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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Source: World Bank, 1998 (unpublished)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