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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1950
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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
728
1.941
668
778
457
549
326
885
3.8755.385Asia
Africa
Europe
LatinAmerica/Caribbean
North America
2050
2005
Bron: United Nations Populations Division, World Population Prospects, The 2004 Revision, medium variant
The young population of developing countries has great growth potential (2005)
300 200 100 00 100 200 300
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FemalesMales
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Millions
Age
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)
300 200 100 00 100 200 300
0-4
10-14
20-24
30-34
40-44
50-54
60-64
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80+ FemalesMales
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
Ma
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tio
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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Durin
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1-180
Day 1
81-36
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Year 2
Dea
ths
per
1000
per
son
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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Sub-Saharan Africa South Asia
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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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28 3037
76
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36
Middle East andNorth Africa
Latin Americaand the
Caribbean
Sub-SaharanAfrica
East Asia andthe Pacific
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?
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