16/6/10 Reducing Maternal Mortality What are the gaps in progress towards achieving MDG 5? Eilish McAuliffe, Centre for Global Health, TCD

16/6/10 Global Action on Maternal Health Safe Motherhood – since 1987 MDG % reduction in the maternal mortality ratio (MMR) from 1990 to 2015 White Ribbon Alliance Women Deliver – launched 2007 Obama’s Global Health Initiative The Countdown to 2015 for Maternal, Newborn, and Child Survival (an independent supra-institutional organisation, health-care professional associations, donors, and governments, with The Lancet as a key partner.) Yet 500,000 pregnancy-related deaths occur annually. Without HIV this would have reduced to 281,500 by 2008 Latest estimates are for the first time showing significant decline from 526,300 in 1980 to 342,900 in 2008 (Hogan et al, 2010).

16/6/10 Hogan et al review ,300 (446,400 – 629,600) 422/100,000 live births ,900 (302,100 – 394,000) 251/100,000 live births yearly rate of decline of 1·5%. To reach MDG 5 target by 2015 needs a decline rate of 5.5% per annum Without HIV would have a decline rate of 2.2% and Global MMR estimate of 206/100,000 in 2008

16/6/10 What’s happening in Africa? The proportion of global maternal deaths in sub- Saharan Africa increased from 23% (18–27) in 1980 to 52% (45–59) in 2008, resulting from both the accelerated increase in the number of maternal deaths in the early 1990s and declines in Asia. Trends in MMRs, excluding deaths from HIV infection, showed decreases during 1980–2008 in eastern and southern Africa, and a slower decline in central and western Africa.

16/6/10 In 1990–2008, countries with substantial declines in MMR included: Egypt Romania Bangladesh India China

16/6/10 What accounts for improvements? Four Drivers of Maternal Mortality are improving in most countries. 1. global TFR has dropped from 3·70 in 1980, to 3·26 in 1990 and 2·56 in income per head (affects nutritional status of mothers & physical and financial access to health care) has been rising particularly in Asia and Latin America. 3. Maternal educational attainment, another strong correlate of maternal mortality, has been rising—eg, average years of schooling of women aged 25–44 years in sub-Saharan Africa increased from 1·5 in 1980 to 4·4 in the steady, slow, rise in coverage of skilled birth attendance could have contributed to maternal mortality declines

16/6/10 But… Nairobi Study (Ziraba et al. Maternal mortality in the informal settlements of Nairobi city: what do we know? Reproductive Health, 2009, 6:6 health-journal.com/content/6/1/6 ) health-journal.com/content/6/1/6 used data from verbal autopsy interviews conducted on nearly all female deaths aged 15–49 years between January 2003 and December 2005 in two slum communities covered by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). Findings Over 86% of maternal deaths and 96% late maternal deaths had sought care at least once from a professional health care worker prior to death. About 62% of maternal deaths occurred in a health care facility compared to only 31% of late maternal deaths definition of maternal death, "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" definition of late maternal death "death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy"

16/6/10 “ these numbers should now act as a catalyst, not a brake, for accelerated action on MDG-5, including scaled-up resource commitments.” (Richard Horton, Lancet, 2010)

16/6/10 Funding Although overseas development assistance for maternal, newborn, and child health has increased, funding for this sector accounted for only 31% of all development assistance for health in (Bhutta et al, Lancet, 2010: ) calls to integrate maternal and child survival programmes into vertical funding mechanisms for the MDGs, such as the Global Fund to fight AIDS, TB, and Malaria. Editorial “The Global Fund: replenishment and redefinition in 2010”. Lancet 2010; 375: 865 “Maternal, newborn, and child health offer a unique opportunity to give the Global Fund a fresh and expanded mandate, rewarding its already great success. New evidence of progress towards MDG-5 only underlines the importance of this more comprehensive approach—a replenished Global Fund for all the health MDGs”. (Richard Horton, 2010)

16/6/10 Systems approach Countdown assesses progress every 2-3 years uses WHO health-systems framework, 6 linked and overlapping components of a health system service delivery, health workforce, information, medical products, vaccines and technologies, And financing and leadership or governance

16/6/10 Supported by IrishAid and Ministry of Foreign Affairs Denmark.

16/6/10 Health Systems Strengthening for Equity (HSSE) Ultimate aim – to improve quality and coverage of EmOC.

16/6/10 MMR estimates by country Country Malawi632 ( ) 743 ( ) 1662 ( ) 1140 ( ) Mozambique411 ( ) 385 ( ) 505 ( ) 599 ( ) Tanzania603 ( ) 610 ( ) 714 ( ) 449 ( )

16/6/10 Sampling CountryNo. of FacilitiesNo. of Providers Malawi84 (near national sample) 631 Mozambique Tanzania90811

16/6/10 15 System components INPUTS OUTCOMES/RESULTS PROCESSES

16/6/10 16 The Enabling Environment Resources (WI)  staff  infrastructure  drugs  equipment Management support (WI) Workplace relationships (WI) Fair and just treatment (OJ)  Supervision  In-service training  Promotion Matching capability and workload (Burnout) INPUTS OUTCOMES/RESULTS PROCESSES Job Satisfaction Performance Organisational Commitment WI = Work Index OJ = Organisational Justice

16/6/10 17 Malawi

16/6/10 18 Light for tasks at night Access to running water (piped or storage container) Malawi

16/6/10 19 Cord ties Sterile gloves Light for tasks at night Access to running water (piped or storage container) Malawi

16/6/10 20 Tetracycline ointment Lignocaine Cord ties Sterile gloves Light for tasks at night Access to running water (piped or storage container) Malawi

16/6/10 21 Sterile gloves Soap antiseptics Tetracycline ointment Lignocaine Cord ties Sterile gloves Light for tasks at night Access to running water (piped or storage container) Malawi

16/6/10 22 Availability of items required for management of obstetric complications, by facility Malawi

16/6/10 23 Most common missing items for management of obstetric complications Malawi

16/6/10 Main providers of EmOC are NPCs/MLPs 80% all CS in districts by NPCs Across all three countries NPCs are providing all of the CEmOC signal functions, although not all NPCs provide all of the signal functions No significant difference in post-operative complications High Retention levels: Retention after 7 yrs: 88% for NPCs vs. 0% for MDs (Mozambique) NPCs 3x more cost-effective (Moz)

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Cadres performing EmOC signal functions in past 3 months CountryCadresAssisted Vaginal Delivery Removal of retained products MalawiClinical Officers88%85% Reg. Nurse Midwives67%22% MozambiqueTécnicos de cirurgia 76%94% MCH nurse middle level73%85% TanzaniaAssistant Medical Officers 60%82% Reg. Nurse Midwives24%33%

16/6/10 Tanzania: Cadres Actively Seeking other Employment

16/6/10 Availability of supervision by type

16/6/10 Views on current supervision “The way of doing supervision of health workers who are providing emergency services during delivery is not good, to be honest, we don’t have that close supervision to tell them that you are supposed to do 1,2,3. There is no good mechanism…” District Health Secretary “Sometimes with shortage of workers you go to supervise but end up joining staff to work with them…You have to be there with them to know their problems, and stay with them to give them the feedback, then help them to solve problems…but you are just rushing the work.” RCH Co-ordinator

16/6/10 Factors affecting job satisfaction In Malawi, Mozambique and Tanzania, substantial portion of job satisfaction levels explained by providers’ perceptions of: –Adequate supervision –Support from management –Adequate pay for work done –Opportunities for career advancement

16/6/10 Factors affecting job satisfaction Management and formal supervisory support outweighed concerns relating to pay threefold in their contribution to job satisfaction levels

16/6/10 Facility attractiveness Facility index dissatisfaction score is formed from combined standardized average scores for each facility on five scales: (i) job satisfaction (reversed), (ii) intention to leave, (iii) satisfaction with supervision (reversed), (iv) management support (reversed), (v) emotional exhaustion. High dissatisfaction facilities (in green): e.g. Edingeni Rural Hospital, Machinga District Hospital,, Nkhatabay District Hospital, Middling facilities (closest to mean line): e.g. Embangweni Hospital, Ekwendini Rural Hospital, Kasunga District Hospital, Mchinji District Hospital. High satisfaction facilities (in black): Kaseye Community Hospital, Mua Hospital, Phalombe District Hospital

16/6/10

In Summary Much can be done to improve the provision of EmOC Addressing problems in the delivery system may have more immediate effect than addressing socio-cultural issues or attempting to manage migration. Many interventions required to improve care are not expensive.

16/6/10 What next? Development and sustainability of a supportive supervision system (planned Tanzania & Mozambique study) Targeted interventions (e.g. Resources, SCM, HRM) to ensure equity in access to and quality of EmOC. Review of pay structures and incentives for NPCs and entire team Assessment of obstetric team dynamics, decision making and impact on quality of care (planned Malawi study)

16/6/10 With Thanks HSSE Team: –Centre for Global Health, Trinity College, University of Dublin –AMDD, Mailman School of Public Health, Columbia University, USA –Centre for Reproductive Health, College of Medicine, Malawi –Ifakara Health Institute, Tanzania –Dept. of Community Health, Eduardo Mondlane University, Mozambique –Realizing Rights: Ethical Globalization Initiative, USA –Regional Prevention of Maternal Mortality Network, Ghana Funders: IrishAid Ministry of Foreign Affairs, Denmark