No Goals at Half-time: What Next for the Millennium Development Goals? MDG 5: Improve maternal health Oona Campbell

The problem of maternal death is large A woman dies each minute -- day in, day out Maternal mortality is the public health indicator with the greatest gap between rich and poor countries

Source: < Maternal deaths per 100,000 live births, % of deaths in developing world

The poor are hardest hit Source: Graham et al Lancet 363(9402):23-27

Why act: maternal deaths considered preventable, subnational & national studies Overall, WHO estimates 98% preventable Source: Maine D. Safe Motherhood Programs: Options and Issues, Center for Population and Family Health, 1993.

Maternal survival is tied to several Millennium Development Goals Is Goal of MDG 5: reduce maternal deaths by 75% by 2015 Linked to MDGs for poverty reduction, female empowerment, and infectious diseases Strengthens efforts to promote newborn survival and improve the health of the child (MDG 4) Improves the welfare of the whole family Supports health systems strengthening

Have we made progress? MDG 5 Target Source: WHO

Epidemiology

Causes of death should drive interventions Excessive bleeding is the main cause of death Most problems can not be predicted or prevented Most life-saving interventions require considerable skill Source Ronsmans C& Graham W 2006; Lancet (9542):

Timing of death is critical Most deaths cluster around labour or within 24 hours after delivery Matlab, Bangladesh Time since pregnancy Source Ronsmans C& Graham W 2006; Lancet (9542):

What Should We Do? Content of Services Organization of Services - Delivery Mechanisms

Many sources of effective single interventions that reduce maternal & neonatal mortality Lancet Series Disease Control Priorities Project DCPP (World Bank) World Health Report; BMJ Cochrane Collaboration (RH Library) Many single interventions but none alone can reduce maternal or neonatal mortality

Organization of Services Fertility component Family planning services Abortion services Obstetric component Delivery Care ANC Postpartum Care General Health Services

Strategies for providing family planning Clinic-based Mobile clinics Community-based distribution Social marketing Target special groups: postpartum, post abortion, adolescents, workplace.

Abortion Policies Source:

Strategies for abortion Legalize abortion Ensure legal services provided Medical Abortion Vacuum Aspiration Reduce barriers Irrespective of legality: – Provide post-abortion care prompt emergency care appropriate care (VA) comprehensive RH services

Why not achieving promise? Family planning – Fatigue/ widening of focus – Lack of political will – US withdrawal from provision of commodities Safe Abortion – Lack of political will/ champions – Anti abortion politics – Training

Delivery care Where women deliver and who attends them, is paramount

WHO? Skilled Attendant (midwife or doctor)

Emergency Obstetric Care (EmOC) ComponentCEmOC (Hospital) BEmOC (Health Centre) Surgery (CS, anaesthesia) X Blood TransfusionX Manual Procedures (Vacuum Aspiration, Removal of retained placenta, Instrumental delivery) XX Medical Treatments ( MgSO4, IV Antibiotics, Oxytocics) xx

Quality Health Centre Strategy focuses on Monitoring woman and baby during labour and for 24 hours postpartum Safety and primary prevention Early detection and basic management of problems Referral to hospital for emergency care

Quality Health Centre strategy is best bet for maternal survival Most effective because skilled attendants can deliver proven interventions More efficient than skilled attendants in the home or hospital Alternative strategies are not as effective or efficient and may not be sustained

Half the worlds women currently give birth with a professional In SA & SSA, most urban women deliver with a professional But only a third of rural women have a professional at birth Where are we now?

Slide with unpublished data Gabrysch S (2008) Slide shows data from a census of Zambian health facilities. It shows limited capability of providing Basic Emergency Obstetric Care functions

The shortage of human resources in developing countries is huge Need to double the supply of health professionals for deliveries Over 300,000 more needed by 2015 to achieve a coverage of 75% 24,000 health centres also are needed

Payments hurt the poor: household costs as percent of GDP/capita Country/ year Normal delivery Complicated delivery Benin, Ghana, Bangladesh (rural) Bangladesh (urban) Removing financial barriers encourages care- seeking A promising approach is to remove fees and fund through general taxes The poor may need additional support Source Borghi et al. Lancet, 2006; 368(9545):

So what is needed?

1A new era of strategic thinking Care during delivery is the priority All women should be able to deliver in health centres, with midwives working in teams Target the women in greatest need: poor and rural women in sub-Saharan Africa and South Asia

Policy makers must make strategic human resource decisions to ensure 100% coverage with health professionals Implement plans now for training and deployment of sufficient numbers of health professionals Ensure skills and competencies to provide evidence- based care: Quality counts Invest in efforts to retain existing staff 2More health professionals for delivery

3Greater financial resources Protect poorest families from the catastrophic consequences of unaffordable emergency care Maternal mortality reduction requires a consistent and significant effort over the next 10 years and beyond National governments need to invest greater resources Donors need to increase financial contributions in low income countries to fill the resource gap

Financial resources have not been adequate Maternal & newborn health not given financial priority despite a burden of disease larger than HIV, TB, or Malaria Global development assistance to maternal and neonatal health in 2003 was US$ 663 million To achieve universal coverage with a health professional, an additional US$1 billion is needed now, increasing to US$6.1 billion in 2015 Maternal & perinatal conditions Childhood cluster & diarrhoeal diseases HIV/AIDS TB Malaria Percent of DALYs Source:

4Robust tracking of progress and accountability Better data and information systems needed to track progress in improved services and maternal health This is to encourage and monitor government and donor commitments

5Political commitment is critical for implementation Necessary to ensure this new era of strategic thinking is translated into programmes Governments, donors, and civil society need to work in concert

Cross-cutting issuess Geographic focus: where problems are Policy change: communication of successful strategies rather than interventions Mechanisms for distributing interventions (delivery mechanisms) Human resource constraints (rural areas) Training Access in remote areas/communication/ referral Financial constraints/ competition for vertical resources Lack of data for routine monitoring

Progress is Possible

The Health Centre Strategy is key Too many women are dying in their prime years Maternal mortality is an MDG that 189 countries have signed up to We need to get on with what works