SECOND INTERNATIONAL CONFERENCE ON MATERNAL AND NEWBORN HEALTH, KIGALI, RWANDA JULY 2010
MATERNAL MORTALITY AND HIV Dr Jose Rolando Figueroa, MD-FACOG Maternal and Child Health Young Child Survival and Development-UNICEF ESARO
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Overview Where and Why are mothers dying? Is HIV contributing to maternal deaths?
How is HIV contributing to maternal deaths? Modeling HIV attributable risk to MM Using HIV interventions to reduce MM Impact of HIV interventions on saving mothers lives Next Steps
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Definitions and Measures of Maternal Mortality ICD-10 definition of a maternal death: “ the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”.
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Definitions and Measures of Maternal Mortality (2) 1. Maternal Mortality Ratio: number of maternal deaths in a period per number of live births during the same period 2. Maternal Mortality Rate: number of maternal deaths in a period per number of women of reproductive age during the same period
3. Lifetime Risk of Maternal Death: probability of a woman dying from maternal causes over the course of her reproductive life span 4. Proportionate Mortality Ratio: reflects contribution of maternal deaths to overall mortality among women of reproductive age
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Where and Why are Mothers Dying? Global estimate of maternal deaths in 2005: 535,900 •
Sub –Saharan Africa & Asia: 90%
•
Industrialized countries: 80% live in Sub-Saharan Africa 1. Women acquire HIV 5-7 years earlier than men
2. SSA: Adolescent girls 3-7 fold higher HIV compared to boys
To date opportunities for integrating responses to HIV and maternal mortality have been overlooked Unite for Children
HIV and Maternal Mortality – What We Know • Globally each year: • 1.4 million live births (and more pregnancies) in HIV+ women • Contribution of HIV/AIDS to MM has not been estimated
• Growing evidence to suggest HIV/AIDS a major cause of maternal mortality in resource constrained settings • Variability between regions and within regions on maternal deaths attributable to HIV/AIDS
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HIV and MM - Intersecting Epidemics • Malawi and Zimbabwe - between 1992-2002 • 10X increase in HIV infection in pregnant women • 1.9 – 2.5 X increase in MMR
(Bicego et al, AIDS 2002, 16: 1078-81)
• HIVNET 024 (Malawi, Zambia, Tanzania) • 42 deaths in HIV+ mothers compared to 0 in HIV- (Chilongozi et al, Paediatr Infect Dis J, 2008, 27: 808-1412)
• AIDS related TB represented 13.1% of all maternal deaths in Tanzania – (1996-97 ) (Ahmed et al INt J Tuberc Lung Dis, 1999, 3: 675-80 ) • In the US, HIV infected women have 13X higher MM compared to HIV uninfected mothers (Louis J et alObstet Gynecol 2007; 110: 385-90 )
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HIV and MM – Direct and Indirect Links – Individual Level • Changing pattern of maternal deaths – SSA • HIV related mortality rates increasing • Surpass other causes
• Increasing lifetime risk of MM • Repeat pregnancies and advanced disease multiply the risks of deaths • Direct and indirect causes of maternal deaths are more severe in HIV + pregnant women Unite for Children
HIV and Maternal Mortality – Population Level • Indirectly lower MM – HIV + women
• Lower fertility rates • Population attributable decline in estimated total fertility up to 0.4% for each % point HIV prevalence in general female population • Higher rates of spontaneous foetal loss Zaba et al, AIDS 2007, Glynn et al, JAIDS 2000, Gregson et al, Science 2004, Lewis et al, AIDS 2004
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Timing of death by stage of pregnancy in HIV infected women Post Partum
Around Delivery 1. Anemia,
Early Pregnancy
2. Hemorrhage, 3. Operative Delivery
1. Ectopic Pregnancy,
1. Direct Infectious morbidity: a. Puerperal Sepsis 2. Infectious Morbidity (NPRI):
2. Spontaneous abortions
a. TB b. Pneumonia
HIV Related MM in Pregnancy Unite for Children
c. Malaria d. Meningitis e. UTI
HIV and Anemia in Pregnancy Risk factor for early death in patients with AIDS (Moore, JAIDS 1998 ) Anemia at delivery higher among HIV+ women at 51% vs HIVwomen at 35% (Naniche, 2009)
Multifactorial causes of anaemia including immune-deficiency
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HIV and TB in Pregnancy Increased susceptibility to TB is a major cause of mortality in HIV positive pregnant women (15% mortality in HIV infected pregnant women) Many cases diagnosed late in the third trimester and/early in the postpartum period: delay in diagnosis because symptoms mimic physiological pregnancy changes 70% co-infection in South-Africa (Gupta CID 2007, Khan M 2001)
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Difficulties using cause of death data • HIV status of most pregnant women unknown
• Some datasets do not list HIV as a possible cause of death • Result: Underestimates of HIV as a cause of maternal death
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Modeling HIV-associated maternal deaths: data needs • Maternal mortality ratios
• Number of live births to all women • Number of live births to HIV-positive women
• The relative per-birth risk of maternal death for HIVinfected versus uninfected women
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Studies examining relative risk of maternal death in HIV+ vs. HIV- women Country
South Africa-2
Year
# maternal deaths
Setting
RR
1997-1998
Tertiary hospital, Durban
101
2.18
Uganda, Zimbabwe
1990s
Kampala, Harare
8
3.00
Republic of Congo
2001
Pointe Noire, city
34
3.85
Uganda
1994-1999
Rakai district
15
5.44
South Africa-1
2003-2007
Hospital in J'burg
76
6.25
Malawi
1990s
National
n.a.
8.10
Zimbabwe
1990s
National
n.a.
9.30
2005-2007
National
2374
9.65
1999-2002
19 participating medical centers
34
13.05
South Africa-3 United States of America
WHO Report – Making Pregnancy safer program, 2008.
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Average
6.76
Median
6.25
Studies examining relative risk of maternal death in HIV+ vs. HIV- women
Background Maternal Mortality Ratio
Background Maternal Mortality Ratio vs. Relative Risk of Maternal Death in HIV+ vs. HIV- women 600.00
Uganda, Zimbabwe
500.00
Malawi
Republic of Congo
400.00 Uganda
300.00
Zimbabwe
200.00
R2 = 0.5893
100.00
United States of South Africa-3 America
0.00 0
1
2
3
4
5
6
7
8
9
10
11
Relative Risk of Maternal Death in HIV+ women
WHO Report – Making Pregnancy safer program, 2008.
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12
13
14
Model results: Plausible range of number of HIV-associated maternal deaths, worldwide, 2008
Relative risk of maternal death
low: 2
Number of live births to HIV + pregnant women (million)
Low: 700,000
6,189
Medium: 1.4 million
High: 2.0 million
medium: 6
high: 10
28,659
48,052
11,572
50,392
80,418
16,731
69,042
106,022
Includes abortion-related deaths WHO Report – Making Pregnancy safer program, 2008.
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Model results: Plausible range of proportion of HIV-associated maternal deaths, worldwide, 2008 Relative risk of maternal death
Number of live births to HIV + pregnant women (million)
low: 2
medium: 6
high: 10
Low: 700,00
1%
5%
8%
Medium: 1.4 million
2%
9%
14%
High: 2.0 million
3%
12%
19%
WHO Report – Making Pregnancy safer program, 2008.
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Model results: Proportion of HIV-associated maternal deaths by region, 2008 MDG Region
% HIV-associated maternal deaths
World Total
9%
Developed Regions
0%
CIS Countries
0%
Developing Regions
9%
Africa
16%
Northern Africa
0%
Sub-Saharan Africa
17%
Asia
1%
Eastern Asia
0%
South Asia
1%
South-Eastern Asia
1%
Western Asia
0%
Latin America and the Caribbean
1%
Oceania
4%
WHO Report – Making Pregnancy safer program, 2008.
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Model results: Countries with most HIV-associated maternal deaths Nigeria
9,865
United Republic of Tanzania
3,216
Kenya
2,250
Malawi
2,124
South Africa
2,122
Zambia
1,778
Uganda
1,774
Mozambique
1,762
Democratic Republic of the Congo
1,670
Cameroon
1,443 Unite for Children
Model results: Countries with highest proportion of HIVassociated maternal deaths Botswana
55%
Lesotho
54%
South Africa
47%
Namibia
41%
Zimbabwe
40%
Zambia
39%
Mozambique
38%
Malawi
32%
Kenya
27%
Uganda
21% Unite for Children
Estimating potential deaths averted: data needs • Number of HIV-associated maternal deaths by cause of death • Interventions that are effective in reducing the number of maternal deaths in HIV-infected women • Effectiveness of each intervention, for each cause of death • Based on the list of interventions • Very little data available Unite for Children
Model result: HIV-associated maternal deaths by cause of death, subSaharan Africa, 2008 Primary obstetric cause Direct
HIV-associated maternal deaths
Deaths as % of all HIVassociated maternal deaths
19,664
38%
3,805
7%
663
1%
Sepsis/infections
8,133
16%
Abortion
6,066
12%
Obstructed labor
409
1%
Ectopic pregnancy
67
0%
Embolism
31
0%
Other direct causes
489
1%
Indirect
30,436
59%
Anaemia
2,178
4%
HIV/AIDS
18,428
36%
Other indirect causes (inc. malaria)
9,830
19%
Unclassified deaths
1,314
3%
51,414
100%
Haemorrhage Hypertensive disorders
Total WHO Report, Making Pregnancy Safer, 2008
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Model results: Reduction in HIV-Associated Maternal Deaths 100%
Anemia prevention, screening, and treament Postabortion care
90%
Safe abortion option
80%
STI diagnosis and treatment Malaria prevention, diagnosis, and treatment
70%
TB preventive therapy (isoniazid prophylaxis) when appropriate Tuberculosis screening and treatment when indicated;
60%
Supportive care, including adherence support and palliative care and symptom management
50%
Advice and support on other prevention interventions, such as safe drinking-water Supportive care, including adherence support
40%
Immunological assessment (CD4 cell count) where available
30%
Clinical evaluation, including clinical staging of HIV disease
20%
Improve quality through addressing health worker bias & combatting stigma
VCT Actions to encourage use of care (to combat stigma)
10%
Antibiotic and other infection control ART for eligible pregnant women
0%
1 WHO Report, Making Pregnancy Safer, 2008
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What is Needed to Alter Current HIV & MM Trajectories • Complex challenge – no silver/magic bullet 1. Incremental approach 2. Strategic priorities 3. Clear goals and targets
• Combination Approaches 1. Integration of ANC and HIV services 2. Integration of HIV and MCH services
• Better job of scaling up what we know works • Prioritization of countries and populations at greatest risk Unite for Children
Impacting Maternal Mortality through HIV Responses Incremental Approach: A. All Pregnant women utilizing health services - ANC
• Know your HIV status 1. Increase VCT coverage to all pregnant women 2. Couple counseling
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Impacting Maternal Mortality through HIV Responses A1: HIV Infected Pregnant Women – ANC
A2. HIV Uninfected pregnant women - ANC
• Initiation of ARV therapy as per guidelines
1. TB Screening + Treatment if needed
• Link ARV treatment to ANC services
2. Malaria IPT and ITN
• TB Screening + Treatment if needed
3. Implement Safe Motherhood Package
• Malaria IPT and ITN • Implement Safe Motherhood Package
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Impacting Maternal Mortality through HIV Responses (2) B. Post –partum - link to MCH Services B1. HIV Uninfected Women • Repeat HIV test • Link to SRH services
B2. HIV Infected Women • Ongoing treatment, care and support • Integrated SRH services Unite for Children
Impacting Maternal Mortality through HIV Responses (3) C. Women not planning to be pregnant Knowledge of HIV status C1. HIV uninfected
• SRH services
• Screening for TB and Malaria C2. HIV infected
• Referral to care and support services • SRH services • Screening for TB & Malaria Unite for Children
Enhancing Quality of Data Quality of HIV impact Data Quality of MM data Establishment of a technical expert team to oversee and review data Requirement of anonymous, confidential reporting of all maternal deaths Audit data from confidential death reports
Use data for re-prioritising goals
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Creating a Supportive Environment for Delivery Strong and Vocal Leadership
Adequate allocation of funds Adequately trained health care personnel Continuous quality assurance and support
Infrastructure development Health care delivery systems in place Set clear targets and monitor progress Use M&E data to monitor & reset priorities Advocacy and Lobbying Unite for Children
THANK YOU MURAKOZE
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