Transcript MDG 5: Improve maternal health Oona Campbell

No Goals at Half-time: What Next for the Millennium Development Goals?
MDG 5: Improve maternal health
Oona Campbell
The problem of maternal death is
large
• A woman dies each minute -- day in, day out
• Maternal mortality is the public health
indicator with the greatest gap between rich
and poor countries
Maternal deaths per 100,000 live births, 2005
99% of deaths in developing world
<100
100-299
Source: http://www.who.int/whosis/mme_2005.pdf
300-499
500-999
1000+
The poor are hardest hit
900
Maternal mortality ratio
800
700
600
500
400
300
200
100
0
Tanzania 1996
Indonesia 2002
Poorest 20%
Source: Graham et al. 2004 Lancet 363(9402):23-27
Richest 20%
Peru 2000
Why act: maternal deaths considered
preventable, subnational & national studies
Jamaica
68
Portugal
75
Tanzania
64
Turkey
51
United States
55
Vietnam
35
Zambia
85
0
Overall,
WHO estimates
98% preventable
10
20
30
40
50
60
70
80
90 100
Percent
Source: Maine D. Safe Motherhood Programs: Options and Issues,
Center for Population and Family Health, 1993.
Maternal survival is tied to several
Millennium Development Goals
• Is Goal of MDG 5: reduce maternal deaths by 75% by
2015
• Linked to MDGs for poverty reduction, female
empowerment, and infectious diseases
• Strengthens efforts to promote newborn survival and
improve the health of the child (MDG 4)
• Improves the welfare of the whole family
• Supports health systems strengthening
Maternal deaths per 100 000 live births
HaveWill
wewe made
progress?
meet MDG 5?
500
450
400
350
300
250
200
150
100
MDG 5 Target
50
0
1990
1995
2000
2005
2010
2015
Source: WHO http://www.who.int/reproductive-health/publications/maternal_mortality_2005/mme_2005.pdf
Epidemiology
Causes of death should drive interventions
1000
900
Most life-saving interventions
require considerable skill
800
Maternal mortality ratio
700
600
500
Most problems can not be
predicted or prevented
400
300
200
Excessive bleeding
is the main cause of death
100
0
Sub-Saharan Africa
South Asia
Haemorrhage
Hypertensive diseases
Sepsis/Inf ection
Obstructed labour
Other direct
A bortion
Indirect causes
Unclassif ied
Source Ronsmans C& Graham W 2006; Lancet (9542):1189-200.
Timing of death is critical
160
Deaths per 1000 person year
140
120
Most deaths cluster
around labour or
within 24 hours after
delivery
100
80
60
40
20
ar
2
Ye
-3
65
D
ay
18
1
91
ay
D
D
ay
43
-
18
0
90
2
84
ay
D
D
ay
37
2
ay
D
D
ay
Time since pregnancy
D
ur
in
g
pr
e
gn
an
c
y
1
0
Source Ronsmans C& Graham W 2006; Lancet (9542):1189-200.
Matlab, Bangladesh
What Should We Do?
• Content of Services
• Organization of Services - Delivery
Mechanisms
Many sources of effective single
interventions that reduce maternal &
neonatal mortality
• Lancet Series
• Disease Control Priorities Project DCPP (World
Bank)
• World Health Report; BMJ
• Cochrane Collaboration (RH Library)
• Many single interventions but none alone can
reduce maternal or neonatal mortality
Organization of Services
 Fertility component
Family planning services
Abortion services
 Obstetric component
Delivery Care
ANC
Postpartum Care
 General Health Services
Strategies for providing family
planning





Clinic-based
Mobile clinics
Community-based distribution
Social marketing
Target special groups: postpartum, post
abortion, adolescents, workplace.
Abortion Policies
Source: http://www.reproductiverights.org/pub_fac_abortion_laws.html
Strategies for abortion
• Legalize abortion
• Ensure legal services provided
• Medical Abortion
• Vacuum Aspiration
• Reduce barriers
• Irrespective of legality:
– Provide post-abortion care
• prompt emergency care
• appropriate care (VA)
• comprehensive RH services
Why not achieving promise?
• Family planning
– Fatigue/ widening of
focus
– Lack of political will
– US withdrawal from
provision of
commodities
• Safe Abortion
– Lack of political will/
champions
– Anti abortion politics
– Training
Delivery care
• Where women deliver and who attends them,
is paramount
WHO?
• Skilled Attendant (midwife or doctor)
Emergency Obstetric Care (EmOC)
Component
CEmOC
BEmOC
(Hospital)
(Health
Centre)
Surgery
(CS, anaesthesia)
Blood Transfusion
X
Manual Procedures
(Vacuum Aspiration, Removal of
retained placenta, Instrumental
delivery)
Medical Treatments
( MgSO4, IV Antibiotics,
Oxytocics)
X
X
x
x
X
Quality Health Centre Strategy
focuses on
• Monitoring woman and baby during labour and for
24 hours postpartum
• Safety and primary prevention
• Early detection and basic management of problems
• Referral to hospital for emergency care
Quality Health Centre strategy is
best bet for maternal survival
• Most effective because skilled attendants can
deliver proven interventions
• More efficient than skilled attendants in the
home or hospital
• Alternative strategies are not as effective or
efficient and may not be sustained
Progress
coverage
looks very different
Where
arein we
now?
in rural and urban areas
32 priority countries by coverage of births with a health
professional
Half the world’s
women currently
give birth with a
professional
25
“Countdown
to 2015”
20
On track (>70%)
Watch (31- 69%)
High alert (<30%)
15
10
In SA & SSA, most
urban women
deliver with a
professional
But only a third of
rural women have a
professional at birth
5
0
Overall
Urban
Rural
Derived from data in DHS Comparative Reports (2005). The context of women's
health: results from the Demographic & Health Surveys 1994-2001.
Slide with unpublished data
Gabrysch S (2008)
Slide shows data from a census of Zambian health facilities.
It shows limited capability of providing Basic Emergency Obstetric Care
functions
The shortage of human resources in
developing countries is huge
• Need to double the supply of health
professionals for deliveries
• Over 300,000 more needed by 2015 to
achieve a coverage of 75%
• 24,000 health centres also are needed
Payments hurt the poor: household
costs as percent of GDP/capita
Country/
year
Benin, 2002
Normal
delivery
Complicated
delivery
3-7
11-51
Ghana, 2002
5-6
16-35
Bangladesh
(rural)
2000-01
Bangladesh
(urban) 1995
11
90-138
12
42
Source Borghi et al. Lancet, 2006; 368(9545):1457-65
Removing
financial barriers
encourages careseeking
A promising
approach is to
remove fees and
fund through
general taxes
The poor may
need additional
support
So what is needed?
1—A new era of strategic thinking
• Care during delivery is the priority
• All women should be able to deliver in health
centres, with midwives working in teams
• Target the women in greatest need: poor and
rural women in sub-Saharan Africa and South
Asia
2—More health professionals for
delivery
• Policy makers must make strategic human resource
decisions to ensure 100% coverage with health
professionals
• Implement plans now for training and deployment of
sufficient numbers of health professionals
• Ensure skills and competencies to provide evidencebased care: Quality counts
• Invest in efforts to retain existing staff
3—Greater financial resources
• Protect poorest families from the catastrophic
consequences of unaffordable emergency care
• Maternal mortality reduction requires a consistent
and significant effort over the next 10 years and
beyond
• National governments need to invest greater
resources
• Donors need to increase financial contributions in
low income countries to fill the resource gap
Financial resources have not been adequate
9
8
7
6
Percent of DALYs
• Maternal & newborn health
not given financial priority
despite a burden of disease
larger than HIV, TB, or
Malaria
• Global development
assistance to maternal and
neonatal health in 2003 was
US$ 663 million
• To achieve universal coverage
with a health professional, an
additional US$1 billion is
needed now, increasing to
US$6.1 billion in 2015
5
4
3
2
1
0
Source:http://www.who.int/healthinfo/global_burden_disease/en/index.html
4—Robust tracking of progress
and accountability
• Better data and information systems needed
to track progress in improved services and
maternal health
• This is to encourage and monitor government
and donor commitments
5—Political commitment is critical
for implementation
• Necessary to ensure this new era of strategic
thinking is translated into programmes
• Governments, donors, and civil society need to
work in concert
Cross-cutting issuess
• Geographic focus:
where problems are
• Policy change:
communication of
successful strategies
rather than
interventions
• Mechanisms for
distributing
interventions (delivery
mechanisms)
• Human resource
constraints (rural areas)
• Training
• Access in remote
areas/communication/
referral
• Financial constraints/
competition for vertical
resources
• Lack of data for routine
monitoring
Progress is Possible
700
500
400
300
200
100
Sri Lanka
Honduras
Bangladesh MM Survey 2001
Thailand
Egypt
China
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
88
19
86
19
84
19
82
19
80
19
78
19
76
19
74
19
72
19
70
19
68
19
66
19
64
19
62
0
19
60
Maternal deaths per 100000 live births
600
Malaysia
Matlab, Bangladesh
India
The Health Centre Strategy is key
• Too many women are dying in their prime years
• Maternal mortality is an MDG that 189 countries have
signed up to
• We need to get on with what works