1. Maternal Death Surveillance and Response and Advocacy Louise Hulton Evidence for Action to Reduce Maternal and Neonatal Deaths in Africa

2. MDSR: Agent of Change

3. Why MDSR? Because every death counts

4. Beyond the Numbers Gwyneth Lewis: Knowing the level of maternal mortality is not enough; we need to understand the underlying factors that led to the deaths. Each maternal death or case of life-threatening complication has a story to tell and can provide indications on practical ways of addressing its causes and determinants. Maternal death or morbidity reviews provide evidence of where the main problems in overcoming maternal mortality and morbidity may lie, produce an analysis of what can be done in practical terms and highlight the key areas requiring recommendations for health sector and community action as well as guidelines for improving clinical outcomes. The information gained from such enquiries must be used as a prerequisite for action.

5. Roadmap for Change MDSR provides mechanism to unpick contributory factors Know the change that needs to happen Package the findings for the right audience Communicate findings – targeted Requires partnership Requires advocacy skills Evidence for Action

6. Advocacy A political process by an individual or a group which aims to influence behaviour, policy and resource allocation decisions within political, economic, and social systems and institutions

7. Advocacy Influence Affect Change Engage Argue Convince Campaign Champion Promote Plead Lobby Expose

8. Advocacy Successful advocacy takes rigorous, in- depth research, careful planning, clearly defined and practical goals. It’s about clear purpose and well-framed arguments. It’s about surveying the landscape (political, social and economic) carefully – before diving in. It’s about sound communication with audiences. And very good design.

9. Advocacy Above all it is about belief in others, and in the possibility of change.

10. Who are advocates? MDSR CliniciansManagersWomenCommunities Professional Bodies CSOsParliamentariansHusbandsFaith GroupsMedia

11. Case Study: Nepal 1998 first MMM study conducted MMR was estimated at 539 per 100,000 live births Method Facility Based MDRs and Verbal Autopsy in Community Report formed basis of national safe motherhood programme interventions

12. Case Study: Nepal Haemorrhage cause in 41% of cases in 1998 Evidence stimulated National Response – Government in partnership with donors and vibrant civil society Safe Blood Policy; partnership with Red Cross; strategies eg named Donors within communities

13. Case Study: Nepal 2008/09 repeat of 1998 study – covering larger geographic area. 8 districts (largely representative of geographic and HDI national picture) Community death and birth surveillance (of Women of Reproductive Age) Community Verbal Autopsy Facility Based Maternal Death Reviews

14. Case Study: Nepal Findings making waves… Haemorrhage – direct cause in 24% of cases dramatically reduced from 41% in 1998 Evidence of progress following national effort to improve access to blood – evidence to action

15. Case Study: Nepal: 2008/09 findings of interest 80% of women in a critical state on admission 18% died within four hours of arrival 39% within the first twelve hours 53% within the first 24 hours 41% of pregnancy related deaths in a health facility, 40% at home; and 14% in transit compared with 21% of deaths in facilities and 67% at home in 1998

16. Case Study: Nepal – Leading Cause of Death of WRA Suicide…. 16% of all deaths to WRA 2008/09 – leading cause of death 10% in 1998 – third leading cause

17. Case Study: UK Enquiry into maternal deaths in the UK started in the nineteenth century The reports are triennial Recommendations have major influence on policy and practice Advocates play major role in promoting this issue to providers and policy makers

18. Case Study: UK – issue Psychiatric deaths related to pregnancy and childbirth but which fell outside the 6 week period for MM Role of eg Association for Improvements in Maternity Services – advocacy CSO – to press for change – hidden deaths Influenced expansion in period of review to include cases within 6 months of end of a pregnancy to establish a real picture of pregnancy related death from psychiatric causes.

19. Case Study: UK – What did it show? Oates Suicide third leading cause of maternal death in 2000-02 In 2003-05 total of 104 psychiatric deaths out of a total of 623 maternal deaths Impact on policy and practice significant.

20. Case Study: UK – Policy SIGN Guidelines NICE Antenatal Care Guidelines NICE Antenatal & Postnatal Mental health Guidelines NSF – Women's Mental Health Strategy NSF – Maternity Standard 11 Clinical Negligence Standards National Specialised Commissioning Group RCPsych RCOG

21. Case Study: UK - Practice Specialised services Consultant Perinatal Psychiatrist Awareness in Maternity Child Health Services Screening at booking clinic +++ educational events Work with families and communities about danger signs Mental Health Charities

22. Case Study: UK ↑ Psychiatric cases reported CEMACH ↓ Suicide with PH PN illness ↓ Suicide among women with current psychiatric contact ↓ Suicide within 6 months pp

23. 2000-02 CEMD UK Evidence maternal mortality in UK is related to social class Rate among socially excluded women 20 times higher than social class 1 Why……..?

24. MSDR and Advocacy Exposing the size of an issue Demonstrating patterns and trends Using stories to raise awareness Working with key actors to unblock bottlenecks Strategic advocacy Evidence based advocacy Partnership not conflict Culture of learning Action!

25. Unleash the Potential Create the Change

26. Thank you! Asante!