Transcript Document

Blood Transfusion
Services and
Health Systems
Strengthening
Lawrence Marum
Centers for Disease Control
and Prevention
Maternal Mortality
• Every year, 287,000 women die from pregnancy- and childbirthrelated complications; 800 deaths per day
– The vast majority of these deaths are preventable with evidence-based
interventions
– 99% of these deaths are in developing countries
– The burden falls disproportionately on women in Sub-Saharan Africa
where one-third of deaths are due to hemorrhage
– HIV-infected women are 8 times more likely to die during pregnancy and
post-partum than uninfected women
– In high prevalence countries up to 25% of deaths during pregnancy and
post-partum are among HIV-infected women
• Impact on families: if the mother dies in childbirth:
– 70% chance her baby will not reach age two
– Her other children are 10 times more likely to die prematurely
• Millennium Development Goal 5: Reduce by three quarters,
between 1990 and 2015, the Maternal Mortality Ratio (MMR)
– Global reduction by 2013 was 45%
– MMR in sub-Saharan Africa in 2013 was 510/100,000 live births
2
Moving Forward Globally:
Ending preventable maternal deaths
worldwide by 2035-reaching MMR = 50
900
CURRENT
AAR
2000-2010
AAR TO
REACH MMR
= 50
Sub-Saharan Africa
-3.8%
-8.8%
Southern Asia (excluding
India)
-5.2%
-6.1%
Asia
-5.7%
-4.3%
Eastern Asia (excluding China)
-3.5%
0%
LAC
-2.2%
-1.9%
OECD MMR Upper Limit
-4.8%
0%
SUB-SAHARAN AFRICA
800
Maternal Mortality Ratio
700
600
SOUTHERN ASIA
(excluding India)
500
400
ASIA
8.8% Annual Rate
of Reduction of
MMR 2010-2035
Accelerated Trend
300
200
100
-
LAC
OECD MMR Upper Limit
EASTERN ASIA
(excluding China)
1990
1995
2000
2005
2010
2015
Years
2020
2025
2030
2035
3
SMGL Programmatic Model
Strengthen district health networks by addressing
the “3 Delays” that lead to maternal mortality
Awareness
•
•
•
Access
Training Safe Motherhood
Action Groups and change
champions to encourage
birth preparedness and to
give birth at a facility
•
Developing birth plans and
involve fathers to ensure
facility births
•
Conducting communication
campaigns (e.g., radio,
drama skits)
•
•
Upgrading facilities and
equipment for Basic and
Comprehensive Emergency
and Neonatal Obstetric Care
(BEmONC and CEmONC)
Appropriate Care
•
Training in BEmONC and CEmONC
plus newborn resuscitation for all
nurses in MCH
•
Improving maternity wards,
and mothers’ waiting
shelters
Hiring, for facilities without skilled
providers and training and
mentoring skilled birth attendants
•
Strengthening
communication and referral
between facilities
Strengthening supply chains,
pharmacies, blood banks, labs, for
essential supplies and medicines
•
Conducting surveillance, including
maternal death reviews
•
Integrating MNCH, HIV and family
planning services
Purchasing ambulances and
motorcycles
A Public-Private Partnership
U.S. Government
Merck for Mothers
Government
of Norway
Project C.U.R.E.
American College
of OB/GYNs
Uganda Ministry
of Health
Every Mother Counts
Zambia Ministry of
Community Development,
Mother and Child Health
How?
contraceptive
coverage
4 ANC visits
skilled attendant at
birth
EmONC
IPTp for
malaria
ENC/PNC
MCH Platform
District
Maternal
Health
Services
Saving
Mothers
Giving
Life
District
Newborn
Health
Services
PEPFAR Platform
lab systems
ART sites
PMTCT sites
pregnant women
counseled and
tested
Safe blood
supply
health workers
State of Maternal Health – Zambia
440 per 100,000 live births Maternal Mortality Ratio (MMR)
33% Modern Contraceptive Prevalence Rate
94% First Antenatal Visit (60% > 4 ANC visits)
19% First Antenatal Visit in first trimester
88% HIV infected pregnant women receiving
efficacious ARVs
48% Facility deliveries
47% Births attended by skilled personnel
38
Perinatal mortality rate (stillbirths and
early neonatal deaths per
1000 pregnancies > 7mo duration)
Sources: WHO World Health Statistics 2012; UNFPA State of the World
Population Report 2012; Zambia Demographic and Health Survey 2007
Emergency Obstetric and Neonatal Care (EmONC)
• Basic (BEmONC) at health center level
– Administer antibiotics, uterotonic drugs (oxytocin) and
anticonvulsants (magnesium sulfate)
– Manual removal of the placenta
– Removal of retained products of conception
– Assisted vaginal delivery (preferably vacuum extractor)
– Basic neonatal resuscitation care
• Comprehensive (CEmONC), typically in hospitals
– Performing Caesarean sections
– Safe blood transfusion
– Care of sick and low birthweight newborns, including
resuscitation
Zambia National Blood Transfusion Service
• ZNBTS, between 2005 and 2014, with PEPFAR,
GFATM and host government (GRZ) funding:
– Increased blood collections from 37,000 to 130,000
– Developed and staffed 9 Provincial Blood Centres
– Initiated capacity for component preparation
• Strategy for Saving Mothers, Giving Life
– Increased quantity of blood for 4 selected districts
– Trained in better transfusion prescription and practice
• Prevention of Post-Partum Hemorrhage (PPH)
• Adequate quantity of blood; safe transfusion practices
• Use of components for treatment of severe PPH
– Piloted Fresh Frozen Plasma at large health centres
Maternal transfusion in 4 rural districts
Reasons for maternal
transfusion in 4 districts
20
18
7
15 6 6
C-section
Hemorrhage
Pre-eclampsia
416
Ruptured
uterus
Retained
placenta
Anemia
Other
• Nationally 35% of blood
issued for maternal
transfusion
• In 4 districts with SMGL
85% of blood for C-sections
– Incomplete information on
reason for C-section
• Ruptured uterus common
due to late arrival at
hospital (3 delays)
Maternal transfusion in 4 rural districts
• Provincial hospitals have
specialist staffs (surgeon,
OB) hence higher, diverse
blood use
• Rural districts blood is
mostly for maternal use
• Presence of adequate HC
staff and an OR also
determine rates of Csection and blood use
District
% blood
used in
maternity
(pre-post)
Change in
quantity of
blood
(pre-post)
Mansa
(Provincial
Hospital)
21%
38%
Nyimba
District
63%
10%
Lundazi
District
80%
44%
Kalomo
District
75%
-28%
Improved Health Outcomes
MMR and HIV Treatment
Baseline 2012
Endline 2013
Change
(facilities only)
310
202
- 35%
Facility
Deliveries (all)
63%
84%
+ 35%
ART for PMTCT
930
1095
+ 18%
ARV Prophylaxis
for infants
523
674
+ 29%
MMR Reduction
Improved Health Outcomes
Managing Maternal Complications
Baseline
Endline
Change
24/7 delivery
services
65%
93%
+ 44%
C-Section Rate
2.7%
3.1%
+ 15%
Case Fatality
Rate (direct)
3.4%
2.2%
- 35%
Improved Health Outcomes
Cause-specific MMR
110
Obstetric hemorrhage
72
59
Obstructed labor and
uterine rupture
13
91
Other direct causes
82
Endline
Baseline
0
20
40
60
80
100
120
Health System Strengthening
Improved Response to complications
Baseline
Endline
Change
No MgSO4
stockouts
22%
87%
+ 295%
No oxytocin
stockouts
78%
98%
+ 26%
All facilities
Health System Strengthening
Maternal Death Reviews
Hospitals and
districts
conducting
regular
Maternal Death
Reviews
Baseline
Endline
Change
50%
100%
+ 100%
Key ingredients of success
• District engagement and leadership
–
–
–
–
Community activism and male involvement
belief in survival - “Mwasupukeni” “you have survived”
Engagement of political and traditional leaders, chiefs
Maternal Death reviews
• Whole of USG approaches
– Unique roles of DoD and Peace Corps
– Strong and collaborative USAID and CDC engagement
• Multi-pronged technical approaches
– Linkage of maternal and perinatal interventions
Conclusions and recommendations
• Maternal mortality reduction requires the availability of
blood transfusion as an essential service (CEmONC)
– Appropriate and timely surgical delivery for approx. 5%
– Distance between CEmONC facilities remains a challenge
• Further evaluation of transfusion needs and outcomes
– Quantity of transfusion; use of FFP and other components
– Prevention of PPH through uterotonics (oxytocin and
misoprostol) and management of labor to reduce blood needs
• Blood services a model for health system strengthening
– Consistent, timely, quality services with life-saving impact
– Partnership and country investments remain critical
Thank you