Maternal Mortality Surveillance System

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					 Maternal Mortality
Surveillance System
          Bangkok, September 6, 2007

        Presented by Dr. Nahla Roushdy
Assistant General Director of MCH Department
    Ministry of Health and Population (Egypt)
27 Governorate
256 District
5000 PHC
Introduction
The Tenth Revision of the International
Classification of Diseases (ICD-10) defines a
maternal death as: 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.
• MOHP supported by USAID carried two national
  maternal mortality studies to estimate maternal
  mortality ratio:-
   –   National Maternal Mortality Study 1992
   –   National Maternal Mortality Study 2000
• MOHP recognized the importance of collecting
  maternal mortality data on a regular basis as a tool
  for policy makers to achieve safe motherhood
  strategy.
• Hence MOHP decided to plan and implement
  a National Maternal Mortality Surveillance
  System (NMMSS) utilizing its potentials.

• A ministerial decree was issued to request
  notification of all maternal deaths to MCH
  department and National Health Information
  Center (NHIC) at all levels .
• Health offices (5000).
• Accurate registration of births and deaths is
  emphasized and monitored.
          Maternal Mortality
         Surveillance System
Objectives:-
• Identification of maternal deaths.
• Determination of maternal mortality ratio at
  the national and governorate level.
• Determination of causes and avoidable factors
  of maternal deaths.
• Development of Improvement Plans and
  taking action to avoid future maternal deaths.
         Steps of Implementation
• Modify death notification form and registers
• Design Maternal Mortality Surveillance System
  Questionnaire
• Design software to collect and analyze data
• Train appropriate staff on how to collect and process
  data on maternal deaths.
• A Ministerial Decree No. 197/2002, was issued to
  form a National Safe Motherhood Committee headed
  by His Excellency Minister of Health and Population
  and encompassing head of all related            health
  sectors.
• Form local Safe Motherhood Committees at
  governorate level
Data Collection Forms
Death Notification Form
       Reproductive Age Moralities
                 (15-49)

  Did the death occur during pregnancy ?      Yes    No
  Did the women have an abortion during the   Yes    No
  six weeks prior to death?
  Did the death occur during labor and        Yes    No
  delivery?
  Did the death occur during the six weeks    Yes    No
  after delivery?
Date of delivery: …………………. Outcome            S.B   L.B
Place of delivery : ………….     Attendant of delivery : ………….
             Maternal Mortality
         Surveillance Questionnaire
                   (MMSQ)
•   Demographic Information
•   Personal Data
•   Obstetric History
•   Prenatal Care History
•   Information about current pregnancy
 MMSQ Cont.
• Information about current labor and delivery
  (Place, attendant, time/duration, method,
  complication, referral, transportation,
  management, medications, blood transfusion, etc)
• Place / date / time of death
• Direct cause of death
• Underlying cause of death
• Other contributing factors
• Information about newborn
               Safe Motherhood
              Committee Decision
Governorate         District                 H. Office
DNFN
Name of deceased women …………………                   Age
Place of residence ……………………………………..
                 .…………………………………………
 Was Death could be avoidable          Yes          No

 If Yes / Factors could be avoidable
  A) Service Providers Factors
Sub standard A.N.C from Obstetrician , G. P, Nurse / Midwife
  B) Women and Family Factors
  - Delay in recognizing problem / Seeking medical care
  - No A.N.C
  - Unwanted pregnancy
  C) Health Facility factors
  - Lack of blood, drugs, supplies and equipment
  - Lack of anesthesia
  - Lack of transportation
  - Long distance to hospital
    Continuous Monitoring of
     The Maternal Mortality
      Surveillance System
1: Performance Check at the Health Offices

2: Performance Check at the District level

3: Performance Check at the Governorate level
Maternal Mortality
Surveillance Cycle
                 Hospital                                     Home



               Interview          Health Offices                  Interview
       DNF
                                Health Officer/Clerk




      MMSQ                        District Health Offices
                            District Assistant Director for MCH



 Avoidable factors
And causes of death          Governorate Health Directorate
                              Safe Motherhood Committee
 Improvement Plan
                                DNF
                               MMSQ
                              Central MCH Department
                             Safe Motherhood Committee
Results
Female deaths, Maternal deaths, and
     Maternal mortality ratios
                     # Female                              %
                    Death (FD)        # Maternal
    Years                                                MD/ FD   MMR
                                      Death (MD)
                   (15-49 years)
NMMS 92                7487               772            10.3 %   174
NMMS 2000               8497              585            6.9 %    84
NMMSS 2004             21553              1251           5.8 %    68
NMMSS 2006             22292              1143           5.1 %    59

NMMS : National Maternal Mortality survey
NMMSS: National Maternal Mortality surveillance system
The pattern of maternal mortality per 100,000 live
          birth in Egypt from 1992-2006
      180
            174
      160
      140
      120
      100
       80
                      84
       60
                               68
       40                               59
       20
        0
            92-93    2000     2004     2006
      Maternal Mortality Ratios
250         1992 - 2006
                                          217

200   174

150                        132

                66%               56%             73%
100
                     59              58                 59
 50

  0
            Total          Lower Egypt    Upper Egypt
              1992        2000    2004     2006
  Time Of Maternal Death 2006
100
80
                         46.9
60
                                        29.7
40       23.4
20
  0
        During    During Delivery   Postpartum
      Pregnancy
 Place Of Maternal Death 2006

100
                        72.6
 80
 60
 40     27.4

 20

 0
      Home       Health Facility
     Direct and Indirect
Causes Of Maternal Death 2006
 100%

         69.5%
 80%

 60%
                     30.5%
 40%

 20%

  0%
        Direct    Indirect
   Direct Cause of Maternal Death 2006
          Postpartum
          He morrhage                                               33.4

Hype rte nsiv e disease                           16.7

          Ante partum
          He morrhage
                                     5.1

                Se psis               5.9

     Rupture d uterus                5.4

   Obstructe d labour                  5.9

              Abortion        1.9

               Ectopic         0.2

                          0            5     10   15     20   25   30      35
     Direct Causes of Maternal Death
                                             NMMS        NMMS    NMMSS
                Cause                                     2000    2006
                                              1992
Postpartum hemorrhage                          35.7       34      33.4
Antepartum hemorrhage                          11.6        9      5.1
Hypertensive disease                           15.9       22      16.7
Sepsis                                          12         8      5.9
Ruptured uterus                                 9.6        8      5.4
Obstructed Labour                               4.4        5      5.9
Abortion                                        6.4        4      1.9
Ectopic                                         0.8        1      0.2
NMMS : National Maternal Mortality survey
NMMSS: National Maternal Mortality surveillance system
 Indirect Cause of Maternal Death2006
        Cardiov ascular                                                    13.2

                 Ane mia                    3.7

Infe ctious and Parasitic       0.6

     Urological dise ase         1.3

 Ne urological disorde r          1.5

     dige stiv e dise ase                         4.7

             Ne oplasm           1

               Diabe te s         1.6

          Othe r Indirect                                   7.3

                            0           2         4     6         8   10   12     14
  Percentage of deliveries conducted by
  Skilled Personnel /at health facilities
100
 90
                                                        74
 80
 70                               61
 60
                    46                                    65
 50
      35
 40                                    48
 30
                       33
 20
        23
 10
  0
      1990         1995           2000                  2005

             Skilled Personnel   at health facilities          DHS
     “I was impressed by the amount of the data being
collected. It appears that Egypt has an excellent vital
statistics system. Vital statistics are the backbone of
any maternal and child health surveillance”.
    “Significant efforts and resources have been
expended to develop models of maternal mortality
surveillance which can be expanded into a nationwide
maternal mortality surveillance system”.


                                  WHO Consultant
                            HANI K. ATRASH, M.D., M.P.H.
                             CDC Atlanta, Georgia, USA
                                     OCT, 1998
       “The surveillance system has been refined to
be more simple, efficient, useful to health care
managers and providers, and acceptable to its
participants”.
      “I am highly impressed by the progress that
has been made in implementing the MMSS at all
levels and congratulate staff at the MOHP, USAID,
and JSI for the excellent work”.

                                  WHO Consultant
                            HANI K. ATRASH, M.D., M.P.H.
                             CDC Atlanta, Georgia, USA
                                     Feb, 2004
    Challenges and Future Actions
• Improving antenatal care, referral system, hospital
  management, pre-service and in-service training of
  health providers, and management of obstetric
  complications and emergencies.
• Actions to ensure that women and their families are
  better informed about the importance of family
  planning and antenatal care, and to ensure that they
  recognize and act on complications during pregnancy
  and delivery
•   Actions to ensure that women and their families
    are better informed about the importance of family
    planning and antenatal care, and to ensure that
    they recognize and act on complications during
    pregnancy and delivery
•   Create community awareness with the role of
    health facilities and the services provided to
    increase community demand and expand benefit.
•   Cooperate with NGOs and private sector to
    provide     distinguished    reproductive   health
    services.
•    Further reduction of maternal mortality and
    achieving MDG 5 is likely to happen soon in Egypt
Thank you