WEEK 2: WORKSHOP; MARTERNAL MOTALITY

Question 1

What is Maternal death?

State examples of maternal death.

Answer 1

A maternal death is the death of a woman while pregnant or
within 42 days of termination of pregnancy, irrespective of
the duration and the site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its
management, but not from accidental or incidental causes.

This includes deaths during pregnancy, childbirth, or within six weeks postpartum.

Question 2

Define the following terms:

*Direct obstetrics death

*Indirect obstetrics death

*Coincidental death

Answer 2

Direct obstetric deaths:
* Deaths resulting from obstetric complications of the pregnancy state (pregnancy, labor and the puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.

Indirect obstetric deaths:
* Deaths resulting from previous existing disease or disease that developed during pregnancy, and which were not due to direct obstetric causes, but which were aggravated by physiologic effects of pregnancy.

Coincidental
* Deaths from unrelated causes which happened to have occurred in pregnancy or puerperium.

Question 3

• Every day, approximately how many women die from preventable causes related to pregnancy and childbirth?
• How many % of all maternal deaths occur in developing countries.
• Compare maternal mortality in women living in rural areas and among poorer communities.

*Compare maternal mortality rate among young adolescents and older women.

Answer 3

• Every day, approximately 800 women die from preventable causes related to pregnancy and childbirth.
• 99% of all maternal deaths occur in developing countries.
• Maternal mortality is higher in women living in rural areas and among poorer communities.
• Young adolescents face a higher risk of complications and death as a result of pregnancy than older women.
• Skilled care before, during and after childbirth can save the lives of women and newborn babies.

Question 4

• According to the United Nations Development Programme (UNDP, 2010), Botswana was on track to achieve the MDGs between 1991 and 2005, with maternal mortality ratio dropping from 326 to 135 per 100 000 live births.
• However, since 2006 the ratio has been escalating reaching a peak of 189 in 2011.

State the 3 leading causes of maternal mortality and percentages.

Answer 4

1. Hemorrhage (28%)
2. Eclampsia (16%)
3. Abortion (13%)

Question 5

• Since maternal mortality is relatively a rare event, the comprehensive
  review of each occurrence is essential to identify issues that may
  provide evident interventions useful in improving the overall care of
  women and in preventing future morbidities and mortalities (The
  American Congress of Obstetricians and GynaecologistsACOG, 2010).
• Mandatory maternal mortality audits at institutional and national
  Level for quality assessment in addressing maternal mortality.

Name the policy Botswana has adopted to deal with issues of maternal death.

Answer 5

• Botswana has adopted the Confidential Enquiry into Maternal Deaths
  (CEMD)

Question 6

State the 5 leading causes of maternal mortality in Botswana.

Answer 6

1. Abortions
   2.Hemmorrhage
   3.Hypertensive disorders
   4.Puerperium sepsis
   5.HIV related infections.

Question 7

State Sub-Standard care factors contributing to maternal mortality rate.

Answer 7

• Inappropriate management (26%): where set out
  guidelines and protocols were not followed, and cases were misdiagnosed.

*Delayed intervention (15%): delays in instituting
appropriate investigation and management.

*Delayed referrals (9%): delays in deciding to refer to the next level of care within the same institution or next referral facility

• Lack of supplies and equipment (6%): There were
  shortages of essential urine dip sticks and drugs like magnesium sulphate and oxytocin.
• Lack of blood and blood products (5%): Botswana has a perennial shortage of blood supply and blood products. Most of the blood is obtained from students and the shortage is exacerbated during school holidays and public holidays.

*Due to the country’s high burden of HIV, blood and blood products are in short supply.

• Shortage of transport (1%), in some cases, there was unavailability of transport during an emergency hence contributing to maternal death.

Question 8

State 15 Key Interventions that can be put in place to curb maternal death.

Answer 8

*Obstetrician and Gynecologist to be charged with the task of supervising, supporting and mentoring health care workers on maternal and newborn health care within their catchment area.

• Establish a well-structured orientation package for newly recruited medical personnel
• Strengthen public health education on the importance of early (8 weeks) antenatal registration.
• Mandate use of obstetric record for all pregnant
  women including those monitored during ANC at the private facilities.

*Domiciliary nursing to be strengthened by ensuring provision of transport in all Districts.

• Strengthening of continuing medical education
  regarding the management of obstetric emergencies, for all health care workers as a requirement for professional registration.
• Strengthen documentation of progress of patients on anti-retroviral therapy (ART) in the Botswana obstetric record at Infectious Disease Control Clinic (IDCC).

*Improve screening and management for all
opportunistic infections in all HIV positive pregnant
women.

• Strengthen logistics of postmortem provision to
  reduce waiting time for all maternal deaths and public education on the importance of postmortem.
• Provide screening and management of diabetes for all pregnant women at initial ANC registration, 20 weeks, 36 weeks and consistently document in the Botswana obstetric record
• Strengthening of routine CD4 count measurement in all HIV positive pregnant women and properly documented in Botswana Obstetric Record to avoid delays in initiating HAART
• Establish structured mentoring and support visits for maternal and newborn health within catchment areas by all hospitals
• Strengthen proper documentation through periodic clinical audits including maternal mortality audits

*Improve communication and teamwork by creating clinical discussions on patient care e.g., morning meetings,

• Setting up of functional comprehensive post abortion counselling clinics in all hospitals.
• Strengthen access and utilization of family planning services through community education.