Report on Maternal Mortality in Palestine

Preparation and report writing: Dr. Souzan Ahmad Abdo

Dr. Khadija Jarrar

Dr. Samar El-Nakhal

Dr. Asaad Ramlawi Ms. Taghreed Hijaz Dr. Khalid Abu Saman Mr. Jamal Radwan Dr. Sawsan Hammad Dr. Salwa Najjab Dr. Elias Habash Dr. Waleed Barghouthi Dr. Ali Shaar Prof. Hamed El-Nakhal Dr. Jamil Abu-Fannonah

Translation: Dr. Malek Quteneh

Ms. Reem Miqdadi

Technical and financial support: United Nations Population Fund (UNFPA)

Members of the National Committee of Maternal Mortality: Ministry of Health Women’s Health Directorate: Dr. Souzan Abdo

Mr. Nadim Jbara

Dr. Dina Abu Sha’ban

Ms. Anwar Fahed

Dr. Sawsan Hammad

Primary Health Care: Dr. Asaad Ramlawi

Dr. Ghedian Kamal

Ms. Taghreed Hijaz

Dr. Fuad Al Issawi

General Administration of Hospitals: Dr. Naim Sabra

Dr. Hasan Al Loah

Dr. Mohammad Dwedar

Dr. Adli Al Haj

Ms. Visa Al Za’anin

Dr. Abdul Razzaq Al Kurd Ms. Sana’ Abu Samra

Palestinian Health Information Center: Dr. Jawad Bitar

Mr. Motasem Hamad

Mr. Izzat Rayyan

UNFPA / Dr. Ali Shaar UNRWA / Dr. Elias Habash PMRS / Dr. Khadija Jarrar Juzoor Foundation / Dr. Salwa Najjab Association of Obstetrics and Gynecology / Dr. Waleed Barghouthi Birzeit University / Institute of Community Health / Dr. Niveen Abu Irmeleh Central Bureau of Statistics / Mr. Khaled Abu Khaled Central Bureau of Statistics / Mr. Rami Al Dibes WHO / Dr. Motasem Hamdan Public Service Association / Dr. Monther Ghazal Al-Sahaba Medical Complex / Dr. Na’eem Ayyoub Union of Health Work Committees / Dr. Jamil Abu-Fannonah NGO’s / Mr. Waleed Sabbah UNRWA / Dr. Maryam Wadi Design: Ms. Majd Assali

For correspondence about this report, please contact: Dr. Souzan Ahmad Abdo - Director General / Women’s Health and Development Directorate / Palestinian Ministry of Health

e.mail: [email protected]

Dr. Samar EL-Nakhal - mobile: 0599790196 e.mail: [email protected]

Table of contents Foreword by Minister of Health

5

Introduction: Maternal mortality at the global level

7

Maternal mortality: definition and causes

8

Maternal mortality in Palestine

9

Surveillance of maternal mortality in Palestine

11

Findings of data analysis based on information contained in the questionnaires

12

Maternal Mortality in Northern Governorates “West Bank”

14

Maternal deaths by district

14

Distribution of cases by place of death

15

Distribution of cases by their characteristics

16

Distribution of cases by parity

17

Maternal mortality ratio by age group

17

Distribution of cases in terms of antenatal care provided

19

Distribution of cases in terms of access to hospital

20

Distribution of cases in terms of time of death

22

Maternal deaths by causes (diagnosis)

24

Analysis of maternal death causes

26

The effect of H1N1 influenza on MMR

28

Maternal mortality in Southern Governorates “Gaza Strip”

29

Rational of the study

29

Methodology

29

Results

31

Discussion

33

Conclusion

42

Recommendations

44

References

47

Report on Maternal Mortality in Palestine

Foreword by Minister of Health Maternal health has a central significance for building a strong nation that is able to respond to the present challenges, create a promising future and raise enlightened and well-educated new generations. Mothers are the cornerstone of society in view of their role in creating the foundation of the family – the structural unit of society. Since its establishment, the Palestinian Ministry of Health has paid an extensive and far reaching attention to various aspects of maternal health. This attention is reflected in the different programs being developed and implemented by the Ministry’s various departments and units at all levels. However, maternal mortality surveillance has been, until recently, lacking a systematic approach and has not received the due attention and focus within the overall monitoring system. To bridge this gap, the Ministry of Health took the initiative to form a Technical Committee on Maternal Mortality tasked with creating a national-level system to provide a systematic monitoring with reliable data necessary for the measurement of this essential indicator. The creation of the Committee and its efforts have laid the foundation for developing and mainstreaming a systematic process for monitoring maternal mortality within the Ministry’s policy and operations. This report on maternal mortality is the outcome of this collective and cooperative effort exerted over several months. It provides a statistical and analytical picture of maternal deaths documented in the West Bank in 2009. This report is the first of a kind in the Palestinian territories. Yet it is limited in its scope, since it addresses cases of maternal death in the West Bank only. A report analyzing maternal mortality data from Gaza Strip is expected to be produced in the next year. This report has been possible thanks to efforts of a large group of professionals and field workers. Their generous efforts are highly appreciated. Our thanks are also due to all those who contributed to the publication of this report in one way or another. We hope that this report will be an important resource laying the grounds for the development of appropriate policies and relevant decisions for protecting the health of Palestinian mothers and upholding their basic right to life. We also hope that it will prompt further research in this important field in order to develop a better understanding of ways to improve the provision of health services for the Palestinian people and contribute to state-building efforts.

5

The Palestinian Ministry of Health extends its thanks and appreciation to the members of the National and Technical Maternal Mortality Committee for their efforts. The Ministry also extends its thanks and appreciation to the United Nations Population Fund (UNFPA) for its continuous support to the Ministry in improving the health of Palestinian women and children. Dr. Fathi Abu Mughli Minister of Health

6

Report on Maternal Mortality in Palestine

Introduction: Maternal mortality at the global level Maternal mortality remains a tremendous challenge for health decision-makers worldwide. Firstly, it reveals the huge gap between the opposite poles of the world, the rich and the poor, since 99% of mortality deaths take place in poor countries and only 1% in the developed countries, which is an apparent indication of inequity. Secondly, it reflects lack attention at all levels, since most of these deaths are preventable once there is a political will to do so. More than half a million women die every year during pregnancy, delivery or postpartum for reasons primarily related to health care systems, quality of and access to antenatal, delivery and postnatal services. Estimations of maternal maternity rates (MMR) have been unchanged for long until a report was published analyzing maternal deaths in 181 countries (“Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5”). The analysis demonstrated a decline in maternal deaths from 526,300 in 1980 to 342,900 in 2008. This means that MMR was estimated at 251/100,000 live births in 2008, compared to 320/100,000 live births in 1990 and 442/100,000 live births in 1980. The highest level of maternal mortality was estimated at 1575/100,000 live births in Afghanistan. This is about 394 times higher than MMR in Italy in 2008, which is the lowest in the world, at 4/100,000 live births. In the Middle East, MMR are relatively low, with the exception of Iraq, Yemen and Morocco. According to UN estimates of 2000, 5% of maternal deaths occur in Arab countries, i.e., around 26,000 deaths per year. In addition, 390,000 women suffer from complications and traumas due to pregnancy and delivery, affecting the quality of their lives and that of their families. WHO recent estimates indicate a decline in MMR in Middle East countries from 299 deaths/100,000 live births in 1980 to 183 in 1990 and 111 in 2000, further decreasing to reach 76 deaths/100,000 live births in 2008. The report attributes the decline in maternal deaths to four major factors: 1. A decline in fertility rates worldwide, from 3.7 in 1980 to 2.5 in 2008, 2. Increased income per capita, which is associated with improved nutrition and access to and utilization of health services, 3. Increased level of mothers’ education, and 4. Increased proportion of births attended by qualified medical personnel. 7

Maternal mortality is not a pure medical/technical issue, but rather a rights and developmental issue. The death of a mother during pregnancy or delivery is a flagrant violation of her basic human right to life, as long as there is a failure to take measures that would prevent negligence in preserving her health and life. The maternal mortality issue should be linked to human rights and put on the list of issues with most challenge for political systems in the world. It requires decision-making in relation to equity and equality at the social and economic levels and the provision of health services to those of most need (CEDAW committee has explained that high mortality and morbidity rates among mothers indicate that there are possible violations of this responsibility. In addition, the UN Special Rapporteur on the Right to Health pointed out that “preventable maternal deaths violate the rights of women to life, health, equality and non-discrimination.”) Concern with maternal mortality has gone through major turning points, resulting in initiatives to draw attention and focus efforts on eliminating this human suffering and waste of the potentials of the family, society’s structural unit, with mothers in its core. The first turning point was represented in the launch of the Safe Motherhood Initiative in 1987 from Nairobi, followed by the International Conference on Population in Cairo in 1994, which focused on reproductive health and reproductive rights. The pivotal turning point was the UN Millennium Summit in New York in 2000, where the world expressed commitment to eight Millennium Development Goals (MDGs), with MDG 5 assigned for reducing maternal mortality by 75% between 1990 and 2015, i.e., by an average of 5.5% per year. There has been a 1.5% reduction per year since then. Countries varied in the achieved reduction in maternal mortality, with some countries recoding a rise in MMR. Overall, 23 countries only are on the right track towards the achievement of the goal of 75% reduction by 2015.

Maternal mortality: definition and causes WHO defines maternal mortality as the death of the mother during pregnancy or delivery or within 42 days after delivery, regardless of gestational age, location of pregnancy (normal or ectopic), and whether the death occurs due to direct or indirect causes or due to any health situation that is complicated by the pregnancy or delivery or as a result of treatment of complications or any medical interventions. MMR reflects the number of maternal deaths in a given year per 100,000 live births in the same year. Since some pregnancy or delivery complications may 8

Report on Maternal Mortality in Palestine

cause mother’s death beyond 42 days from delivery, some countries use the term of “late maternal deaths” to describe deaths that occur within one year after delivery or pregnancy termination. Such deaths may comprise 10% of all maternal deaths. Most maternal deaths occur during delivery or immediately after delivery. Causes of maternal deaths are categorized in three main groups: • Direct causes related to delivery, • Indirect causes related to pregnancy and its impact on the health situation of the woman, and • Accidental causes and accidents not related to pregnancy. Direct causes: They constitute about 80% of maternal mortality. The most common direct causes are bleeding, accounting for 25%, and puerperal sepsis, constituting 15%, eclampsia (hypertensive disorders of pregnancy), 12%, complications of unsafe abortion, 12%, and obstructed labor, 8%. Bleeding is the main cause of maternal mortality in both Africa and Asia, while hypertension is the most common cause of death in Latin America and the Caribbean. The main causes of maternal deaths during childbirth in developed countries are complications related to Caesarian section and anesthesia. Indirect causes: They constitute about 20% of the causes of maternal mortality, and include heart disease, anemia, liver diseases, renal problems, HIV/AIDS, and cancer. Accidental causes: Such as traffic accidents and murders. Predisposing factors: These are not a cause of death in themselves but they do increase the likelihood of maternal death during pregnancy or childbirth. These factors cause a delay on three levels: the first level is the delay in making the decision to seek health services when needed. The second level is the delay in accessing health services. The third level is the delay in utilizing health services until it is too late.

Maternal mortality in Palestine Estimates of maternal mortality in the Palestinian territories vary widely in the absence of a well-structured national monitoring system. In 1980, WHO estimated maternal mortality in Palestine at 181 (114-275) per 100,000 live births, and reduced the estimate to 92 in 1990 and to 52 in 2000.

9

In a report published by WHO in 2009, maternal mortality in the Palestinian territories for 2008 was estimated at 46 per 100,000 live births. These estimates rank the Palestinian territories in the 83rd place among the world countries in terms of MMR and in the 12th place among Arab countries, trailing behind al Gulf countries, Jordan, Tunisia, Libya and Egypt. Based on WHO estimates, maternal mortality has been reduced from 92 in 1990 to 46 in 2008, reflecting a 3.8% decline per year. This is higher than the average worldwide reduction of 1.3% and lower than the target reduction according to MDG 5 (5.5%). Maternal mortality rates in 2008 per 100,000 live births / WHO estimates

According to the findings of the demographic survey carried out in 1995 by the Palestinian Central Bureau of Statistics (PCBS), maternal mortality was estimated at 74/100,000 live births. According to MoH 2005 annual report, the rate of documented and reported maternal deaths in Gaza Strip was 15.4 /100,000 live births, and in the West Bank was 1,8/100,000 live births. These figures are unrealistic, especially for the West Bank. This is due to weaknesses in the documentation and reporting of maternal deaths, which is originally due to errors in the classification of causes of death: In most death certificates issued by various health institutions, the direct cause of death is registered as cardiac arrest, and in most cases, the real reason which led to this condition is not documented. In addition, personnel documenting death certificates do not pay attention to the need to fill the box that indicates whether the deceased woman was pregnant or within 42 days after childbirth or abortion. Thus maternal deaths go without being documented. Estimations of MMR by the UN Relief and Works Agency for Palestine Refugees (UNRWA) for the period between 1995-2002 stood at 17.5/100,000 live births in the West Bank and 23.7/100,000 live births in Gaza Strip. These figures were 10

Report on Maternal Mortality in Palestine

concluded on the basis of a retrospective audit of the refugee population in Palestinian refugee camps.

Surveillance of maternal mortality in Palestine* • A questionnaire to monitor maternal mortality was developed by a team of health professionals from the primary health care (PHC) department and the information systems unit, drawing on experiences from other countries and local experiences. • The questionnaire was reviewed by all team members before being finalized. • In 2008, training was offered to the mother and child health (MCH) team, composed of obstetricians, MCH supervising physicians and nursing supervisors, in all Directorates of Health and they were assigned the task to fill the questionnaire over a period of three months in the final quarter of 2008. The questionnaire is composed of three parts. The first part is designated for documenting deaths of women in reproductive age: to be filled for each deceased woman in the age group 15-49 years. If the deceased woman was pregnant or died within 42 days after childbirth or abortion (maternal death), the second part of the questionnaire should be filled. The third part should be filled by the Technical Committee on Maternal Mortality after reviewing the questionnaire and any other relevant data. The Committee should record its general assessment of the case in this part. The maternal mortality part contains demographic and personal data about the deceased woman and information on her obstetric history, antenatal care, and the history of last pregnancy, in addition to questions about place of delivery, history and complications that occurred during delivery, referral, transportation, as well as on the direct cause of death and predisposing factors. Information is to be taken from interviews with: parents, providers of antenatal care, providers of care during delivery and the postpartum period. Part of the information is to be taken from the antenatal care record and hospital medical record. During 2009, a total of 25 questionnaires were filled. They were numbered according to the date of death reporting and year (1/2009 – 25/2009). The Committee reviewed and assesses each individual case and came up with * Based on Palestinian Ministry of Health Reports in 2010, maternal mortality ratio was 32 per 100,000 livebirths.

11

conclusions in relation to the condition of the woman during pregnancy, delivery and postpartum. Information was also reviewed on case management in the hospital when the complications occurred and comparisons were made between symptoms, diagnosis and treatment (whenever such information was available and according to the information contained in the questionnaire). At the end of each review, the Committee gave a general assessment as to whether it was possible to prevent the death of the woman or not.

Findings of data analysis based on information contained in the questionnaires The Committee decided to endorse 23 out of the 25 cases of maternal deaths reported during 2009, since the death in two cases occurred within a period exceeding 42 says after delivery (late maternal mortality). This decision was based on WHO definition of maternal mortality as the death of the mother during pregnancy or delivery or within 42 days after delivery or termination of pregnancy. Thus, the number of maternal deaths reported and registered by the Palestinian Ministry of Health (MoH) was 23 deaths. This a record number of reported and officially documented maternal deaths in the Palestinian territories. Compared to MoH data during the past ten years, one can notice that MoH is now dealing with the issue of maternal mortality with more seriousness, resulting in enhanced commitment of all stakeholders to ensure reporting and documentation. The filled questionnaires are being referred to the National Committee on Maternal Mortality, which examines and comments on the cases and develops the appropriate recommendations with respect to necessary measures for reducing maternal deaths as much as possible. Maternal mortality reported cases 2000-2009 (MoH)

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Report on Maternal Mortality in Palestine

By reviewing MoH reports, it is noticed that only one case of maternal death was reported in 2005 as well as in 2007, while two cases were reported in 2004 and two other cases in 2006. However, the reporting has been improved during 2008 to reach 11 cases. This reflects MoH increased concern with the issue of maternal mortality reporting and documentation, which was evident in the instructions given to Departments of Health in all districts to report maternal death cases using the questionnaire that was in the piloting stage at that time. Compared to 2008, the number of reported and documented cases by MoH doubled in 2009. However, there is no guarantee that this is the real number of maternal deaths. The Committee still maintains that there are missing cases due to the multitude of service providers. This may include difficult cases that were referred to Israeli hospitals and died there. In summary, there has been a great deal of improvement in the reporting and documentation of maternal deaths. However, there is still a need to improve the monitoring and surveillance mechanism in order to be able to obtain a real indicator that can be used to measure the level of health service provision in Palestine.

13

Maternal Mortality in Northern Governorates “West Bank” The ratio of maternal deaths to the number of live births in the West Bank in 2009 was 36.42/100,000 live births, considering that the total number of births in the West Bank in that year was 63,144 live births. This ratio falls within the range of Who estimate for 2008, which was 46 (27-71). Maternal deaths were the second larger cause of deaths for women in the reproductive age in 2009, with acute myocardial infarction (MI) ranking first. While 36 women died from MI, 23 died from reasons related to pregnancy or childbirth. This was followed by breast cancer, which was responsible for 22 women in reproductive age during 2009 (based on MoH statistics for 2009). This means that pregnancy and childbirth remain among the high risk factors for women’s lives in their reproductive age in the Palestinian territories. Yet maternal deaths should not be compared with other deaths because “pregnancy and childbirth are not an illness but rather a normal physiological process for women to the benefit of humanity, which could be accompanied by unpredictable but treatable complications,”

Maternal deaths by district maternal mortality ratio varied between districts. The highest ratio was recorded in Tulkarem district, reaching 68.5/100,000 live births, followed by Bethlehem at a rate of 61.1/100,000 live births, and Ramallah at 43.94/100,000 live births. The ratio in Hebron district was 37.6/100,000 live births, and in Jenin 13.4/100,000 live births. In terms of numbers, seven deaths were registered in Hebron area, followed by four deaths in Ramallah, three deaths in each of Bethlehem, Nablus and Tulkarem, and one death in each of Jerusalem, Jenin and Qalqilya districts. There were no maternal deaths in Jericho, Salfit and Tubas districts.

Jerusalem

Tubas

Jenin

Tulkarem

Qalqilya

Salfit

Nablus

Ramallah

Bethlehem

Jericho

Hebron

District

West Bank

Maternal mortality rate by district, 2009

Number of 63144 18605 1452 4911 9104 9096 1623 2739 4378 7473 1290 2473 live births, 2009

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Report on Maternal Mortality in Palestine

Number of maternal deaths Maternal mortality rate

23

7

0

3

4

3

0

1

3

1

0

1

36.42 37.62 0.00 61.09 43.94 32.98 0.00 36.51 68.52 13.38 0.00 40.44

Distribution of cases by place of death All cases of death occurred in the hospital, except one case of a woman, who died in the road to the hospital after being involved in a traffic accident. In 12 cases, women died in governmental hospitals (53%) and in 10, the death occurred in private sector hospitals (43%). Based on MoH annual report, about half of births took place in the public sector and the other half in the private sector. Maternal mortality ratio in governmental hospitals was estimated at 38.37/100,000 live births (31,270 live births took place in governmental hospitals in 2009). Maternal mortality ratio in private hospitals was estimated at 32.54/100,000 live births (30,731 live births took place in private hospitals in 2009). These data may call for more in-depth examination of caused leading to these deaths in order to draw conclusions on how to improve the quality of services both in the public and private sectors. M/M by Place of death (Reported/2009/West Bank)

Unknown, 1 Private Hospital, 10 MOH Hospital, 12

15

Distribution of cases by their characteristics Age at first marriage: In around half of cases, the women were married at an early age below 18 years of age and 48% were married when they were older than 18. This indicates that half of deaths were associated with a social risk factor. Educational level: 22% of the deceased mothers had 6-12 years of schooling, 3% had 13-14 years of schooling and 17% had more than 14 years of education. However, it is difficult to associate the educational level with maternal mortality risk factors, since the educational level was not recorded in the questionnaire for more than half (52%) of the cases. M/M by Age at first marriage (Reported/2009/West Bank)

Unknown, 1 18 years, 11

Distribution by Education (Reported/2009/West Bank)

Missing, 12 6-12 years, 5 13-14 years, 2 >14 years, 4

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Report on Maternal Mortality in Palestine

Distribution of cases by parity The number of pregnancies and parity are directly linked to increased probability of maternal mortality. Research indicate that maternal death probability is 1:400 during the first pregnancy, 1:200 during the second and 1:100 during the fourth. Maternal death probability increases to 1:500 during the eighth pregnancy, which means that one out of every 50 women in their eighth pregnancy will die for reasons related to pregnancy. Distribution by parity (Reported/2009/West Bank)

Missing, 8 >5 times, 4 3-5 times, 7 0-2 times, 4

The number of pregnancies and/or parity were not indicated in a large proportion of cases (36%). However, 47% of cases (11, or about half of cases) were in their fourth pregnancy or higher, indicating that they were at a relatively higher risk of maternal mortality.

Maternal mortality ratio by age group The analysis demonstrated that more than half of the deceased women were in the age group 20-29 years and 26% in the age group 30-39 years. On the other hand, 6% were less than 20 years of age and 13% were 40 years or older. The lowest maternal mortality (18.65/100,000 live births) was recorded among 17

the youngest age group, who accounted for 8.5% of total births in 2009. The highest rate was among the older age group, amounting to 143.74/100,000 live births. This means the risk of maternal mortality for this group is more than three times (3.3) higher than the risk of maternal mortality for mothers in all age groups. Maternal Mortality By Age (Reported/2009/West Bank)

40=