INTRODUCTION TO FAMILY HEALTH 8 MDGs Goal 1 : Eradicate Extreme Poverty & Hunger Goal 2 : Achieve Universal Primary Education Goal 3 : Promote Gender Equality & Empower Women Goal 4 : Reduce Child Mortality Goal 5 : Improve Maternal Health Goal 6 : Combat HIV/AIDS, Malaria & Others Diseases Goal 7 : Ensure Environmental Sustainability Goal 8 : A Global Partnership For Development Component of family health: 1.Maternal health 2.Child health 3.Adolescent health 4.Women’s health 5.Men’s health 6.Geriatric health 7.Mental health Definition : Family : A fundamental social group in society typically consisting of one / two parents & their children Social unit of two / more persons related by blood, marriage, / adoption & having a shared commitment to the mutual relationship Health : Health is a state of complete physical, mental & social well-being & not merely the absence of disease / infirmity (WHO) Maternal health : The health of women of childbearing age (from pre -
pregnancy, pregnancy, delivery & the postpartum period) Maternal Health Maternal mortality : global tragedy! Annually , 585,000 women die of pregnancy related complications •99% in developing world •Only 1% in developed countries Maternal health : scope of prob •180–200 million pregnancies per year •75 million unwanted pregnancies •50 million induced abortions 20 million unsafe •600,000 maternal deaths (1 per minute) •1 maternal death = 30 maternal morbidities For each woman who dies during pregnancy, 30 women suffer complications. Initiatives should include: Family planning Management of complications of abortion Management of complications of pregnancy & childbirth Global Causes of Maternal Mortality •hemorrhage (24.8%), •infection (14.9%), •obstructed labor (6.9%) •unsafe abortion (12.9%) •Indirect causes ( 19.8%) → Mostly preventable! Multiple factors affect WHY a woman dies during pregnancy The “ Three Delays’ Model ”: 1)Delay in decision to see care: lack of information about problems/warning signs, social factors 2)Delay in reaching care: having transportation, road conditions 3)Delay in receiving care: lack of equipment / personnel at facility, lack of funding, poor attitude of personnel Poor Maternal Health Services in Developing Countries Good quality maternal health services are not universally available & accessible > 35% receive no antenatal care ~ 50% of deliveries unattended by skilled provider ~ 70% receive no postpartum care during first 6 weeks following delivery 1 Child Health Adolescent Health issues : High risks behavior Smoking Drugs Addiction Motor Racing Pornography Promiscuous Women’s Health issues : Infections – STDs, HIV/AIDS Reproductive cancer Violence against women Single mother Unwanted pregnancies /Abortions Family planning Infertility Prostitution Female genital mutilation Sexual dysfunction Men’s Health issues : Erectile Dysfunction Androgens deficiency Male infertility Prostate cancer Testicular cancer Metabolic Syndrome Geriatric Health issues : Increasing aging population Deteriorating health Low income Inadequate housing Poor personal care Poor health care Poor mobility & transportation Poor community support facilities / services Ageing & low QOL Mental Health : serious mental illness is common, affecting about 1% of any population at any time > 10 % suffer from the milder emotional disturbances, personality disorder, drug / alcohol abuse, family disruption, delinquencies, child abuse etc. In Malaysia : 10 % of the population suffer from MDD. Most developed depression between age 20 – 40 commit suicide in the next 10 -15 years cause immense social disability & economic burden MATERNAL HEALTH & MORTALITY Maternal mortality Definition: Death of a woman woman while pregnant / within 42 days of termination of pregnancy, irrespective of the duration & site of the pregnancy, from any cause related to / aggravated by the pregnancy / its management but not from accidental / incidental causes (ICD -10) Causes of maternal mortality •Direct death : Resulting from obstetric complications of pregnancy state (pregnancy, labor & puerperium ); from interventions, omissions, incorrect treatment / from a chain of events resulting from any of the above. •Indirect death : From either a previous existing disease / from a disease which developed during pregnancy & was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy. •Fortuitous death : Are those resulting from causes not related to / influenced by pregnancy Maternal mortality ratio ( INDICATOR) Is the ratio of the number of maternal deaths during a given time period per 100,000 live births during the same time -period. = Number of maternal death x 100k Total live births in specified period of time Rationale for use: Complications during pregnancy & childbirth are a leading cause of death & disability among women of reproductive age in developing countries. The maternal mortality ratio represents the risk associated with each pregnancy, i.e. The obstetric risk. It is also a MDG indicator. General indicator of the overall health of a population Status of women in society Functioning of the health system Other measures of maternal mortality a)Maternal mortality rate Maternal deaths per 100,000 women of reproductive age = Number of maternal death x 100k No.of woman in reproductive age gp b) Lifetime risk of maternal death •probability of maternal death in population •risk that a woman who survives to age 15 will die of maternal causes at some point during her reproductive lifespan •takes into account both the maternal mortality ratio & the total fertility rate (probable number of births per woman during her reproductive years). c)Proportion of maternal deaths among female deaths (PMDF) Proportion of all deaths of women of reproductive age gp (15-49 d/t maternal causes = Number of maternal death Total number of all female death MM Rate •Numerator included in denominator •Maternal deaths per 100,000 women of reproductive age •Measures the risk to women whether they are pregnant / not •Compound measure of the level of fertility VS MM Ratio •Numerator not included in denominator •Maternal deaths per number of live births •Measures risk of death a woman face with each pregnancy •Preferred because denominator easier to capture routinely from hospital records/vital registration Maternal morbidity •Definition (There is no universally agreed definition for maternal morbidity, although WHO is working on producing one ) •“Maternal morbidity is defined as morbidities that occur during pregnancy / childbirth / within 42 days after giving birth . They can be acute, / chronic, lasting for months / even years. Many of these are conditions that may cause difficulty in pregnancy, & aggravate existing morbidities, which can lead to more severe consequences for women (AMREF written evidence).” •Maternal morbidity consists of a series of complications, including: Obstetric fistula Perineal damage Prolapsed uterus Stress incontinence Puerperal infection & sepsis, haemorrhage, hypertensive disorder(pre -eclampsia ) & fits Anaemia Infertility Ectopic pregnancy Depression & suicide Trend •Every day, 800 women die from pregnancy -related causes during pregnancy, childbirth & postpartum. •Over 99% annual deaths occur in developing countries •Most are avoidable, as the health -care solutions to prevent / manage complications are well known. •About 56% of the deaths occurred in Sub -Saharan Africa with another 29% in South Asia these two regions together account for 85% of maternal mortality in the world (World Bank ) • Maternal mortality is higher in women living in rural areas & among poorer communities •Young adolescents face a higher risk of complications & death as a result of pregnancy than older women •Between 1990 & 2010, maternal mortality worldwide dropped by almost 50% (WHO, 2012 ) • The ratio has declined from 530 deaths per 100,000 live births(1950) to 28 deaths in 100,000 live births (2009) •a decline of 94% / 1.6 percentage points a year on average • Globally 45% of postpartum deaths occur within the first 24 hours & 66% occur during the first week (Nour , 2008) Causes of maternal deaths : •Postpartum haemorrhage •Obstetric embolism •Associated medical condition •Hypertensive d/o in pregnancy •Obstetric trauma •Puerperal sepsis •Unsafe abortion Risk factors : •Socioeconomic & cultural factors •Health Status of the Woman •Woman's Reproductive Status/Other •Demographics /Access to Health Services •Health Care Behavior/Use of Health Service •Unknown/Unpredicted Factors Socioeconomic & cultural factors: •Women's status in family & community Education , occupation, income, social & legal autonomy •Family's status in community Family income , land, education of others •Community's status Aggregate wealth, community resources (e.g. doctors, clinics, ambulances) Health status •Nutritional status (anemia, height, weight) •Infections & parasitic diseases •(malaria, hepatitis, tuberculosis) •Other chronic condition(DM,HPT) •H/o complication in previous pregnancy. Reproductive status •Age •Parity •Birth spacing •Breast feeding Demographic factors •Access to health services •Location of services for family planning, prenatal care, other primary care, •emergency obstetric care; range of services available; quality of care; •access to information about services Health care behaviour/use of health services •Use of family planning, prenatal care, modern care for labor & delivery, harmful traditional practices, illicit induced abortion 2 Prevention 1.Safe Motherhood •Means ensuring that all women receive the care they need to be safe & healthy throughout pregnancy & childbirth •Global Safe Motherhood Initiative (SMI) was launched to reduce the burden of maternal death & ill-
health in developing countries •The Ten Safe Motherhood Action Messages 1. Advance Safe Motherhood Through Human Rights 2. Empower Women : Ensure Choices 3. Safe motherhood is a vital economic & social investment 4. Delay marriage & first birth 5. Every pregnancy faces risks 6. Ensure skilled attendance at delivery 7. Improve access to quality reproductive health services 8. Prevent unwanted pregnancy & address unsafe abortion 9. Measure progress 10. The power of partnership •During the 10th Anniversary of the SMI, a Technical Consultation was conducted to review & articulate lessons learned from 10 years of the Ten Safe Motherhood Action Messages. They identified that the ten action messages should emphasize the need to address the broad social, economic, & political context that contributes to women’s risks of dying during pregnancy & childbirth to promote access to essential obstetric care to prevent / treat serious obstetric complications 3 2.Legislative & policy actions •Changes in legislation & policy is essential in terms of family planning, adolescents & children, barriers to access, regulation of practice, delegation of authority, abortion 3.Society & community interventions •The support of families & communities •Women need support in obtaining access to essential care •Training of traditional birth attendance •Balanced & sufficient diet •Women's overall health •Prevention of unwanted pregnancy & prevention & management of unsafe abortion 4.Health sector actions •Client -centred family planning information & services •Contraceptive counselling for women •Basic antenatal & postpartum care •Skilled attendant •Good -quality obstetric services at referral centres for complications Preventive strategies/Safe Motherhood in Malaysia: •Basic antenatal & postpartum care •Home -based maternal health card •Risk approach system using colour -coding system •Referral & feedback system •Skilled attendance at delivery/Safe delivery – hospital, low risk birthing centre, alternative birthing centre, transit houses (half way house) •Training of health staff •Clinical Practice Guidelines •Registration & training of traditional birth attendants (TBA) •Contraceptive counselling & services •Confidential Enquiry into Maternal Death Confidential Enquiry into Maternal Death (CEMD) •Introduced in 1991 •Objective: to identify preventable / avoidable factors present in the management of the cases & also the constraints, for remedial actions •an audit of every maternal death - is a way of improving current performance by deciding on the ideal ( setting standards ), looking at the real situation (measuring current performance) & finding ways of moving from real to the ideal. •enables the health care providers & managers to draw on the experience of others to improve further the quality in the provision of maternal health care. •Shortfalls in quality are identified & remediable actions are taken at the operational levels. Recommendations were made to the relevant programmes & agencies. •Relevant forms: Borang Notifikasi Kematian Ibu – Borang KIK/KI – 1 (Pindaan 2012) Borang Executive Summary – Borang KIK/KI – 2 (Pindaan 2012) Borang Laporan Kematian Ibu – Borang KIK/KI – 3 (Pindaan 2012) Borang Maklumbalas Kematian Ibu (Negeri & Daerah) – Borang KIK/KI – 4 (Pindaan 2012) •Method : Step 1: Examine case records & interview staff Step 2: Interview the household of the deceased person Step 3: Use this information to reconstruct the circumstances leading to the death Step 4: Assign a Cause of Death Process 1 •Step 1: Report the death to the Deputy Director of Health Services at the District level •When? Within 24 hours of death •Who will do it? •If the death occurs at home, in transit, at the sub -center: ANM to PHC Medical Officer •At the PHC: PHC Medical Officer •Public Hospital / Private Hospital: Respective hospital authorities Process 2 •Step 2: Form a Maternal Death Investigation Team at PHC •When? Within 15 days of the death •Who will be in the team? PHC Medical Officer Administrator 1 Nursing Staff Process 3 •Place the findings of the team before the district -level Maternal Deaths Medical Audit Committee on a monthly basis •Place all reports before the District RCH Committee chaired by the District Collector, which receive s relatives of the deceased who give their account of the events •Place the minutes of both meetings before the Commissioner Process 4 •Provide feedback to relevant FRU(first referral units) & PHCs •Provide feedback to relevant personnel involved in the case •Conduct annual analysis of maternal deaths to understand causes of death & formulate appropriate response MMR & MDG •The MDGs are a framework for measuring progress in development & focuses on improvement of people’s lives •MDG 5 focus on improving maternal health 1.Maternal mortality ratio 2.Proportion of births attended by skilled health personnel 3. Contraceptive prevalence rate 4.Adolescent birth rate 5.Antenatal care coverage (at least one visit & at least four visits) •There are 2 targets to achieve to improve maternal health. 5a) to reduce maternal mortality by three quarters between 1990 & 2015. 5b) to achieve universal access to reproductive health by 2015 Maternal near miss ( severe acute maternal morbidity ) •pregnant woman admitted to the ICU, / undergoing a hysterectomy, / receiving a blood transfusion, / presenting a cardiac / renal complication, / having eclampsia was found to be at increased risk of dying during pregnancy, childbirth / in the early postpartum period. •occurrence of a near miss was positively associated with : 1) low & very low birth weight 2) admission of the neonate to the ICU 3) stillbirth , early neonatal death 4) prolonged maternal postpartum stay A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy
pregnancy, pregnancy, delivery & the postpartum period) Maternal Health Maternal mortality : global tragedy! Annually , 585,000 women die of pregnancy related complications •99% in developing world •Only 1% in developed countries Maternal health : scope of prob •180–200 million pregnancies per year •75 million unwanted pregnancies •50 million induced abortions 20 million unsafe •600,000 maternal deaths (1 per minute) •1 maternal death = 30 maternal morbidities For each woman who dies during pregnancy, 30 women suffer complications. Initiatives should include: Family planning Management of complications of abortion Management of complications of pregnancy & childbirth Global Causes of Maternal Mortality •hemorrhage (24.8%), •infection (14.9%), •obstructed labor (6.9%) •unsafe abortion (12.9%) •Indirect causes ( 19.8%) → Mostly preventable! Multiple factors affect WHY a woman dies during pregnancy The “ Three Delays’ Model ”: 1)Delay in decision to see care: lack of information about problems/warning signs, social factors 2)Delay in reaching care: having transportation, road conditions 3)Delay in receiving care: lack of equipment / personnel at facility, lack of funding, poor attitude of personnel Poor Maternal Health Services in Developing Countries Good quality maternal health services are not universally available & accessible > 35% receive no antenatal care ~ 50% of deliveries unattended by skilled provider ~ 70% receive no postpartum care during first 6 weeks following delivery 1 Child Health Adolescent Health issues : High risks behavior Smoking Drugs Addiction Motor Racing Pornography Promiscuous Women’s Health issues : Infections – STDs, HIV/AIDS Reproductive cancer Violence against women Single mother Unwanted pregnancies /Abortions Family planning Infertility Prostitution Female genital mutilation Sexual dysfunction Men’s Health issues : Erectile Dysfunction Androgens deficiency Male infertility Prostate cancer Testicular cancer Metabolic Syndrome Geriatric Health issues : Increasing aging population Deteriorating health Low income Inadequate housing Poor personal care Poor health care Poor mobility & transportation Poor community support facilities / services Ageing & low QOL Mental Health : serious mental illness is common, affecting about 1% of any population at any time > 10 % suffer from the milder emotional disturbances, personality disorder, drug / alcohol abuse, family disruption, delinquencies, child abuse etc. In Malaysia : 10 % of the population suffer from MDD. Most developed depression between age 20 – 40 commit suicide in the next 10 -15 years cause immense social disability & economic burden MATERNAL HEALTH & MORTALITY Maternal mortality Definition: Death of a woman woman while pregnant / within 42 days of termination of pregnancy, irrespective of the duration & site of the pregnancy, from any cause related to / aggravated by the pregnancy / its management but not from accidental / incidental causes (ICD -10) Causes of maternal mortality •Direct death : Resulting from obstetric complications of pregnancy state (pregnancy, labor & puerperium ); from interventions, omissions, incorrect treatment / from a chain of events resulting from any of the above. •Indirect death : From either a previous existing disease / from a disease which developed during pregnancy & was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy. •Fortuitous death : Are those resulting from causes not related to / influenced by pregnancy Maternal mortality ratio ( INDICATOR) Is the ratio of the number of maternal deaths during a given time period per 100,000 live births during the same time -period. = Number of maternal death x 100k Total live births in specified period of time Rationale for use: Complications during pregnancy & childbirth are a leading cause of death & disability among women of reproductive age in developing countries. The maternal mortality ratio represents the risk associated with each pregnancy, i.e. The obstetric risk. It is also a MDG indicator. General indicator of the overall health of a population Status of women in society Functioning of the health system Other measures of maternal mortality a)Maternal mortality rate Maternal deaths per 100,000 women of reproductive age = Number of maternal death x 100k No.of woman in reproductive age gp b) Lifetime risk of maternal death •probability of maternal death in population •risk that a woman who survives to age 15 will die of maternal causes at some point during her reproductive lifespan •takes into account both the maternal mortality ratio & the total fertility rate (probable number of births per woman during her reproductive years). c)Proportion of maternal deaths among female deaths (PMDF) Proportion of all deaths of women of reproductive age gp (15-49 d/t maternal causes = Number of maternal death Total number of all female death MM Rate •Numerator included in denominator •Maternal deaths per 100,000 women of reproductive age •Measures the risk to women whether they are pregnant / not •Compound measure of the level of fertility VS MM Ratio •Numerator not included in denominator •Maternal deaths per number of live births •Measures risk of death a woman face with each pregnancy •Preferred because denominator easier to capture routinely from hospital records/vital registration Maternal morbidity •Definition (There is no universally agreed definition for maternal morbidity, although WHO is working on producing one ) •“Maternal morbidity is defined as morbidities that occur during pregnancy / childbirth / within 42 days after giving birth . They can be acute, / chronic, lasting for months / even years. Many of these are conditions that may cause difficulty in pregnancy, & aggravate existing morbidities, which can lead to more severe consequences for women (AMREF written evidence).” •Maternal morbidity consists of a series of complications, including: Obstetric fistula Perineal damage Prolapsed uterus Stress incontinence Puerperal infection & sepsis, haemorrhage, hypertensive disorder(pre -eclampsia ) & fits Anaemia Infertility Ectopic pregnancy Depression & suicide Trend •Every day, 800 women die from pregnancy -related causes during pregnancy, childbirth & postpartum. •Over 99% annual deaths occur in developing countries •Most are avoidable, as the health -care solutions to prevent / manage complications are well known. •About 56% of the deaths occurred in Sub -Saharan Africa with another 29% in South Asia these two regions together account for 85% of maternal mortality in the world (World Bank ) • Maternal mortality is higher in women living in rural areas & among poorer communities •Young adolescents face a higher risk of complications & death as a result of pregnancy than older women •Between 1990 & 2010, maternal mortality worldwide dropped by almost 50% (WHO, 2012 ) • The ratio has declined from 530 deaths per 100,000 live births(1950) to 28 deaths in 100,000 live births (2009) •a decline of 94% / 1.6 percentage points a year on average • Globally 45% of postpartum deaths occur within the first 24 hours & 66% occur during the first week (Nour , 2008) Causes of maternal deaths : •Postpartum haemorrhage •Obstetric embolism •Associated medical condition •Hypertensive d/o in pregnancy •Obstetric trauma •Puerperal sepsis •Unsafe abortion Risk factors : •Socioeconomic & cultural factors •Health Status of the Woman •Woman's Reproductive Status/Other •Demographics /Access to Health Services •Health Care Behavior/Use of Health Service •Unknown/Unpredicted Factors Socioeconomic & cultural factors: •Women's status in family & community Education , occupation, income, social & legal autonomy •Family's status in community Family income , land, education of others •Community's status Aggregate wealth, community resources (e.g. doctors, clinics, ambulances) Health status •Nutritional status (anemia, height, weight) •Infections & parasitic diseases •(malaria, hepatitis, tuberculosis) •Other chronic condition(DM,HPT) •H/o complication in previous pregnancy. Reproductive status •Age •Parity •Birth spacing •Breast feeding Demographic factors •Access to health services •Location of services for family planning, prenatal care, other primary care, •emergency obstetric care; range of services available; quality of care; •access to information about services Health care behaviour/use of health services •Use of family planning, prenatal care, modern care for labor & delivery, harmful traditional practices, illicit induced abortion 2 Prevention 1.Safe Motherhood •Means ensuring that all women receive the care they need to be safe & healthy throughout pregnancy & childbirth •Global Safe Motherhood Initiative (SMI) was launched to reduce the burden of maternal death & ill-
health in developing countries •The Ten Safe Motherhood Action Messages 1. Advance Safe Motherhood Through Human Rights 2. Empower Women : Ensure Choices 3. Safe motherhood is a vital economic & social investment 4. Delay marriage & first birth 5. Every pregnancy faces risks 6. Ensure skilled attendance at delivery 7. Improve access to quality reproductive health services 8. Prevent unwanted pregnancy & address unsafe abortion 9. Measure progress 10. The power of partnership •During the 10th Anniversary of the SMI, a Technical Consultation was conducted to review & articulate lessons learned from 10 years of the Ten Safe Motherhood Action Messages. They identified that the ten action messages should emphasize the need to address the broad social, economic, & political context that contributes to women’s risks of dying during pregnancy & childbirth to promote access to essential obstetric care to prevent / treat serious obstetric complications 3 2.Legislative & policy actions •Changes in legislation & policy is essential in terms of family planning, adolescents & children, barriers to access, regulation of practice, delegation of authority, abortion 3.Society & community interventions •The support of families & communities •Women need support in obtaining access to essential care •Training of traditional birth attendance •Balanced & sufficient diet •Women's overall health •Prevention of unwanted pregnancy & prevention & management of unsafe abortion 4.Health sector actions •Client -centred family planning information & services •Contraceptive counselling for women •Basic antenatal & postpartum care •Skilled attendant •Good -quality obstetric services at referral centres for complications Preventive strategies/Safe Motherhood in Malaysia: •Basic antenatal & postpartum care •Home -based maternal health card •Risk approach system using colour -coding system •Referral & feedback system •Skilled attendance at delivery/Safe delivery – hospital, low risk birthing centre, alternative birthing centre, transit houses (half way house) •Training of health staff •Clinical Practice Guidelines •Registration & training of traditional birth attendants (TBA) •Contraceptive counselling & services •Confidential Enquiry into Maternal Death Confidential Enquiry into Maternal Death (CEMD) •Introduced in 1991 •Objective: to identify preventable / avoidable factors present in the management of the cases & also the constraints, for remedial actions •an audit of every maternal death - is a way of improving current performance by deciding on the ideal ( setting standards ), looking at the real situation (measuring current performance) & finding ways of moving from real to the ideal. •enables the health care providers & managers to draw on the experience of others to improve further the quality in the provision of maternal health care. •Shortfalls in quality are identified & remediable actions are taken at the operational levels. Recommendations were made to the relevant programmes & agencies. •Relevant forms: Borang Notifikasi Kematian Ibu – Borang KIK/KI – 1 (Pindaan 2012) Borang Executive Summary – Borang KIK/KI – 2 (Pindaan 2012) Borang Laporan Kematian Ibu – Borang KIK/KI – 3 (Pindaan 2012) Borang Maklumbalas Kematian Ibu (Negeri & Daerah) – Borang KIK/KI – 4 (Pindaan 2012) •Method : Step 1: Examine case records & interview staff Step 2: Interview the household of the deceased person Step 3: Use this information to reconstruct the circumstances leading to the death Step 4: Assign a Cause of Death Process 1 •Step 1: Report the death to the Deputy Director of Health Services at the District level •When? Within 24 hours of death •Who will do it? •If the death occurs at home, in transit, at the sub -center: ANM to PHC Medical Officer •At the PHC: PHC Medical Officer •Public Hospital / Private Hospital: Respective hospital authorities Process 2 •Step 2: Form a Maternal Death Investigation Team at PHC •When? Within 15 days of the death •Who will be in the team? PHC Medical Officer Administrator 1 Nursing Staff Process 3 •Place the findings of the team before the district -level Maternal Deaths Medical Audit Committee on a monthly basis •Place all reports before the District RCH Committee chaired by the District Collector, which receive s relatives of the deceased who give their account of the events •Place the minutes of both meetings before the Commissioner Process 4 •Provide feedback to relevant FRU(first referral units) & PHCs •Provide feedback to relevant personnel involved in the case •Conduct annual analysis of maternal deaths to understand causes of death & formulate appropriate response MMR & MDG •The MDGs are a framework for measuring progress in development & focuses on improvement of people’s lives •MDG 5 focus on improving maternal health 1.Maternal mortality ratio 2.Proportion of births attended by skilled health personnel 3. Contraceptive prevalence rate 4.Adolescent birth rate 5.Antenatal care coverage (at least one visit & at least four visits) •There are 2 targets to achieve to improve maternal health. 5a) to reduce maternal mortality by three quarters between 1990 & 2015. 5b) to achieve universal access to reproductive health by 2015 Maternal near miss ( severe acute maternal morbidity ) •pregnant woman admitted to the ICU, / undergoing a hysterectomy, / receiving a blood transfusion, / presenting a cardiac / renal complication, / having eclampsia was found to be at increased risk of dying during pregnancy, childbirth / in the early postpartum period. •occurrence of a near miss was positively associated with : 1) low & very low birth weight 2) admission of the neonate to the ICU 3) stillbirth , early neonatal death 4) prolonged maternal postpartum stay A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy
