. Kathmandu, Nepal: MOH/Nepal, New ERA/Nepal, and ICF.
5) https://dohs.gov.np/wp-content/uploads/2021/07/DoHS-Annual-Report-FY-2076-77-for-website.pdf
6) https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/postpartum-complications/art-
20446702
7) https://www.msdmanuals.com/home/children-s-health-issues/general-problems-in-newborns/overview-of-
general-problems-in-newborns
8) http://www.inquiriesjournal.com/articles/708/maternal-mortality-in-nepal-addressing-the-issue
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