This is the Novant Health PowerPoint templateInternational Maternal & Infant Mortality
Medge D. Owen, MD, Professor of Obstetric Anesthesia Medical Director of Global Health Novant Health Maya Angelou Women’s Health & Wellness Center
Objectives
Compare worldwide differences in maternal and newborn mortality.
Identify factors that contribute to mortality in health care settings in resource poor countries.
Discuss Kybele’s approach to partnership and empowerment that has led to sustained improvements in healthcare.
MDG 4: 2/3 reduction in <5 child mortality
MDG 5: 3/4 reduction in maternal death
How close did we get?
Millennium Development Goals 1990-2015
Photo by Yesim Unal
1990 2015
% reduction 43%
156 countries
25 countries
WHO, UNICEF, UNFPA, World Bank estimates Lancet 2014;384:980-1008; WHO 2015
What has accounted for improvement? More countries are adopting policies & strategies such as free
obstetric care and better rural referral practices
Skilled birth attendants at delivery increased from 55% to 65%
Contraception use increased from 52% to 61%
The global total fertility rate has deceased from 3.7 to 2.6
Anti-retroviral treatment is more available
Maternal education and family income have increased
Bull World Health Organ 2010;88:718-718A Hogan M. Lancet 2010 :375:1609-23 UN MDG goals report 2011
Kassebaum. Lancet 2014;384:980-1004
INTRODUCTION
Ghana has implemented interventions to promote health facility access
But the question is: what happens when the patient gets to the hospital?
Ghana has emphasized access, without fully addressing quality of care within institutions
MMR has not been reduced in tertiary hospitals
• Millicent 33 year old G3P2 • 41 5/7 weeks pregnant • Arrived at hospital shortly
before midnight in labor • Slow progress, meconium
amniotic fluid • By 9:30 am 8 cm dilated • By 1:00 pm 10 cm dilated • At 3:43 pm delivered male
infant Apgars 3 and 5 • At 6:20 pm a call for help…
Name and photo changed to protect identity
Neonatal Deaths 3 million/year
One baby, too many
through medical education partnerships www.kybeleworldwide.org
Kybele’s Educational Model
Development • Monitoring / Evaluation
• Total Faculty Participation = 708 – 68 institutions, 12 countries – 28 medical, nursing & other disciplines
• Target Countries = Turkey, Croatia, Ghana, Georgia, Armenia, Brazil, Egypt, Romania, Mongolia, Vietnam, Serbia
• New sites = Bosnia, Moldova • In-country Programs or Site Visits = 83 • Major Meetings Hosted = 31
Kybele Profile since 2003
Local medical volunteers with Kybele (50+ people)
WF-FMC Affiliated Faculty / Staff WF Residents / Fellows / Students / Other Terry Bogard Vernon Ross Medge Owen Laura Dean Michael Rieker Shahla Namak Nichole Taylor Margaret Harper Mary Watkins Nancy Pearson Shelma Williams Lauren Reavis Mikki Garris Melvin Seid Susan Christmas Matt Hatch Ronny Bell Mandisa Jones-Haywood Brett Nicks Lisa Washburn Dupe Akinola Mario Rojas Bryan King Corey Seidel Amy Bamber Martha Harrelson (Red=Multiple Trips)
Anesth-OB Anesth-OB Anesth_OB Anesth-OB CRNA OB/Family Med Anesth MFM L&D nurse L& D nurse manager L&D nurse L&D nurse CRNA Lyndhurst OBGYN Midwife Anesth-OB Public Health Anesth Critical Care EM Neonatology Neonatology Neonatology Respiratory Therapy Neonatal Nurse Practitioner Neonatology Neonatal Nurse Practitioner
Brittany Clyne Lydia Grondin Brian Paitsel Paddy McConville Steven Contag Justin Traunero Jessica Sola-Avedo Allison Palliser Jimmy Turner Sidney Mahaffey Jennifer Stanislaus Jessica May Austin Taylor David Goodman Lu Adams Emily Hirschmiller Sung Min Kim Other: Shirley Turley Kristin Bryant Robin Sizemore Gary Smith Anthony Haywood Louisa Oates Kathi Barnhill Walidah Muhammad Joe Jowers
OB Anesth OB Anesth OB Anesth OB Anesth MFM-OB Anesth Anesth Anesth Anesth SRNA Anesth SRNA OB Anesth OBGYN Anesth Anesth WF Med student
Consultant Student FMC Patient Photographer Equipment WFU student WFU student WFU student WFU student
Reducing Maternal & Newborn Morbidity and Mortality
in LMIC Approaches can be: Specialty or systems driven
Approaches must be: Locally sustainable Cost efficient Collaborative
Global Health Partnerships
Keys for Success
Step 2: Education and Cooperation
Step 3: Overcome Barriers – Have a Strategy
Step 4: Results - Monitoring and Evaluation
Dr. George Yankee, Ghana Health Minister with Dr. Medge Owen, WFUSM
Objective: To create a “Center of Excellence” for 50% Reduction of Maternal & Newborn Mortality
Ghana Jan 2007-Present
• They have high work volumes
• Many high risk cases are referred late
• They depend on resources: equipment, medication and blood
• Staff numbers are inadequate
• Lack organization and problem solving skills 1Acta Obstet Gynecol Scand 2012;91:87-92 ; 2Perinatol 2012;36:79-83
Characteristics of Regional Referral Hospitals
MMR in Ghana decreased from 470 to 380 maternal deaths/100,000 live births between 2005 and 2013 (MGD target 185)
In tertiary hospitals MMR is higher than the national average:
Koforidua – MMR 957 (2004-2009) Semin Perinatol 2012;36(1):79- 83
Tamale Teaching Hospital – MMR 842 (2008) Ghana Med J 2011;45(3):105-110
Korle Bu Teaching Hospital – MMR 840 (2012) Internal source
Komfo Anokye Teaching Hospital – MMR 1004 (2008-2010) Acta Obstet Gynecol Scand 2012:91(1):87-92
Maternal Mortality Ratio in Ghana
Hospital Based Delay Ridge Regional Hospital, GHANA
Of 926 admissions, 83 min avg. waiting time to be seen; max. 1 day, 2.5 hours
4 operating rooms for entire hospital: Median Decision to Delivery times Emergency CS = 4 hrs, Elective CS = 3 days
Maternal and Newborn Mortality Not that Simple
• Causes of death are multifactorial, complex and interconnected
• It is important to address the entire healthcare system, not just one of the parts
• Botswana: Root cause analysis – It was more than just the disease entity that killed the
patient – The high number of contributing factors demonstrate poor
quality of care
MORTALITY AUDIT – AVOIDABLE FACTORS
Unavailability of size 18 cannula Operational
Temporary failure of oxygen system Operational
Unavailability of blood Operational
Risk factor of hemorrhage not identified Clinical
Missed diagnosis pelvic abscess Clinical
Discharged too early Leadership
Inadequate monitoring Leadership
An integrated approach is needed that is broad and deep
Health Systems Strengthening
GOALS
• Improve the capacity of all in identifying and solving service delivery problems
• Use a data driven, quality improvement approach for system change
• Reduce maternal and newborn death
Methodology Through joint efforts (case review, clinical & death audits),
deficiencies of the system were identified.
97 improvement activities were jointly
identified
1. Follow the degree of implementation of the improvement activities
2. Determine the number of deaths averted or lives saved (as a measure of performance)
3. Determine which factors were most highly associated with improved performance
Implementation of Activities 68%
Risk-Adjusted Mortalities
Total delivery 6049 7465 8230 8133 9357
Composite Prevalence (Hemorrhage + HTN disorders)
6.2 9.1 15.9 16.9 19.7
Risk Adjusted Mortality Index 1.1 1.8 3.2 2.9 3.3
Estimated MMR (EMMR) 533 686 1052 1102 1250
Observed MMR (OMMR) 496 388 328 369 385 Performance – Maternal death averted/100,000 births (EMMR-OMMR)
37 298 724 722 870
# Maternal deaths averted/year - 18 66 67 94
Total # maternal deaths averted = 245
Mathematical Model : R= K1∑Pi + K2(100-∑Pi)
0
200
400
600
800
1000
1200
1400
MMR 1 OMMR MMR 2
Observed MMR /Counterfactual Scenarios
2006
479
479
479
2007
446
496
533
2008
272
388
686
2009
149
328
1052
2010
165
380
1102
2011
146
380
1250
To resize chart data range, drag lower right corner of range.
Newborn Statistics Ridge Regional Hospital
Years 2011 2012 2013 2014 2015 2016 Neonatal Death Rate 38.0 31.1 23.8 17.1 23.6 25.1
% NICU Deaths 38% 29% 19% 13% 15% 16%
Neonatal Death Rate = deaths/live births x 1000 % NICU Deaths = deaths/admissions x 100
In Summary
Change can be slow
Conclusion:
www.kybeleworldwide.org
Education is the most powerful weapon which you can use to change the world
Nelson Mandela
Objectives
MDG 4: 2/3 reduction in <5 child mortalityMDG 5: 3/4 reduction in maternal death
We did not make it
What has accounted for improvement?
Maternal mortality “hot” spots
One baby, too many
Slide Number 18
Global Health Partnerships
Ghana Jan 2007-Present
Slide Number 22
Slide Number 25
Slide Number 26
Slide Number 27
Slide Number 34
Slide Number 35