Maternal Health Initiatives to Reduce Maternal Mortality: Need for Political Commitment Ambassador Dr. Eunice Brookman Amissah, MB. ChB, FWACP. FRCOG Ipas Vice President for Africa FIRST EXTRAORDINARY ASSEMBLY OF ECOWAS HEALTH MINISTERS IN OBUDU MOUNTAIN RESORT NIGERIA Delivered by Dr Ejike Oji Country Director, Ipas Nigeria
Transcript
Maternal Health Initiatives to Reduce Maternal Mortality:
Need for Political Commitment
Ambassador Dr. Eunice Brookman Amissah, MB. ChB, FWACP. FRCOG
Ipas Vice President for Africa
FIRST EXTRAORDINARY ASSEMBLY OF ECOWAS HEALTH MINISTERS IN OBUDU MOUNTAIN RESORT
NIGERIA
Delivered by Dr Ejike OjiCountry Director, Ipas Nigeria
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Hundreds of pregnant women, alive at sunset last night never saw the sunrise this morning. Some of them died in labour, some died of hemorrhage in a hospital lacking blood, some died in the painful convulsions of eclampsia and some died on the table of an unskilled abortionist trying to terminate an unwanted pregnancy.”
-- Dr. H. Nakajima, Director-General, WHO, 1999
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And morbid as it sounds these are still the conditions we face today for too many women in Africa. Half a million women die each year performing their physiological function of giving birth most are in Africa. These deaths are only a part of the tragic picture: For every woman who dies, an estimated 15 to thirty more suffer from devastating health problems most of which are life long. This tragedy is mainly a result of lack of critical RH services inadequate care at the time of childbirth but also due to many other factors outside the health system. There is overwhelming evidence that motherhood can be safer for all women and experts over the past two decades have largely come to agree on a set of life saving strategies that can and do work even in low resource settings. What we need is for Governments which is all of us here and other stakeholders to commit to making safe motherhood a priority and a reality for women.
Safe Motherhood: a human right
“Safe Motherhood is a human right… our task is to ensure that in the next decade it is not regarded as a fringe issue, but as a central issue”
James Wolfensohn—Word Bank- 1998
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James Wolfensohn of the World Bank stated on World Health Day in 1998 SLIDE Almost a decade later not much has happened in the statistics in our countries. In some countries things have gotten even worse Pregnancy is not a disease and so it is unacceptable that so many women should die just bearing children All the knowledge and all the technologies are available and in use in the developed countries. Maternal deaths and disability are therefore an utterly preventable tragedy which need not continue.
OVERVIEW
• Look at MMR globally and in Africa
• Review causes of MM
• What we have learnt
• International and Regional mandates and agreements
• What is working
• Essential interventions in low resource countries
• What needs to happen in our countries to reduce MMR
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Global – Regional – MMR statistics
Comparison of 1990 and 2005 MMR by UN-MDG Regions
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Figures released by UNFPA, WHO, UNICEF, World Bank in October 2007: compares Total number of women dying in pregnancy or childbirth: 1990: 576,000 - 2005: 536,000 The Global MMR has fallen by 4.5%. But in Africa alone sadly MMR have rather gone up In countries like Canada and other developed nations the lifetime risk of maternal death is 1 in 11,000 In sub-Saharan Africa it is 1 in 18
Maternal Mortality
Maternal Death is The death of a woman while pregnant or within forty two days of birth or termination of a pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. WHO
– MM best indicator of status of health system of a country.
– Maternal Health is the cornerstone and endpoint of health for newborns, children and women themselves
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SLIDE-
Causes of Maternal Mortality
Direct Medical causes – 80% maternal deaths
• Severe bleeding –PPH (24%)
Infections (15%)
Unsafe abortions (13%) (Estimated 20-30 in Africa)
Eclampsia (12%)
Obstructed labour (8%)
Other direct causes (8%)
Indirect---Conditions aggravated by pregnancy eg malaria, anemia, diabetes, heart disease, HIV AIDS (20%)
• Estimated 15% of deliveries will need skilled care
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The two major causes of MMR in our region are Haemorrhage---before, during or after delivery In Africa second is unsafe abortions as highligthed Other preventable indirect causes include malaria It is estimated that bout 15% of all deliveries have complications requiring skilled intervention These estimates help to focus attention on relevant areas
Carte PAI pour l’Afrique de l’Ouest-2005
TPC Loi Anémie Soins prénatal
Accouchement s
TFT TMM IRR
Sierra Leone 6 C élevé 30 % 25% 6.3 1800 66.1
Guinée 6 C élevé 59% 31% 5.5 1600 59.3
Niger 8 D très el 30% 15% 7.5 1200 67.0
Sénégal 13 E élevé 82% 47% 5.7 1200 59.2
Mali 7 D très el 25% 24% 6.7 1200 67.4
Nigeria 6 E élevé 60% 31% 6.0 1000 58.3
Benin 16 C élevé 80% 60% 6.3 990 52.7
Burkina Faso 12 C élevé 59% 41% 6.8 930 60.7
Cote d’Ivoire 15 E élevé 83% 45% 5.2 810 61.7
Ghana 22 C /B très el 86% 44% 4.5 740 51.1
Togo 24 D élevé 43% 32% 5.4 640 61.6Liberia 6 C/B très el 83% 58% 6.3 560 57.7
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CPR
Abortion Law
Anaemia
Pre-natal
care %
Attended
delivery %
TFR MMR
RRI
Cuba 70 A med 100 99 1..5 95 14.5
Singapore
74 A low 100 100 1..5 107.1
Italy 91 A low 100 100 1..2 12 5.3
Sweden 78 A low 100 100 1..8 7 6.7
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Nairobi 1987→ Colombo 199710 Action Messages
• Advance SM through human rights• Empower women, ensure RH choices• Maternal health is a vital social and economic investment• Delay marriage and first birth• Every pregnancy faces risks• Ensure skilled attendance at delivery• Improve access to quality maternal health services• Prevent unwanted pregnancy and address unsafe abortion• Measure progress• Recognize the power of partnerships
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The Safe Motherhood initiative in Nairobi was a landmark event. For the first time the full extent of the situation was recognized. There was outrage especially over MMR in Africa. At the 10 year review in Colombo further alarm was raised as not only had the previous targets not been reached, in many countries the MMR s had actually increased! New strategies and initiatives were recommended for adoption by countries
Every pregnancy faces risks!!!
• Any woman can develop serious life-threatening complications at delivery
• No reliable way to predict
• All women should have access to high quality obstetric care through pregnancy and especially during and immediately after child birth--EmOC
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The overarching message from SMI +10 was that Every pregnancy faces risks: Any woman can develop serious life-threatening complications at any time during pregnancy and there is as yet no reliable way to predict this All women should have access to high quality and obstetric care throughout pregnancy And especially during delivery have access to the skills identified to be critical to save lives EmOC
Decline in Maternal Mortality in Sri Lanka, 1950-1985
0200400600800
1000120014001600
1940-1945 1950-1955 1960-1965 1970-1975 1980-1985
Source: Bulletin of Vital Statistics, 1979, Department of Census and Statistics, Colombo, Sri Lanka, 1981; and T. Nardarajah,“The Transition from Higher Female to Higher Male Mortality in Sri Lanka.” Population and Development Review 9(2):317-325, 1989.
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This is Sri Lanka which can be compared to countries in our region By the end of the 2nd World War ( 1945 ) MMR was at the natural level of about 1500 Then came a steep decline which has continued till now
Sri Lanka– A Developing Country
• Same GDP as Cote d’Ivoire ($ 750)
• MM in Sri Lanka is 60 ---Cote d’Ivoire 810
• Improved national family planning program
• CPR =60% with 40% for modern methods
• Fertility rate reduced to 2.3 births
• Focused investments in health intervention:
– Improved road networks and other infrastructure
– FP/ MNCH services reach community level and arefree
– Delivery by trained attendants of over 96%
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This is Sri Lanka SLIDE This is evidence that it is possible to reduce MMR drastically even in poor countries. That it is not only about money But about commitment at high political level to make a difference and taking pragmatic action What did they do right? Also addressed socio-economic issues and status of women. Including --Increased age at marriage Free education for women up to University
Need for national commitment and investment
“…safe motherhood is a matter of economic good sense - the resources needed to tackle maternal mortality should be seen not as a cost but an investment”
Gro Harlem Bruntland -WHO
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Vital economic investment is needed in training skilled health providers and equipping health facilities to provide EMOC: National development plans and policies should have RH programmes that include EMOC The conventional wisdom is that Safe Motherhood interventions are costly In reality they have been shown to cost as little as USD 3 per person per year We need to invest in most cost effective interventions In the words of the former WHO DG, Gro Harlem Bruntland, SLIDE---
Unsafe abortions: a major cause of MM
• 45 million abortions occur globally every year
• 20 million of these are unsafe (WHO)
• 68,000 women die annually globally from of unsafe abortion--- 40,000 in Africa alone
• Globally Unsafe abortion accounts for 1 in 8 maternal deaths. In Africa 1 in 3-4
• 7 million women survive but sustain long term injuries
• Tragic because deaths and disabilities are totally preventable
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SLIDE These deaths are tragic because totally preventable
Reducing abortion related maternal deaths
If we address unsafe abortions as we should we will already eliminate 20 to 40% of unnecessary maternal deaths
• INCREASING FAMILY PLANNING UPTAKE to reduce unplanned,unwanted pregnancies is key and will reduce many unwantedpregnancies and unsafe abortions but not all
• INITIATE SAFE ABORTION SERVICES within existing national lawsand expand PAC SERVICES TO DECENTRALIZED LEVELS
• Restrictive laws do not prevent abortions- only make themunsafe
• Urgent need to REVIEW RESTRICTIVE PRIMITIVE COLONIALABORTION LAWS = SAVES LIVES
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SLIDE It is generally acknowledged that restrictive abortion laws do not prevent women from seeking abortions. Only drives them underground and makes them unsafe. Need to review the primitive and restrictive colonial abortion laws that have kept African women shackled three decades after the last African country gained independence!! In some countries they still operate the 1861 laws of their former colonial master England
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Maternal mortality rate Abortion related Obstetrical risk
Abortion law and maternal mortality in Romania
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Let us look at a practical example of the role of abortion in MMM This graph shows the classic example of how unsafe abortion engendered by restrictive laws can affect maternal mortality. Up until 1965 abortion was legal in Romania. During the repressive regime of Ceausescu abortion became restricted. As you can see there was a steep and tragic rise in MMR mostly as a result of deaths from abortion etc until 1989 when Ceausescu’s regime was overthrown The abortion law was liberalized again leading to a dramatic fall in MMR That is all it took to make a difference: LIBERALIZING THE LAW Please tell Hon Ministers not to worry . I am NOT advocating here that anybody should go make a coup in order to change abortion laws. I hope we can do that by sensitizing them to the issue
Essential Interventions to Reduce MMR
• Possible at appropriate levels across the HC system
• Vacuum Extraction for prolonged 2nd stage
• Safe abortion within the law. And PAC
• Basic EmOC including Mg SO4 for Eclampsia
• Assisted Vaginal deliveries
• Comprehensive EmOC
• Building skills of Midwives ++++
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Over the last two decades the international community has come to identify these interventions as critical to save women’s lives and reduce MMR. including Basic Emoc and safe blood, Caesarian Section, Basic life support advanced life support They require infrastructure development, equipment and trained professionals with the requisite skills. Many of our countries have been working at this. And in many countries such services are already available but not to the majority of our women especially in rural areas and peri-urban slums. From the statistics we have it is obvious a lot more needs to be done and perhaps adopting additional interventions.
Maternal health is about total national mobilization and commitment
• Not just RH Unit
• Health professionals ObGyns and midwives key
• Whole health sector involvement especially at political level
Continental Policy Framework on Sexual and Reproductive Health and Rights
October 2005, • Endorsed by the African Union Heads of State ,
January 2006.• Calls for increasing resource allocation to health in
order to improve access to essential RH services
Maputo Plan of Action to operationalize framework• Adopted: Special Session of the AU Conference of
Ministers of Health, Maputo, Mozambique, September 2006
• MDG 5 reduce MMR by 75% by 2015
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Our Heads of state and Hon Ministers have taken the first step by adopting a Continental Policy Framework on Sexual and Reproductive Health and Rights that in 2005 And the MPA Establishes the very minimum standards from which countries can create appropriate RH services including improved maternal health services for all African women. MDG 5 The next logical indeed critical step is to domesticate these excellent documents and implement them at country level.
Generating political commitment and priority: The Shiffman Process
Transnational influence:
- SMI, Women Deliver Conference in London
- Donor support
Domestic advocacy
• Unity among advocates
• Existence of clear indication a problem exists
• Advancement of practical policy solutions
• Presence of effective political champions to front the cause . Ministers of Health
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How do we make that decision and the commitment and generate the needed political support? Jeremy Shiffman, a Visiting Fellow at the Center for Global Development in Washington DC conducted a study between 2003 and 2006 of the political priority given to the reduction of maternal mortality in five countries: Guatemala, Honduras, India, Indonesia and Nigeria and identified certain factors that shape political priority. SLIDE Transnational influence Domestic advocacy National political environment Factors under each category include: Transnational influence: International advocates/organizations put reduction of MM on the global agenda by: promoting global norms that death from pregnancy-related complications is totally unacceptable, and pushing governments to embrace the norms providing resources (technical & financial) Domestic advocacy Unity among advocates Existence of clear indication the problem exists - generating evidence of its magnitude and impact Presence of effective political champions to front the cause Organization of attention generating events that promote widespread concern for the issue (SMI Nairobi 1987) Agenda setting: practical policy solutions - advancement of clear policy alternatives: RECOGNITION THAT PROBLEM IS SURMOUNTABLE National policy environment Political factors/understanding of country context (eg of Romania)
Indonesia experience
• 1st SM Conf 1988 – Opening address by President Suharto
• MM reduction targets in national development plan
• Midwife programme launched 1989-at least one midwife in everyone of 68,000 villages (World Bank support)
• Agenda, Policy formulation, Enactment
• Donor forum organized to support: : UNICEF; USAID; WHO; WB etc
• MMR drastically reduced
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Following NBI Conf Indonesia the MOH organized its 1st SM Conf - invited President Suharto to give the keynote address There followed a burst of political priority at national policy level: MM reduction targets in National Development Plan for the 1st time Midwife programme launched to expand access to skilled attendance at birth to rural women: at least one midwife in every one of 68,000 villages in the country (World Bank support) MOH organized seminar for all provincial heads to devise strategies to reduce MM Series of district audits initiated Seminars organized to encourage cooperation between health and local government on reduction of MM 1996: launch of national campaign to raise the plight of pregnant women dubbed Gerakan Sayang Ibu – “Movement to Cherish Mothers”. President gave keynote address again (2nd time in 3 months) Consequently donor interest in reduction of MM in Indonesia shot up and donor forum organized by MOH and WHO to discuss coordination of activities MMR in Indonesia inevitably fell dramatically.
Interventions with Greatest Potential for Large Scale Reduction
in MMR
• Improved access to Contraceptive Services to reduce risk of maternal death—(29%)
• Access to Safe Abortion Services and Improve PAC services –(25%)
• Prevent / Reduce PPH including with Misoprostol a-cheap miracle drug as part of AMTSL (20%)
• Adopt task shifting and use non physicians
Bixby Program on Population, FP and Maternal Health
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With the target dates for the MDGs approaching there is need to accelerate the pace of change to reduce maternal deaths in our countries The known interventions have been shown to work but take time and huge investments including training --- And faced with human and financial resource constraints studies have been done which identify 3 interventions with the greatest potential to reduce MMR on a large scale –up to about 75% and which can be applied even at community levels of the health delivery system and at minimum cost These are : SLIDE Presentations at recent African First ladies Summit in LA all bore witness to the potential of these interventions to reduce MMR on a large scale.
Enabling Environment Created How to carry this forward in ECOWAS
countries:
Commit to address the issue at the highest political level
Move from rhetoric to action: --IMPLEMENT!!
The knowledge and technologies are all known
Focus investments in RH and Maternal health
Continue with efforts to increase skilled attendance
Improve national Contraception /Family Planning uptake
• Address Unsafe Abortion at legislative, policy and service delivery levels
• Address urgently Post partum Haemorrahge
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SLIDE: We must to increase access to safe services-CAC
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Our Role??—To be Political Champions
Mobilize health and political leaders as
persuasive advocates and champions
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We need to mobilize high policy makers as well as political champions such as we have in this room to move forward the agenda to halt these senseless deaths of women. Reducing MMR should REMAIN high on the national agenda!!!
“----women are not dying because of diseases we cannot treat. They are dying because societies have yet
to decide that their lives are worth saving.”
Dr Mahmoud Fathala
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Finally Hon Ministers Ladies and gentlemen, It is unacceptable that more than two decades after the Safe Motherhood Initiative was launched in Nairobi, in Africa, maternal deaths continue to take such a tragically heavy toll on women in our countries . We need to consider these low cost and critical but effective measures outlined here to rapidly reduce MMR in our countries to meet the MDGs. There has been A LOT of TALK and talk about talk -------- WE NEED TO ACT NOW to stop the senseless deaths of our women I would like to end with the with the damning statement by Dr. Mahmoud Fathalla of Egypt, the doyen of RH in Africa.
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Thank you for your attention, and I look forward to our discussions
