1. Using DSS to monitor progress toward improvement in maternal health William Stones Department of Obstetrics & Gynaecology Aga Khan University, Nairobi

2. In the next 15 minutes… The burden of maternal morbidity and mortality Link to neonatal outcomes Three delays Use of services: understanding at the population level Potential ‘3D’ based indicators What obstetricians are doing

4. Maternal Morbidity: where are the population level data? Haemorrhage Eclampsia Obstructed labour –Ruptured uterus –Obstetric fistula Sepsis –Unsafe abortion –Puerperal fever –HIV related Malaria Anaemia

5. The link to neonatal outcomes

7. Problem Even where MMR is high (eg SSA, Afghanistan) events are uncommon in relation to survey rounds and typical populations covered. How sensitive to ‘progress’? ? Need to focus on major morbidity as well as mortality- but how to capture? –Link with facility data on major morbidity and deaths –Include well defined morbidities in surveys, eg eclampsia Neonatal mortality is much more common so more amenable to conventional DSS approach

8. The Three Delays In seeking care for a pregnancy complication In reaching a health facility In receiving appropriate care once at the health facility

9. Seeking care: DSS scope Population level knowledge about maternal and neonatal complications –Bleeding –Blood pressure, fits –HIV, malaria –Cord care, warmth and breastfeeding Antenatal care –Uptake: visits and quality Community activation –Panchayati Raj, Asha Sahayogini –Marginalised sub-groups –Village level services

10. Reaching care: DSS scope GIS Transport mapping Community activation –Cost sharing –Vehicle maintenance Telecommunications Seasonality

11. Care at health facilities: DSS scope Links to HMIS, facility records Post discharge survey rounds –Experience of care –Content of care –Population level CS rates and determinants Community activation –Activism for facility upgrading –Consumer forum –Constituency funds

12. Cross cutting: skill mix Who does ANC? Impact of ‘task shifting’ for ARV rollout –Diversion from maternal health –Potential gains in numbers of staff in post Skilled attendance at delivery –Can recognise and manage complications The midwife –Regulatory context –Competencies –Livelihood

14. Meanwhile the obstetricians are…