Maternal Mortality in Papua New Guinea and Australia

Maternal Mortality in Papua New Guinea and Australia Max Brinsmead MB BS Ph. D December 2017

Definition The number of women who die from pregnancy- related or pregnancy-aggravated disease Up to 6 weeks postpartum Per 100, 000 babies liveborn Ranges from 6500 in rural Afghanistan to Less than 10 in most of the developed world Has risen from <400 in PNG to >600 Was 141 at PMGH in 2010 (17 deaths) Worldwide average is 400

Maternal mortality should take into account. . . The number of children a woman has This will be reflected in the lifetime risk of pregnancy-related death Worldwide average is 1: 74 Ranges from 1: 6 in Sierra Leone to 1: 30, 000 in Sweden

Maternal Mortality at PMGH in 2010 Haemorrhage PPH (7 women) With APH in two of these One with acute uterine inversion Infection (Sepsis and or septic shock) In 7 women in total Two with malaria One with HIV One with TB Hypertensive Disease In 3 women in total One death associated with Caesarean section One death due to Amniotic Fluid Embolism

Aggravating Factors Chronic anaemia Malnutrition Malaria TB HIV Associated with up to 50% of maternal deaths in high prevalence areas And has doubled MMR in many countries

Reducing Maternal Mortality General Measures Reducing poverty Better nutrition More education Improving the status of women Improving access to health care Appropriate healthcare staff and facilities Antenatal care and screening for risk

Reducing Maternal Mortality Specific Measures Blood transfusion Antibiotics Safe anaesthesia Overcome legal and cultural barriers to abortion FAMILY PLANNING Using research and technology to improve maternity care

Research and Technology 1 Postpartum Haemorrhage Causes 140, 000 deaths worldwide Prevent by… Providing an oxytocic agent within 2 min birth Using controlled cord traction Uterine massage after placental delivery Treat with… Non pneumatic anti shock garment Intrauterine balloon tamponade

Research and Technology 2 Puerperal sepsis Causes 80, 000 deaths worldwide Prevent by… Hand hygiene Perineal hygiene Chlorhexidine vaginal douches intrapartum Treat with… Appropriate antibiotic by best route available

Research and Technology 3 Unsafe Abortion Causes 68, 000 deaths worldwide Prevent by… Better contraceptives Provide with… A combination of Mifepristone and Misoprostol Reusable and simple devices for suction curettage

Research and Technology 4 Obstructed labour Causes 40, 000 deaths per year worldwide And 73, 000 women left with urinary fistula Detect by… Better training and use of Partographs Treat with… Ventouse and symphysiotomy Requires a robust and re useable instrument Safe and Simple Caesarean section

Research and Technology 5 Preeclampsia and Eclampsia Complicates 5% of pregnancies Prevent by… Identification of at risk groups then aspirin + Ca supplements Detect by… Robust and reliable tests for proteinuria Treat with… Simple and acceptable protocols for Mg. SO 4

Categories of Maternal Death

Maternal Deaths in Australia 2012 - 2014

40 -Year Trend in Maternal Mortality Australia

Maternal Mortality by Age 2014 -2017

Indigenous Maternal Deaths in Australia 1991 - 2014

Causes of Maternal Death in Australia 2012 -14

Direct Maternal Deaths in Australia 2012 14

Maternal Mortality in the Netherlands 1993 -2005

Practice Points from the 2014 Australian MM Report Two thirds of maternal deaths occur postpartum In 50% of cases examined by an expert committee potentially avoidable factors were identified for allcause deaths And 100% of direct obstetric deaths Two thirds of those involved aspects of professional care Consider ruptured splenic artery as a cause of severe abdominal pain in a pregnant woman, especially if there are signs of peritonism and hypovolaemic shock

Practice Points from the 2014 Australian MM Rpt 2 Risk assess all pregnant women for thromboembolism and follow prophylaxis guidelines Patients at risk of placenta accreta require tertiary level evaluation and care All obstetric services require guidelines for the care of women who decline blood transfusion. All pregnant women should be screened for mental health and domestic violence issues