Strategies to Improve Maternal Health in the Next Decade Annette 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Source: World Bank, 1998 (unpublished) Advance safe motherhood through human rights: Rationale

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 years  Motherless children, especially girls, have higher infant mortality and are less educated

Source: Burkhalter B, REDUCE Model, University Research Corp 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 $18m sepsis $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 are twice as likely to die from childbirth as women in their twenties  32% of 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, 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 schemes  emergency transport systems  birth preparedness plans  see 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 Comprehensive Basic  surgical interventions  anesthesia  blood replacement

Source: Maine D, et al 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)

*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, 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 Care  reorganize services to ambulatory care  provide counseling and information  training in MVA for treatment of incomplete abortion  provide family planning counseling before discharge  male partner involvement

Source: WHO, 1993 Maternal Deaths due to Abortion

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