Maternal_Outcomes

Page history last edited by sanjay 2 days ago

A woman in Achham is over 200 times more likely to die in pregnancy in Achham than in the United States. Reducing maternal mortality is the single most important rationale for Nyaya Health's building of health infrastructure in Achham.  The only way to reduce maternal mortality is to build clinical services, train staff, do extensive community outreach, and measure our impact in quantitative terms.  As with all our programs, we believe that aggregate, online, public access databases are an important aspect of transparency and, with proper standardization, can greatly improve accountability in global health practice.  Please see our other data pages as well in the sidebar to the right. 

 

    1. Background
      1. Primary Outcome
      2. Additional Measures 
        1. Signal functions
        2. Additional Delivery-Related Measures
        3. Antenatal Care Services
        4. Additional Data Collected
    2. Targets
    3. Current Data
    4. References

 

Background

According to the Averting Maternal Disease and Disability group, the following complications contribute to 85% of all maternal deaths:
  • antepartum hemorrhage
  • prolonged/obstructed labor
  • postpartum sepsis
  • complications of abortion
  • pre-eclampsia/eclampsia
  • ectopic pregnancy
  • ruptured uterus
 
Our programs, to be effective, must target these core causes of maternal mortality, through the following core interventions: 
  • family planning services, including condoms, injectables, oral agents, intrauterine devices, and vasectomy
  • antenatal care, at least four visits per pregnancy
  • routine delivery services within a health center
  • safe abortion services conducted by a trained provider
  • parenteral antibiotics for peripartum infections
  • parenteral oxycotocic drugs for postpartum hemorrhage
  • parenteral anticonvulsants for eclampsia
  • manual removal of placenta
  • removal of retained products
  • assisted vaginal delivery for obstructed labor
  • cesarean section
  • blood transfusion for postpartum hemorrhage
 

Primary Outcome

Ultimately, our goal is to reduce maternal mortality at a population level.  This is expressed commonly as the Maternal Mortality Ratio (MMR), which is a public health outcomes measure that describes the risk of pregnancy in a population.  Its units are deaths per 100,000 live births.  The current best estimate of MMR in Achham is 800.  This is 200x higher than the MMR of 4 in many communities in the United States.   The most precise data on MMR are taken from facilities data.  These, however, are typically not very accurrate since they grossly underestimate MMR in areas such as Achham where only a small number of pregancies actually take place in medical facilities.  In Achham, for example, the number is 0.5%, or 1 in 200.    Greater details regarding the methodology for our mortality assessments are provided on our Mortality Data page.
  

Additional Measures 

Signal functions

WHO-defined "signal functions" are procedures that combat these complications.  These are clinical process measures, describing the number of each type of intervention that our clinic delivers over time: 
  • parenteral antibiotics
  • parenteral oxycotocic drugs
  • parenteral anticonvulsants
  • manual removal of placenta
  • removal of retained products
  • assisted vaginal delivery 
 
If we perform each of the signal functions at least 3 times per month, we are considered a basic emergency obstetric care facility under the UN system, for which they advocate at least four for every 500K population.  Addition of blood transfusion and cesarean section constitute a comprehensive EMOC, for which they advocate at least one for every 500K population.

 

Additional Delivery-Related Measures

Additional clinic process measures include: 

  • number of deliveries over time
  • number of deliveries provided by midwives
  • number of deliveries for which there was at least one post-partum clinic visit

 

Additional clinical outcomes measures include: 

  • maternal mortality rate among deliveries at Nyaya facilities
  • referral rate of deliveries at Nyaya facilities 

 

Additional public health process measures include:

  • percent deliveries conducted at a medical facility in the district

 

Antenatal Care Services

There are several clinical process measures that can help guide our assessment of the quality of antenatal care services we are providing.  These include the percentage of women who deliver at our clinic who have received: 

  • tetanus toxoid 
  • vitamin A
  • iron supplementation
  • folic acid supplementation
  • at least four antenatal visits 

 

For each of these, we can calculate public health process measures, estimating the percentage of women in the entire district who have received each of these interventions.

 

Additional Data Collected

We maintain a complete record of all the maternal complications that happen at our clinic.  In addition to providing aggregate data on these, we review each case as a clinical team to assess how we our staff treated the complications and where there are areas for improvement.  These are individual patient-level data that are part clinical process (in that we look at what actions we took with the patient) and clinical outcomes (in that we look at what actually happened to the patient) measures.    

 

Targets

The following projections represent Nyaya Health's goals for the district of Achham in reducing maternal mortality. They are based on calculations for our catchment population of 60,000. 

 

 

Nyaya members: edit the targets page by logging in with your google apps ID here.

 

Current Data

(July 24, 2008 to April 14, 2009)

 

 

References

Nepal Further Analysis: Improvements in Maternal Health in Nepal.  Further Analysis of the 2006 Demographics Survey

 

USAID Maternal and Neonatal Program Index (2001) 

 

Nepal Demographic Survey 2006

 

Beyond the Numbers: Reviewing Maternal Deaths to Make Pregnancy Safer

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