Strategies to Improve Maternal Health in the Next

DecadeAnnette Bongiovanni

USAID LAC SOTA March 2001

Safe Motherhood Inter-Agency Group Action Messages 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

Ensure Skilled Attendance at Delivery

Improve Access to Quality Maternal Health Services

Prevent Unwanted Pregnancy and Address Unsafe Abortion

Measure Progress Power of Partnership

Source: World Bank, 1998 (unpublished)

Advance safe motherhood through human rights: Rationale

% Deliveries Attended by Trained

Professionals

0

20

40

60

80

100

Poorest

20%

2nd 3rd 4th Richest

20%% people in the country

Peru

Bolivia

15.1

92.4

13.3

81.6

Advance safe motherhood through human rights: Strategies

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 ICPD, and the Beijing Conference

Social and Economic Investment: Rationale

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

Source: Burkhalter B, REDUCE Model, University Research Corp. 2001.

Social and Economic Investment: Rationale

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 $18msepsis $13m

obstructed labor $11m

Social and Economic Investment: Strategy

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

* Source: Buvinic, "Costs of Adolescent Childbearing", 1998, IDB.

Delay First Birth: Rationale

Early childbearing in 4 LAC countries is associated with harmful economic effects *

fertility fewer traditional nuclear families and absent fathers begets teen mothers

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. 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 20

Delay First Birth: Strategies 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)

*Source: Vanneste, et al., "Prenatal screening in rural Bangladesh", 2000

Every Pregnancy Faces Risks: Rationale

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.

Every Pregnancy Faces Risks: Strategies

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

Source: Li XF, Fortney JA, 1996.

Ensure Skilled Attendance at Birth: Rationale

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*

Ensure Skilled Attendance at Birth: Strategies

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 post-partum 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)

Quality Improvement Teams at the local level to identify problems and solutions to increase demand for maternal health services, e.g.,community-based financing

schemesemergency transport systemsbirth preparedness planssee the QAP presentation

Access to Quality Services:Strategies

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 complicated deliveries

Source: World Health Organization, 1991

Access to Quality Services: Essential Obstetric Care

management of problem pregnancies (anemia, diabetes, etc.)

medical treatment of complications (hemorrhage, sepsis, eclampsia, etc.)

manual procedures (removal of placenta, repair of

episiotomies, etc.) monitoring labor (includes Partograph) neonatal special care

Com

pre

hen

siv

e

Basic

surgical interventions anesthesia blood replacement

Source: Maine D, et al. 1987

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 Hours Days

Post-partum hemorrhagePre-natal Hemorrhage

212

Ruptured uterus 1

Eclampsia 2Obstructed delivery 3Infection 6

*By convention, estimated complication rate is 15% of all live births.

Access to Quality Services: Indicators % 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)

% 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)

Source: Billings D., Pop Council, 2001.

Address Unsafe Abortions: Rationale (data from Bolivia)

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

Address Unsafe Abortions:Strategies

National insurance could cover cost of care for “treatment of complications of hemorrhage during the first half of pregnancy”

Post Abortion Carereorganize services to ambulatory careprovide counseling and informationtraining in MVA for treatment of incomplete

abortionprovide family planning counseling before

dischargemale partner involvement

Source: WHO, 1993

Maternal Deaths due to Abortion

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Measure Progress: Rationale 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

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.: 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