MDG 5 MDG 5 INTERVENTIONS: INTERVENTIONS:

Improve Maternal HealthImprove Maternal HealthSolveij Rosa Praxis

Maternal Mortality:

The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the

duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its

management but not from accidental or incidental causes. [14]

Maternal Health Targets:

TARGET 5A: Reduce maternal mortality ratio by three quarters by 2015

Indicators:

• Maternal mortality ratio

• Percentage of births attended by skilled health personnel

Maternal Health Targets:TARGET 5B: Achieve, by 2015, universal access to reproductive health, including family planning

Indicators:

• Total fertility rate (TFR)

• Contraceptive prevalence rate (CPR: refers to use of modern contraceptive methods among married women of reproductive age)

• Adolescent birth rate

• Antenatal care coverage

• Unmet need for family planning

Impacts.

Maternal Mortality: 350,000-500,000 girls and women die each year from pregnancy and childbirth complications. (UNFPA)

Maternal Morbidity: 15 and 20 million girls and women suffer from maternal morbidities every year. (UNFPA)

Productivity Loss: $15 billion (UNFPA)

Progress. 5A

Maternal mortality ratio, 1990 and 2010 (Maternal deaths per 100,000 live births, women aged 15-49).Source: The Millennium Development Goals Report 2013

Maternal mortality has declined by nearly half since 1990, but falls far

short of the MDG target.

• Maternal mortality ratio: 240 per 100,000 births in LDCs (versus 16 per 100 000 in developed countries)

• Percentage of births attended by skilled health personnel: 55% to 66 % in LDCs from 1990-2011 [Urban: 75-->84%; Rural: 44-->53%]

Progress. 5B

Progress Lag. Why?

• I. Lack of Attention and Funding: “children are the most vulnerable of the vulnerable.” As a result, it can be easier to secure the resources needed to meet their basic needs. “But women have often remained invisible.”

• II. Complex Interventions: good maternal health “requires skilled personnel and a health system that delivers” – as opposed to routine immunization and many other child-health interventions that can be carried out with relatively basic resources at the community level.

Intersectional Issues.

ECONOMIC

Poverty/Inequality: Women most affected have the worst status and least resources.

Health Disparities: Ninety nine percent (99 per cent), of maternal and newborn mortality occurs in the developing world(UNICEF)

SOCIAL/CULTURAL

Gender inequality: Lack of education; Economic dependency on men

Sexism: gender discrimination, violence, reproductive biases (high fertility rates, early marriage)

“Men often decide whether their pregnant wives live or die. A woman recovers from a caesarean that saved her and her child—which her husband only reluctantly agreed to when her condition became critical. [...] Taboos prohibit women from being treated by male doctors further limit access to vital care.” (UNICEF)

INSTITUTIONAL/POLITICAL

War/conflict/violence: restricts access to basic health care

History of Imperialism: health development partnerships with developed world can lack trust

Reproductive health and DevelopmentFamily planning is the foundation for human development, and its interdependency with other development goals means that, with progress, it

can provide the “demographic dividend”.Poverty and Hunger—birth spacing reduces incidence of low birth weight and poor maternal nutrition, more economic

security and less hunger

Education—reduces need for girls to drop out of school because of unintended pregnancy or care for younger siblings

Gender Equality—empowers women, enabling them to achieve desired family size

Maternal and Child Health—reduces maternal death due to unintended pregnancy(abortion, complications), increases child survival

HIV/AIDS—preventing unwanted pregnancies among HIV+ women key in preventing mother-to-child HIV transmission

Environment—family with fewer children needs less land, food, and water and puts less pressure on country’s forests and tillable land

Responsive strategy

I.Local/community-based

II.Empowerment/community ownership/collaboration

III.Efficiency/business model (incentives): *goal is to make intervention adoption as easy as possible*

Interventions Framework.

EFFECTIVE INTERVENTIONS(5 levels): clinical interventions; protective interventions; enabling environment; and socioeconomic interventions. [1] (UNFPA)

HEALTH SYSTEMS to Deliver Interventions: Multi-tiered maternal health programs are complicated and multi-faceted, involving education, the spread of information, health provider training, client transport, use of proper equipment, and the establishment of quality health facilities.

Community-level

First-level health facilities

Referral facilities

COMPREHENSIVE POLICIES and STRATEGIES: underlying frameworks that set out how the resources needed to deliver results will be mobilized and deployed. [2]; there must be a “comprehensive national health policy & strategy” to ensure this health infrastructure is supported, sustainable and effective. [2] (WHO)

Intervention Areas.

3 Intervention Areas:1. Access to family planning—counseling, services, supplies2. Access to quality care for pregnancy and childbirth

• antenatal care• skilled attendance at birth, including emergency obstetric and neonatal care• immediate postnatal care for mothers and newborns

3. Access to safe abortion services, when legal (as per paragraph 8.25 of the Programme of Action for ICPD)

3 High-Impact Interventions:1. Access to contraceptive services for all women, to prevent unwanted pregnancies (and complications associated with pregnancies)2. Access to care by a skilled attendant for pregnancy and childbirth3. Access to emergency obstetric care for all women and newborns with complications.

http://kihefoblog.wordpress.com/2013/07/10/meet-sister-beatrice-the-mother-of-family-planning-at-kihefo/

Intervening at CAUSAL PATHWAY for

Safe Motherhood.

GOAL: Access to quality obstetric care with trained providers for Safe Motherhood.

CAUSAL PATHWAY... for intensive care, near-misses, and maternal death.

Postpartum hemorrhage (PPH), Severe Aenemia

Obstructed labor

Unsafe Abortion

Infection/Sepsis

Pre-eclampsia, Eclampsia (hypertensive disorders)

GOAL: Access to quality obstetric care with trained providers for Safe Motherhood.

CAUSAL PATHWAY... for intensive care, near-misses, and maternal death.

Postpartum hemorrhage (PPH), Severe Aenemia

Obstructed labor

Unsafe Abortion

Infection/Sepsis

Pre-eclampsia, Eclampsia (hypertensive disorders)

Intervening at CAUSAL PATHWAY for

Safe Motherhood.

2. Access to care by a skilled attendant for pregnancy and childbirth

Intervention:MOMS with

Misoprostol Address PPH

3. Access to emergency obstetric care for all women and newborns with complications

Intervention:MOMS with

Misoprostol Address PPH

Intervention: MOMS with Misoprostol Address PPH

Challenges for resource-poor, socioeconomically disadvantaged settings.1. Inadequate number of health care facilities staffed with trained providers in emergency obstetric care (EmOC).

Challenges for resource-poor, socioeconomically disadvantaged settings.1. Inadequate number of health care facilities staffed with trained providers in emergency obstetric care (EmOC).2. Financial barriers to care, with high costs for maternal health care services, including unofficial payments to access care, and the cost of drugs, supplies and transportation.

3. Lack of effective technology to manage complications in home births, where most of the deliveries occur in poor settings.

Intervention: MOMS with Misoprostol Address PPH

Response...

COMMUNITY-BASED

MOMS (Midwives and Others with Midwifery Skills)

trained as skilled health workers

for short-term goal of *protecting births in the HOME.*

Intervention: MOMS with Misoprostol Address PPH

Midwives and Others with Midwifery Skills (MOMS) “midwives are usually women working with and for women, and as such have not caught the attention of politicians and policy-makers” (UNFPA)

MOMS perform 3 essential functions:

• supervise and preferably provide hands-on quality care that is acceptable to women and their families, at the point where women need it most–close to where they live and frequently give birth, and within reach of emergency care whenever necessary

• teach and supervise other health workers who need some midwifery skills, but are not required to be experts

• work with, educate and help empower communities to recognize the need and increase demand for skilled midwifery services

Intervention: MOMS with Misoprostol Address PPH

https://vietnam.unfpa.org/public/pid/6629 http://tanzania.unfpa.org/

http://www.unfpa.org/sowmy/resources/docs/photos/1_TorfinnS_Sudan.jpghttp://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862013001100804&lng=en&nrm=iso

Midwives and Others with Midwifery Skills (MOMS)

Challenges to scaling up midwifery capacity:

1. Lack of numbers of midwives and in most cases poor quality of midwifery training. Lack of investment meant clinical and theory training were not updated.

2. Lack of funding for pre-service, in-service and continuing training, and for employment of midwives.

3. Competition and conflicts between physicians and nurses, physicians and midwives, nurses and midwives – with midwives trying to establish professional space.

4. Lack of incentives and lack of polices and plans to develop human resources for health. There is also need for support for the basics such as housing, light, water, topping up of salaries.

5. Need for close relationships between women and midwives. Where midwives worked with women and women’s groups the midwifery profession was usually stronger.

Intervention: MOMS with Misoprostol Address PPH

Midwives and Others with Midwifery Skills (MOMS)

Investing in MOMS:

•Numbers

• raising the profile of midwives• financial, human or technical support

•Quality

• strong regulation

• development of strong and credible professional associations and education institutions

• supportive supervision of both public and private midwives

Intervention: MOMS with Misoprostol Address PPH

IMPACTS DISCUSSION

“No country has managed to reduce their maternal mortality figures without

investing in the capacities of midwives working at the community level undertaking home births.” (UNFPA)

http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862013001100804&lng=en&nrm=iso

Intervention: MOMS with Misoprostol Address PPH

Postpartum Hemorrhage (PPH) and Misoprostol

• PPH is the leading cause of maternal death worldwide.correct diagnosis and management of PPH in a timely manner determines level of

maternal deaths in poor settingsmethod used in “developed” countries, oxytocin, requires injection and refrigeration rural, resource-poor areas lack the necessary drugs and skilled attendance at delivery

• Misoprostol is a uterotonic increasingly used in obstetrical and gynecological practice including the control of PPH. inexpensive tablet, it is easy to store, stable in field conditions, and

has an excellent safety profile with multiple routes of administrationuseful in these rural, resource-poor settings and home births with

a skilled attendant or health worker trained in PPH prevention use

Intervention: MOMS with Misoprostol Address PPH

MOMS...Postpartum Hemorrhage (PPH) and Misoprostol• Study (2005-7): Intervention trial in Tigray region of Ethiopia, 966 participants.

Focusing on the safety of misoprostol for prophylaxis of PPH at home births attended by TBAs. (Traditional Birth Attendants...term now updated to MOMS.)

http://www.berkeley.edu/news/media/releases/2006/03/28_misoprostol.shtml

TBAs (MOMS) trained... ✓ to administer misoprostol for PPH✓ in visual perception of approximate 500ml

and 1000ml of blood loss✓ to know when to safely refer women to

clinics for additional treatment

Intervention: MOMS with Misoprostol Address PPH

MOMS...Postpartum Hemorrhage (PPH) and Misoprostol• Study: Intervention trial in Tigray region of Ethiopia, focusing on the safety of

misoprostol for prophylaxis of PPH at home births attended by TBAs.

http://www.berkeley.edu/news/media/releases/2006/03/28_misoprostol.shtml

Results...✓ “prophylactic use of misoprostol in home births is a safe and feasible

intervention” “women in intervention areas were significantly less likely to be referred for additional treatment related to excessive bleeding (8.9%) compared to women in non-intervention areas (18.9%)”

✓ over half of referrals were being addressed by interventions at home, which lowers the risk for maternal death by PPH and “relieves the overtaxed health care system”

Intervention: MOMS with Misoprostol Address PPH

MOMS...Postpartum Hemorrhage (PPH) and MisoprostolImplications and Impacts:

✓ “[w]here women deliver far from a health facility, they must be empowered with an effective means of preventing the leading cause of maternal death. […] at the lowest level of the health care system – community health care workers, such as TBAs, and even the mother herself – can and should use misoprostol in home births to prevent PPH.” [19]

✓ Misoprostol can be very useful in settings of home births with traditional, or unskilled, birth attendants trained in PPH prevention. In 2006, Nigeria became the first country in the world to approve the distribution of misoprostol for PPH, followed later that year by India, and by Tanzania in 2007.

http://bixby.berkeley.edu/research/maternal-health/miso/nigeria/

Intervention: MOMS with Misoprostol Address PPH

MOMS...Postpartum Hemorrhage (PPH) and Misoprostol

Study: Intervention trial in Tigray region of Ethiopia, focusing on the safety of misoprostol for prophylaxis of PPH at home births attended by TBAs. (Traditional Birth Attendants...term

now updated to MOMS.

✓ Barriers: Abortion stigma-fear that women would use misoprostol to induce abortion

✓ fear of misuse at the home level✓ concerns that home use would discourage facility deliveries✓ registration of misoprostol for obstetric indications is time consuming✓ some countries do not have a drug distribution network that can reach poor women

in the remote areas at affordable prices[16]

Intervention: MOMS with Misoprostol Address PPH

Follow-UpProgram-Specific Funding✓Bixby Center for Population Health and Sustainability, UC Berkeley✓Venture Strategies Innovations✓Continued funding—realistic affordable and sustainable financing strategies, for governments working with their own finance ministries as well as with donors

Family Planning and Maternal and Newborn Care Funding: In 2010, global investment was at about $11.8 billion annually. “Doubling the modest, current global investment in family planning and maternal and newborn care—to just over $24 billion combined annually—would reduce maternal mortality by at least 70%, halve the number of newborn deaths and do so at a lower total cost than investing in maternal and newborn care alone.”(Guttmacher) [17] In September 2010, United Nations Secretary-General Ban Ki-moon and Heads of State and Government launched the “Global Strategy for Women’s and Children’s Health” with stakeholders pledging over $40 billion in resources for women’s and children’s health.

Intervention: MOMS with Misoprostol Address PPH

Follow-Up

GENERAL Take-Aways for Maternal Health Interventions [16]

‣ Political commitment beyond the health sector

‣ Notable champion(s) and partner collaboration

‣ Community provision of services and scale-up vision

‣ Community engagement, innovative human resource strategies

‣ Establishment of effective strategies and systems

Intervention: MOMS with Misoprostol Address PPH

Follow-Up: SPECIFIC Lessons Responding to Major Challenges of Poor, Rural Maternal Health in Developing World:1.QUALITY SERVICES: Training community-based health providers is a central strategy in overcoming the under-supported, underfunded health care facilities and inadequate number of professional health care providers, at least in the short term.2.COMMUNITY-BASED ACCESS: MOMS or TBAs are central in overcoming financial barriers to care associated with facilities and can reach women where they are at--in the home.3.APPROPRIATE TECHNOLOGICAL INNOVATION: Appropriate, effective technology, like misoprostol, can manage complications in home births, where most of the deliveries occur in poor settings. [15]

Intervention: MOMS with Misoprostol Address PPH

thank youthank youhttp://bixby.berkeley.edu/wp-content/uploads/2009/03/cropped-mama-+-baby+TBA-bang.jpg

UNDP http://www.undp.org/content/undp/en/home/mdgoverview/mdg_goals/mdg5/UNICEF—Maternal Health http://www.unicef.org/maternalhealth/index_587.htmhttp://www.unicef.org/health/index_maternalhealth.htmlUNFPA http://www.unfpa.org/webdav/site/global/shared/documents/publications/2009/Focus-on-5.pdfSkilled Birth Attendant http://www.unfpa.org/public/home/mothers/pid/4383Life and Death: http://www.unfpa.org/webdav/site/global/shared/factsheets/srh/EN-SRH%20fact%20sheet-LifeandDeath.pdfMOMS: http://www.unfpa.org/webdav/site/global/shared/documents/publications/2006/midwives_mm.pdfCosts and Benefits FP http://unfpa.org/webdav/site/global/shared/documents/Reproductive%20Health/Fact%20Sheets/AIU_2012_Estimates%20Factsheet_ENGLISH.pdf Fact Sheets http://www.unfpa.org/public/mothers/pid/4390/index.htm Maternal Death Fact Sheet http://www.unfpa.org/webdav/site/global/shared/factsheets/srh/EN-SRH%20fact%20sheet-LifeandDeath.pdfGuttmacher Institute (Induced Abortion Worldwide): http://www.guttmacher.org/pubs/fb_IAW.htmlFamily Planning and Maternal Health Costs and Benefits: https://www.guttmacher.org/presentations/Adding-It-Up.pdf[17] http://www.guttmacher.org/pubs/gpr/13/2/gpr130212.htmlWHO Maternal and Infant Health Strategy http://www.who.int/pmnch/activities/advocacy/global_strategy_resources/en/Cost-Effectiveness http://www.who.int/choice/en/ Intervention Packages: World Health Organization, UNICEF, UNFPA, The World Bank and different members of The Partnership for Maternal, Newborn and Child Health (PMNCH) http://www.who.int/pmnch/activities/jointactionplan/srhp_packages.pdf?ua=1[12] http://www.who.int/pmnch/media/press/2010/20100603_countdownpressrelease/en/

Bixby Centerhttp://bixby.berkeley.edu/wp-content/uploads/2010/05/Avoidable-maternal-deaths-three-ways-to-help-now-09.pdfhttp://bixby.berkeley.edu/research/maternal-health/miso/nigeria/[13] http://bixby.berkeley.edu/wp-content/uploads/2011/01/2010-Prata-et-al-MM-in-Dping-Cs-in-Womens-Health.pdf[14] http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf?ua=1[15] http://bixby.berkeley.edu/wp-content/uploads/2010/05/Avoidable-maternal-deaths-three-ways-to-help-now-09.pdfFHI 360 Family Planning http://www.fhi360.org/sites/default/files/media/documents/FHI360-FP_brochure_v5_WEB.pdf [16] Intervention Strategies for Contraceptive Prevalence Rate (Sub-Saharan Africa successes) http://www.fhi360.org/sites/default/files/media/documents/africa-bureau-case-study-report.pdfStatistics:IndexMundi http://www.indexmundi.com/map/?t=0&v=2223&r=af&l=enWorld Bank http://data.worldbank.org/indicator/SH.XPD.PCAP/countries

Citations