Global Health; Reproductieve

gezondheidszorg

Reproductive Health; global perspective

• Doelstelling– Inzicht geven in belang reproductieve

gezondheidszorg

Reproductieve gezondheidszorg• Inhoud

– Theorie;

• Demografie & anticonceptie & infertiliteit• MDG 5; Maternale sterfte; oorzaken en oplossingen

– Praktijk; Verhalen uit het veld; consult online

– Dr. Schagen v. Leeuwen aan het woord; Ethiopie

- Vragen

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Bron: United Nations Populations Division, World Population Prospects, The 2004 Revision, medium variant

Global Population Growth;a developing country phenomenon

Developing countries

Developed countries

Billions

Bron: United Nations Populations Division, World Population Prospects, The 2004 Revision, medium variant

Global Population Growth;a developing country phenomenon

Developing countries

Developed countries

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1.941

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3.8755.385Asia

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Bron: United Nations Populations Division, World Population Prospects, The 2004 Revision, medium variant

The young population of developing countries has great growth potential (2005)

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Bron: United Nations Populations Division, World Population Prospects, The 2004 Revision, medium variant

In the developed countries there are fewer and fewer young people, more and more elderly (2005)

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Age Millions

• Worldwide 210 million conceptions

• 80 million no life baby of which:

• 42 million induced abortions • 35 million miscarriage/ectopic

• 3 million babies are stillborn

Unmet need for family planning

Bron:The Lancet; Countdown to 2015 decade report(2000-10) taking stock of amternal, newborn, and child survival; jun 2010

World abortion laws 2007: grounds on which abortion is permitted

Bron: Brown, H. BMJ 2007;335:1018-1019

Infertiliteit

• 3% nooit zwanger, 4.5% geen kind

• Subsahara Africa infertiliteit 7-31 %

Stellingen

• Onze planeet kan geen 9 miljard mensen herbergen en een menswaardig bestaan bieden

• Iedereen moet gratis toegang krijgen tot anticonceptie

• Geen zorg voor onvruchtbaarheid vermindert de kans op acceptatie van family planning

Introductie MDG 5

• Millenium Development Goals; MCG 5; Improve maternal health. Reduce by 75% the MMR and achieve universal access to reproductive health

VN uitspraak • “Our world possesses the knowledge and

resources to achieve the MDGs… falling short of the Goals would be an unacceptable failure, moral and practical.”

Ban Ki Moon

Maternal Mortality Rate; WHO 2008

Introductie

• Highlight on maternal mortality: • Every day in 2008, about 1000 women

died due to complications of pregnancy and child birth

• US: life time risk; 1: 2100

• Subsahara Africa: life time risk; 1:31

Bron: Are we making progress in Maternal Mortality? NENGLJMED may 26 2011

MMR world

1 moedersterfte elke minuut

• Malawi; zwangerschap => Chichewa “pakati”;“ the place between life and death”

Moedersterfte (WHO definitie); overlijden moeder in zwangerschap of tot 42dagen na zwangerschap van een oorzaakgerelateerd of verergerd door zwangerschap

Maternal mortality is the health indicator that shows the widest gaps between rich and poor, both between countries and within them

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Tanzania 1996 Indonesia 2002 Peru 2000

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Poorest 20% Richest 20%

Maternal Mortality

Maternal Mortality: a Small Part of a Larger Problem

Poor Healthand

Disability

UN

ICE

F/C

-79-

53/G

ood

smith

Vooruitgang

Maternale sterfte wereldwijd• In 1980 > 526.300 (onzekerheidsinterval 446400 –

629600)

• In 2008 > 342.900 (onzekerheidsinterval 302100 – 394300)

Maternal Mortality Ratio per 100.000 live births wereldwijd

• In 1990 320 (272-388)• In 2008 251 (221-289)• Ofwel een reductie van ongeveer 22%Bron: Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards

Millennium Development Goal 5Margaret C Hogan, Kyle J Foreman, Mohsen Naghavi, Stephanie Y Ahn, Mengru Wang, Susanna M Makela, Alan D Lopez, Rafael Lozano,Christopher J L MurrayLancet 2010; 375: 1609–23

Vooruitgang

Bron: Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5Margaret C Hogan, Kyle J Foreman, Mohsen Naghavi, Stephanie Y Ahn, Mengru Wang, Susanna M Makela, Alan D Lopez, Rafael Lozano,Christopher J L MurrayLancet 2010; 375: 1609–23

MDG 5 Target

Introductie

Majority of these deaths can be prevented with timely medical treatment and functioning health systems

Timing of death is critical

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year Most deaths cluster around labour or within 24 hours after delivery

How much time do we have? • It is estimated that, if untreated, death

occurs on average in• 2 hours: from Postpartum Hemorrhage• 12 hours: from Antepartum Hemorrhage• 2 days: from Obstructed Labor• 6 days: from Infection

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Haemorrhage Hypertensive diseases Sepsis/Infection Obstructed labour

Other direct Abortion Indirect causes Unclassif ied

Most problems can be prevented or treated during delivery or immediate postpartum

Most problems can not be predicted or prevented antenatally

Excessive bleeding is the main cause of death

To avert death and disability

…We Need to Ensurethat Women have Access To…

…We Need to Ensurethat Women have Access To…

Emergency Obstetric Care

10

EmOC Signal Functions(UNICEF,WHO,UNFPA,1997)

Basic EmOC -health centre

1. iv/m antibiotics

2. iv/m oxytocics

3. iv/m anticonvulsants

4. manual removal placenta

5. assisted vaginal delivery

6. removal of retained products

Comprehensive EmOC

- Hospitals

All six Basic functions plus:

7. caesarean Section

8. blood transfusion

EMOC;well trained nurses and midwives

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Latin Americaand the

Caribbean

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South Asia

Births in millions, 2004 Percent of births attended by skilled personnel, 1996-2004

Evidence

Bron: Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5Margaret C Hogan, Kyle J Foreman, Mohsen Naghavi, Stephanie Y Ahn, Mengru Wang, Susanna M Makela, Alan D Lopez, Rafael Lozano,Christopher J L MurrayLancet 2010; 375: 1609–23

Illustratie: 40% zorg dekking voorkomt 105.000 doden voor US dollar 0,54

Bron: PLOS 2010

Maternal disability

• Short- or Long-term Illness caused byobstetric Complications

The Most Serious Is Obstetric Fistula (An Abnormal Passage Between Vagina

and Bladder or Rectum Often Caused by Obstructed

Labor When it is Not Treated with Cesarean Section)

Maternal disability

• VVF = vesicovaginal fistula (continu lekken van urine door de vagina)

• RVF = rectovaginale fistula (wisselende passage van ontlasting of flatus door de vagina

• Obstructed labour: hoofd van bab te groot, draait of presenteert zich verkeerd, en gaat vast zitten in het geboortekanaal

• Het weke deel van de vagina zit vast tussen het harde hoofd en bekken druk necrose

• De baby sterft en het hoofdje slinkt, dit kan dan door geboortekanaal

Maternal disability

Safe Motherhood

• A woman’s ability to have a safe and healthy pregnancy and delivery; at a time she wants

Hoe bereik je safe motherhood? • Providing high-quality maternal health

services to all women– Care by skilled personnel– Emergency care for complications– Services to prevent and manage

complications of unsafe abortions– Family planning– Health education and services for

adolescents– Community education

Prioriteit

•Empower women, ensure their choices

• Advance safe motherhood through human rights• Safe motherhood as a vital economic and social

investment• Delay marriage and first birth• Every pregnancy faces risks• Ensure access to high quality maternal health services• Prevent unwanted pregnancy and address unsafe abortion• Measure progress• The power of partnership

The Three delays

The theoretical framework of the three phases of delay:

• (1) The decision-making process

• (2) The delay to reach the health facility

• (3) Delay before receiving adequate care

Recognition

ReferralRecognition

ResponsivenessReferralRecognition

Video

‘Dead mums don’t cry’ BBC http://www.youtube.com/watch?v=5g0vzs8bC8s

Consult Online

Casus Obstetrie

• G6P4, AD 25 wkn;

• Presentatie met RR 160/110, zonder klachten

• Urine: massieve albuminurie• Echo: intacte graviditeit cf 24-25 wkn

Beloop

• Gedurende opname: perifeer oedeem en dyspnoe

• LO/ pulmones: basaal crepitaties

Differentiaal Diagnose

• Pre-eclampsie• Infectie ziekte

Beleid Tropenarts

• Medicamenteus; R/ Methyldopa 500mg 3dd1; R/ Nifedipine 20mg 2dd1 en R/ Furosemide 80mg 2dd1

Hierop normalisering v/d tensies naar 120/80, afname dyspnoe-> maar wat nu gezien AD 25 wkn!?Consulteren casus aan CO

Definities

Pre-eclampsia• Hypertension (>140/90)• Proteinuria: > 1+ protein

Eclampsia• Convulsions or unconsciousness• Pre-eclampsia• No other causes for convulsions or

unconsciouness

Kliniek

• BP > 140/90• Proteinuria 1+ or more• Headache• Blurred vision• Epigastric or upper abdominal pain• Hyperreflexia, clonus• Breathlessness (pulmonary oedema)• Oliguria (<100 ml/4 hours)

Beleid

• Control the convulsions• Control the bloodpressure• Manage complications• Deliver the baby

Risico’s eclampsie

• Aspiration• Intracerebral hemorrhage

• The risk is directly proportional to the total number of fits since cerebral oedema occurs as a consequence of the fits

Vraagstelling tropenarts CO

• Waarom presenteert een multiparae met een blanco voorgeschiedenis zich met pre-eclampsie?

• Afwachten of inleiden gezien AD25wkn?

• Advies tav aanvulling huidige behandeling?

Reacties CO

• Waarom presenteert een multiparae met een blanco voorgeschiedenis zich met pre-eclampsie?

– Mgl heeft pte in eerdere zws ook ongemerkt hypertensie gehad

– Multiparae kunnen ook opeens hypertensie ontwikkelen

Reacties CO

• Afwachten of inleiden gezien AD25wkn?– Termineren zwangerschap => Moeder is nu

belangrijk, kind zeer wrs niet te redden. Longoedeem is zeer ernstige pre-eclampsie

– inleiden met misoprostol ½, ¼, tablet misoprostol in fornix posterior.

– Indien klinisch toch stabiel dan dexamethason 6mg 1m 2dd voor 2dgn voor longrijping kind

Reacties CO

• Advies tav aanvulling huidige behandeling?– Geef O2– Vochtbalans! indien UP<: overweeg

dopamine infuus (5dpls p/minuut)– Adviseer tubaligatie– Sluit malaria en PCP uit tav dyspnoe

Afloop casus

• Zwangerschap is getermineerd, moeder is ingeleid, kind is overleden, moeder goed hersteld

Tropenopleiding www.tropenopleiding.nl

Vragen?