This program is brought to you by Emory University. Hi, I'm Lynn Sibley Professor at Emory Universities Nell Hodgson Woodruff School of Nursing, and Rollins School of Public Health. I would like to invite you today, for the first module in the course, Childbirth A Global Perspective. We are filming in the Woodruff Health Science Center Plaza. It's a lovely, lovely place. Let's get started. Maternal health is health of women during pregnancy. Childbirth and the 42 days after childbirth, what we call the postpartum period. The experience of childbirth is also very fulfilling. Yet, for far too many women in the world, it is a time of suffering and even death. In this first module, I will give an overview of maternal mortality. I will talk about what is a maternal death. The extent, distribution and causes of maternal death. And who is most likely to die? Then I will talk about the very encouraging signs of progress over the past two decades. What still needs to be done to accelerate that progress, and what you yourself can do to help stop this tragic, because it's unnecessary, and preventable loss of life. Our knowledge about the extent and causes of maternal death at a global level is quite recent. Just under 30 years. The newly emerging information about maternal mortality lead to the first international Safe Motherhood Conference held in Nairobi, Kenya in 1987. This seminal conference raised global awareness of devastating maternal death rates and formally established the Global Safe Motherhood Initiative. The initiative's two main goals were to highlight the plight of child-bearing women and reduce maternal mortality by 50%, by the year 2000. Initially, funding agencies, the United Nations, or UN Agencies. Which include the World Health Organization, UNICEF, the United Nations Fund for Population Activities, the World Bank, and partner governments. Focused on two main strategies to reduce maternal mortality. These strategies were to increase the availability of antenatal care. And to train traditional birth attendants, or lay midwives, to better reach women, especially those women living in rural areas. By the year 2000, however, the goal of reducing maternal mortality by 50% was far from realized. The global community then reaffirmed it's commitment to safe motherhood in 2000, when the U.N. member states issued eight millennium development goals, or MDGs. To accelerate progress to overall human development. The fifth goal, MDG5, targeted a reduction in the maternal mortality ratio by 75%, and universal access to reproductive health services both by 2015. Let's take a look at what has happened by drawing on the recently published trans and maternal mortality 1990 to 2013 published by the UN agencies and the World Bank. This document is referenced at the end of this module. Lets begin with a few definitions. In the International Statistical Classification of Diseases and Health Problems, tenth revision. That is the ICD-10. The World Health Organization defines maternal death as a 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 pregnancy or it's management. But not from accidental or incidental causes. This definition allows for the identification of maternal deaths based on cause as either direct or indirect. A direct maternal death is one that results from obstetric complications of pregnancy, childbirth and the post partum. Including interventions, as well as omissions or incorrect treatments. Or a chain of events resulting from any of the above. For example, a death that is due to severe bleeding, or high blood pressure. Or complications of anesthesia, or a cesarean section is classified as a direct maternal death. An indirect maternal death is one that results from a previously existing disease. Or from a disease that develops during pregnancy and that may be aggravated by the physiologic effects of pregnancy. For example, a death due to the worsening of an existing heart condition or infectious disease is classified as an indirect maternal death. The concept of death during pregnancy, child birth, and the postpartum included in the ICD-10, is also defined as any death related to pregnancy, child birth, or the postpartum. Even if it is due to accidental or incidental causes. This broader definition allows the measurement of deaths, that are related to pregnancy but they do not strictly conform to the standard definition of maternal death. This broader definition is especially important than settings where accurate information about the cause of death is limited or unavailable. In addition, complications of pregnancy or childbirth can lead to death after 42 days postpartum. This is especially true with the increased availability of modern life sustaining procedures. The ICD-10 now has a code for capturing late maternal deaths. Occurring between 42 days and one year postpartum. Some countries, with more developed civil registration systems, use this classification. The World Health Organization aims to achieve a globally consistent set of estimates in maternal death, in line with the ICD-10 definitions. However, accurate identification and classification of the cause of maternal death is not always easy, or even possible, in fact it is quite challenging. In countries with good civil registration systems and good assignment of the cause of death data on the extent and causing maternal brutality are generally accurate. Yet even in these countries, there may be under reporting. This happens as a result of mis-classification or the incomplete recording of information. Under-reporting due to mis-classification, for example, may result from a failure to identify deaths during early pregnancy and or the late postpartum. Or deaths, at the extremes, of maternal age. It may result from confusion about classifying the cause of death, as direct, or indirect. Or as accidental or incidental, or from a lack of understanding of the ICD-10 rules for coding. Fortunately, in 2012, the World Health Organization published the application of ICD-10 to deaths during pregnancy, childbirth, and the postpartum. ICD maternal mortality, to help reduce errors in the coding in maternal deaths. This guidance is a tremendous help to countries, and to those that are tasked for the cause of death assignment. In countries with incomplete civil registration systems, it is very difficult to accurately measure the extent and causes the maternal death. For example, the deaths of women of reproductive age might now be recorded at all, particularly where many births occur at home. Even if such deaths are recorded, the pregnancy status or cause of death may be unknown. So that the deaths are not reported as maternal deaths. And in countries where medical certification of cause of death does not exist, accurate assignment of a female death as a maternal death is especially challenging. Global estimates of maternal mortality where civil registration systems are incomplete, or do not exist. Are based on data obtained from a variety of sources, including censuses, household surveys, reproductive-age mortality studies, and verbal autopsies. I will not describe these approaches now. Further information can be found in the Trends in Maternal Mortality, 1990 to 2013 document. Suffice it to say, each of these approaches has limitations when it comes to estimating the true extent and causes of maternal mortality. The estimates are necessarily based on statistical modeling. Let's now take a look at measures in maternal mortality. The extent of maternal mortality in a population is a function of two things. One is the risk of death in a single pregnancy or live birth. The other is a fertility rate. That is the number of pregnancies or birth that are experienced by women of reproductive age in the population. Although there are various measures of maternal mortality, I want to highlight three measures because I will use these today. The first measure is the maternal mortality ratio, called the MMR. The second is the adult lifetime risk of maternal death. And the third measure is the proportion of maternal deaths. Each of these measures gives a slightly different, but important picture. The MMR, the most common measure of maternal death, is defined as the number of maternal deaths during a given time period per 100,000 live births during the same time period. The adult lifetime risk of maternal death is defined as a probability that a 15 year old woman will eventually die from a maternal cause. This measure takes into account both the MMR and also the total fertility rate. So for example, compared with women who have fewer pregnancies, women in high fertility settings face a risk of maternal death multiple times. The last measure, the proportion of maternal deaths, is defined as a number of maternal deaths in a given period, divided by the number of deaths among women of reproductive age, 15 to 49 years, from all causes.
