Transcript Strategies to Reduce Maternal Mortality in the Next Decade

Strategies to Improve
Maternal Health in the Next
Decade
Annette Bongiovanni
USAID LAC SOTA March 2001
Safe Motherhood
Inter-Agency Group
Action Messages
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Advance safe motherhood
through human rights
Empower Women, Ensure Choices
Safe motherhood as a Vital Social
and Economic Investment
Delay Marriage and First Birth
Every Pregnancy Faces Risks
Safe Motherhood
Inter-Agency Group Action
Messages
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Ensure Skilled Attendance at
Delivery
Improve Access to Quality Maternal
Health Services
Prevent Unwanted Pregnancy and
Address Unsafe Abortion
Measure Progress
Power of Partnership
Advance safe motherhood
through human rights:
Rationale
100
% Deliveries Attended by Trained
80
Professionals
92.4
81.6
60
40
20
0
Peru
15.1
Bolivia
13.3
Poorest
20%
2nd
3rd
4th
% people in the country
Source: World Bank, 1998 (unpublished)
Richest
20%
Advance safe motherhood
through human rights:
Strategies
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Increase awareness among First Ladies
Utilize the Legislative Framework to
educate on compliance with existing
laws that protect women
Develop local maternal health
committees to investigate & mitigate
maternal deaths
Optimize existing conventions
i.e.,
Convention on the Elimination of all Forms of
Discrimination Against Women, Convention on the
Rights of the Child, the Program of Action of the
Social and Economic
Investment: Rationale
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Maternal causes of morbidity and
mortality comprise the biggest
contribution to DALYs lost among
women 15-45 years
Motherless children, especially
girls, have higher infant mortality
and are less educated
Social and Economic
Investment: Rationale
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Source:
Total production losses in LAC for
2000:
 maternal disabilities for direct causes =
$532 million
 maternal deaths for direct causes =
$106 million
post-partum hemorrhage
$28m
unsafe abortion
$27m
hypertensive disorders
$18m
sepsis
Burkhalter B,
REDUCE Model, University Research Corp. $13m
2001.
Social and Economic
Investment: Strategy
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Provide ministries of health,
planning, economics, and finance
with costing data and information
to improve resource allocation
and the efficiency and
effectiveness of maternal health
services
Introduce financing schemes
such as national health insurance
to recover costs
Delay First Birth: Rationale
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Early childbearing in 4 LAC countries is associated with
harmful economic effects *
  fertility
 fewer traditional nuclear families and absent fathers
 begets teen mothers
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Among the poor, adolescent childbearing:
  mothers’ monthly wages (90%lower than adults in Barbados)
  child nutritional status, but
  mothers’ contribution to household income which is
associated with improvements in child well-being.
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Girls 15-19 are twice as likely to die from childbirth as
women in their twenties
 32% of 20-24 yr in 9 LAC countries have given birth before age
*
Source: Buvinic, "Costs of Adolescent Childbearing", 1998, IDB.
20
Delay First Birth:
Strategies
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Promote social policies that
expand the schooling and
income earning opportunities of
poor women
IEC messages that promote
delayed childbirth (teen mothers
=vulnerable mothers) and
continuing education of mothers
after childbearing (educated
mothers = educated children)
Every Pregnancy Faces
Risks: Rationale
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Risk assessment cannot determine which
women can safely delivery at home without
a skilled attendant; all women need to have
a trained health professional assist their
deliveries
Prenatal screening by trained midwives
failed to identify women who would need
special care during delivery*
Hemorrhage is the major cause of maternal
mortality in LAC and often is not identified
during prenatal visits.
*Source: Vanneste, et al., "Prenatal screening in rural Bangladesh", 2000
Every Pregnancy Faces
Risks: Strategies
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Risk assessment works best on an individual
case-by-case basis. Complications identified
during pregnancy should indicate the
appropriate level of care a women might need
during delivery (e.g., home with a skilled
attendant, in a health center, or in a hospital)
Risk approach is not useful for demographic
targeting purposes
Train TBAs to identify danger signs of
pregnancy and refer women with
complications to EOC facilities
Ensure Skilled Attendance
at Birth: Rationale
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Previous interventions aimed at
prenatal care and traditional birth
attendant training have had little
impact on  maternal mortality
Majority of maternal deaths occur
around the time of labor and
delivery and immediate post-partum
80% of all post-partum deaths occur
during the first week post-partum*
Source: Li XF, Fortney JA, 1996.
Ensure Skilled Attendance
at Birth: Strategies
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Develop a strong cadre of professional
practitioners to assist deliveries and provide
them with the necessary resources
Incorporate post-partum visits into maternal
health programs; investigate the feasibility of
TBA home visits during the first week postpartum to identify complications for referral
Encourage TBA involvement in health facility
births
Explore feasibility and effectiveness of
maternity waiting homes and birthing centers
Ensure Skilled Attendance
at Birth: Strategies (con’t)
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Quality Improvement Teams at the
local level to identify problems and
solutions to increase demand for
maternal health services, e.g.,
 community-based financing schemes
 emergency transport systems
 birth preparedness plans
 see the QAP presentation
Access to Quality Services:
Strategies
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4 Basic Essential Obstetric Care (E
OC) facilities per 500,000 inhabitants
(or 20,000 births)
1 Comprehensive E OC facility per
500,000 inhabitants (or 20,000 births)
EOC clinical standards should be
incorporated into national
reproductive health guidelines;
managers should use clinical
standards as a supervisory tool
Develop appropriate referral systems
to adequately manage normal versus
Access to Quality Services:
Essential Obstetric Care
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management of problem pregnancies
(anemia, diabetes, etc.)
medical treatment of complications
(hemorrhage, sepsis, eclampsia, etc.)
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manual procedures
(removal of placenta, repair of
episiotomies, etc.)
 monitoring labor (includes Partograph)
neonatal special care
 surgical interventions
 anesthesia
 blood replacement
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Source: World Health Organization, 1991
Access to Quality Services:
Indicators
Distance to the nearest referral facility
(estimated interval from the beginning of the
symptom until the receipt medical assistance
to prevent death)
Complication
Post-partum hemorrhage
Pre-natal Hemorrhage
Ruptured uterus
Eclampsia
Obstructed delivery
Infection
Source: Maine D, et al. 1987
Hours
Days
2
12
1
2
3
6
Access to Quality Services:
Indicators
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% deliveries attended by trained health
professional (physician, nurse, or nurse midwife
who has at least 18 months of obstetrical training and
attends an average of 5-10 deliveries per month)
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% deliveries by cesarean-section
met need for obstetric care
# women w/ complications who are treated during a
defined time period (in a specific geographic area)
estimated* # women with complications during the same
defined time period (in the same area)
*By convention, estimated complication rate is 15% of all live births.
Address Unsafe Abortions:
Rationale (data from Bolivia)
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35% of Bolivia’s maternal mortality
is attributable to abortion
complications
47-50% of hospital gynecological
beds are abortion complications
60% total ob/gyn expenditures in
public hospitals incurred on
patients with abortion
complications
Source: Billings D., Pop Council, 2001.
Address Unsafe Abortions:
Strategies
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National insurance could cover cost
of care for “treatment of
complications of hemorrhage during
the first half of pregnancy”
Post Abortion Care
 reorganize services to ambulatory care
 provide counseling and information
 training in MVA for treatment of
incomplete abortion
 provide family planning counseling before
discharge
 male partner involvement
Maternal Deaths due to
Abortion
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
DR
r
Pe
r
il
a
s
y
al ico ica
iti
ia
la
il v gua raz Ha ma agu ura ado l S
e x ma
E
B
r
d
u
e
t
Bo a r a
a
n
M Ja
Ec
ua Nic Ho
P
G
u
Source: WHO, 1993
Measure Progress:
Rationale
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Rarely necessary to measure maternal
mortality ratios (MMR) more often
than every 5-10 years due to expense
and wide confidence intervals
Process and Outcome Indicators are
more appropriate to measure the
progress of maternal health programs
Measure Progress:
Strategies
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As a proxy for MMR, Skilled Attendance at Birth is a
more accessible annual indicator
Maternal Death Review (WHO tool)--combination of
a verbal autopsy and clinical audit
Measure process and outcome indicators, e.g.:
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contraceptive prevelance rate
average number of pre-natal visits per woman
% pregnant women with prenatal visits in the first trimester
% births in institutions
# facilities that have MCH norms available
total # of facilities
 # women with complications treated in facilities
total # of women with complications