1. Averting Maternal Death and Disability (AMDD) Developed for use in AMDD-partnered projects February 2002 By Nadia Hijab & Czikus Carriere Developed for use in AMDD-partnered projects February 2002 By Nadia Hijab & Czikus Carriere Program Orientation A Tool for Self-Learning Program Orientation A Tool for Self-Learning

2. This Presentation Covers: Causes of Maternal Death and Disability Evolution of Understanding of the Problem Central Role of Emergency Obstetric Care UN Process Indicators The AMDD Program

3. What Is Maternal Death? The death of a woman while she is pregnant …From any cause related to or aggravated by the pregnancy World Health Organization (WHO) within 42 days of the termination of the pregnancy… within 42 days of the termination of the pregnancy… …or…

4. WHO Estimates 515 000 Maternal Deaths Each Year MORE THAN ONE WOMAN DIES EVERY MINUTE from pregnancy-related causes

5. What Is Maternal Disability? Short- or Long-term Illness Caused by Obstetric Complications Short- or Long-term Illness Caused by Obstetric Complications The Most Serious Is Obstetric Fistula (An Abnormal Passage Between Vagina and Bladder or Rectum Often Caused by Obstructed Labor when it is Not Treated with Cesarean Section) The Most Serious Is Obstetric Fistula (An Abnormal Passage Between Vagina and Bladder or Rectum Often Caused by Obstructed Labor when it is Not Treated with Cesarean Section)

6. What Do Women Die Of? They Die Of Obstetric Complications That Need Not Be Fatal They Die Of Obstetric Complications That Need Not Be Fatal

7. OBSTETRIC COMPLICATIONS Hemorrhage21% Unsafe Abortion14% Eclampsia13% Obstructed Labor 8% Infection 8% Other11% Hemorrhage21% Unsafe Abortion14% Eclampsia13% Obstructed Labor 8% Infection 8% Other11% Account for about 3/4 of Maternal Deaths DIRECT

8. OBSTETRIC COMPLICATIONS Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis And Increasingly HIV / AIDS Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis And Increasingly HIV / AIDS Account for about 1/4 of Maternal Deaths INDIRECT

9. Most Obstetric Complications Occur Suddenly If women do not receive medical treatment on time, they will probably suffer disability… If women do not receive medical treatment on time, they will probably suffer disability… Or Die Without Warning

10. WHERE DO WOMEN DIE TODAY? 99% of Maternal Deaths Today Occur in Africa, Asia and Latin America 99% of Maternal Deaths Today Occur in Africa, Asia and Latin America

11. WHAT ABOUT THE REST OF THE WORLD? Maternal Mortality Used to be Very High in Europe and the U.S. So was Infant Mortality. Maternal Mortality Used to be Very High in Europe and the U.S. So was Infant Mortality. In 1915, Maternal and Infant Mortality Rates Were as High in the U.S. As They Are in Africa Today

12. WHAT HAPPENED NEXT? Better Living Conditions Reduced Infant Mortality in the U.S. By over 40% Between 1915 and 1933 Better Living Conditions Reduced Infant Mortality in the U.S. By over 40% Between 1915 and 1933

13. BUT MATERNAL MORTALITY “The well known triad of fever, haemorrhage and toxaemia predominated…” (Irvine Loudon) “The well known triad of fever, haemorrhage and toxaemia predominated…” (Irvine Loudon) REMAINED THE SAME

14. …Until the late 1930s There was then a “steep and sustained decline which has continued in most Western countries at much the same rate for over fifty years” (Irvine Loudon) There was then a “steep and sustained decline which has continued in most Western countries at much the same rate for over fifty years” (Irvine Loudon)

15. What Happened To Reduce Maternal Mortality In The West? Effective treatment for obstetric complications was developed and used, e.g., antibiotics for infection, blood transfusions for hemorrhage Effective treatment for obstetric complications was developed and used, e.g., antibiotics for infection, blood transfusions for hemorrhage

16. Most Obstetric Complications Can Neither Be Predicted Nor Prevented… Can Neither Be Predicted Nor Prevented… But If Women Receive Effective Treatment In Time, But If Women Receive Effective Treatment In Time, …Almost All Can Be Saved

17. How Much Time Do We Have? It is estimated that, if untreated, death occurs on average in: 2 hours from Postpartum Hemorrhage 12 hours from Antepartum Hemorrhage 2 daysfrom Obstructed Labor 6 daysfrom Infection 2 hours from Postpartum Hemorrhage 12 hours from Antepartum Hemorrhage 2 daysfrom Obstructed Labor 6 daysfrom Infection

18. To Avert Death and Disability… …We Need To Ensure That Women have Access To… …We Need To Ensure That Women have Access To… Emergency Obstetric Care (EmOC)

19. How Can We Improve Access To EmOC? By making sure health facilities provide the services needed to save women’s lives. By making sure health facilities provide the services needed to save women’s lives. Eight key functions “signal” a facility’s ability to provide EmOC Eight key functions “signal” a facility’s ability to provide EmOC

20. EmOC Key Functions Cover These Services: Antibiotics (intravenous or by injection) Oxytocic Drugs (ditto) Anticonvulsants (ditto) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery Surgery (Cesarean Section) Blood Transfusion

21. Basic and Comprehensive EmOC Facilities Antibiotics (intravenous or by injection) Oxytocic Drugs (ditto) Anticonvulsants (ditto) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery Antibiotics (intravenous or by injection) Oxytocic Drugs (ditto) Anticonvulsants (ditto) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery BASIC EmOC Facilities Provide The First Six Services

22. Antibiotics (intravenous or by injection) Oxytocic Drugs (ditto) Anticonvulsants (ditto) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery COMPREHENSIVE Basic and Comprehensive EmOC Facilities EmOC Facilities Provide All Eight Services Surgery (Cesarean Section) Blood Transfusion

23. THE GOOD NEWS Not all these functions need hospitals and doctors Well-trained nurses and midwives can perform most functions at Basic EmOC Facilities An Important Point For Resource Poor Areas An Important Point For Resource Poor Areas

24. How Can We Tell We Are Making a Difference? If we know we have provided enough EmOC… …and if we know that these services are being used by women suffering obstetric complications… WE CAN BE CONFIDENT THAT WE ARE SAVING WOMEN’S LIVES WE CAN BE CONFIDENT THAT WE ARE SAVING WOMEN’S LIVES

25. How Do We Know Which Women Will E xperience Complications? WE DON’T

26. …But we do know that of any population of pregnant women at least 15% will experience an obstetric complication …This is as true of pregnant women in the US and Europe as of women in Africa, Asia and Latin America Nobody Knows Why This Happens. It Is a Fact of Life Nobody Knows Why This Happens. It Is a Fact of Life

27. Can We Really Tell If Services Are Functioning? In 1991, UNICEF and Columbia University developed 6 Process Indicators to do just that In 1991, UNICEF and Columbia University developed 6 Process Indicators to do just that These were issued by UNICEF/WHO/UNFPA in 1997: Guidelines for Monitoring Availability and Use of Obstetric Services These were issued by UNICEF/WHO/UNFPA in 1997: Guidelines for Monitoring Availability and Use of Obstetric Services …And Are Being Used?

28. In general, process indicators show you the changes in the conditions that lead to an outcome (such as death or disability) In general, process indicators show you the changes in the conditions that lead to an outcome (such as death or disability) Process Indicators

29. Access to… THE 6 PROCESS INDICATORS tell us about changes in: Utilization of… and Quality of… EmOC Services

30. INDICATOR # 1 For every 500,000 population, there should be at least: For every 500,000 population, there should be at least: 1 Comprehensive EmOC Facility 4 Basic EmOC Facilities 1 Comprehensive EmOC Facility 4 Basic EmOC Facilities

31. INDICATOR # 2 Geographical Distribution of EmOC Facilities Geographical Distribution of EmOC Facilities EmOC Facilities should be well- distributed to serve 500,000 people Minimum: 1 Comprehensive and 4 Basic EmOC Facilities

32. INDICATOR # 3 Proportion of All Births in EmOC Facilities Proportion of All Births in EmOC Facilities At Least 15% of All Births in the Community Should Take Place in EmOC Facilities At Least 15% of All Births in the Community Should Take Place in EmOC Facilities

33. INDICATOR # 4 Met Need for EmOC Services At Least 100% of Women Estimated to Have Obstetric Complications Should Be Treated in EmOC Facilities

34. INDICATOR # 5 Cesarean Sections As a Percentage of All Births Cesarean Sections As a Percentage of All Births Minimum: 5% Maximum:15% Minimum: 5% Maximum:15%

35. INDICATOR # 6 Case Fatality Rate Proportion of Women With Obstetric Complications Admitted to a Facility Who Die: Proportion of Women With Obstetric Complications Admitted to a Facility Who Die: Maximum Acceptable Level: 1%

36. CALCULATING ALL 6 INDICATORS Gives you an indication of where the problems lie and where action is needed. Also, these indicators are sensitive to change: within months, you can know if your project is making a difference Gives you an indication of where the problems lie and where action is needed. Also, these indicators are sensitive to change: within months, you can know if your project is making a difference

37. ACCESS TO EmOC Problems: Does Indicator # 1 show you need more EmOC facilities? Does Indicator # 2 show you need better distributed EmOC facilities? Problems: Does Indicator # 1 show you need more EmOC facilities? Does Indicator # 2 show you need better distributed EmOC facilities? Action: Most countries already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population Action: Most countries already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population

38. UTILIZATION OF EmOC Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population? Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities) Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section? Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population? Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities) Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section? Problems

39. UTILIZATION OF EmOC Do you have enough qualified staff? Do you need to train staff on management of emergency obstetric complications? Does hospital management need improvement? What’s the supply situation like? What’s the equipment situation like? Do you have enough qualified staff? Do you need to train staff on management of emergency obstetric complications? Does hospital management need improvement? What’s the supply situation like? What’s the equipment situation like? If all the above is in place, conduct focus groups in the community to find out why women are not coming for care Action: Collect More Info First Action: Collect More Info First

40. QUALITY OF EmOC Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities? Problem:

41. QUALITY OF EmOC Find out if your EmOC facilities are really functioning Check staff numbers, skills, management capacity, supplies and equipment Lobby your health ministry for more support – and get the community to lobby with you Find out if your EmOC facilities are really functioning Check staff numbers, skills, management capacity, supplies and equipment Lobby your health ministry for more support – and get the community to lobby with you Action: Get More Info Action: Get More Info

42. Any Country Can Avert Maternal Death And Disability If It Makes Good EmOC Any Country Can Avert Maternal Death And Disability If It Makes Good EmOC Available And Accessible on Time Available And Accessible on Time

43. The AMDD Program The AMDD Program Was Established in 1999 at Columbia University’s School of Public Health, Heilbrunn Department of Population and Family Health The AMDD Program Is Dedicated to Improving the Availability, Quality and Utilization of Life-saving Obstetric Services in Developing Countries AMDD Partners Projects in Close to 50 Countries, Within a Framework That Links Technical Know-How With Management Capacity and Human Rights AMDD Is Funded by a Generous Grant From the Bill and Melinda Gates Foundation

44. AMDD Partners Project Partners: United Nations Children’s Fund (UNICEF): projects in Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka United Nations Fund for Population Activities (UNFPA): projects in India, Morocco, Mozambique and Nicaragua Regional Prevention of Maternal Mortality (RPMM) Network: teams and projects in19 sub-Saharan African countries CARE: projects in Ethiopia, Rwanda, Tanzania, Peru and Tajikistan Save the Children: projects in Mali and Vietnam Reproductive Health for Refugees (RHR) Consortium: projects in 12 countries Project Partners: United Nations Children’s Fund (UNICEF): projects in Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka United Nations Fund for Population Activities (UNFPA): projects in India, Morocco, Mozambique and Nicaragua Regional Prevention of Maternal Mortality (RPMM) Network: teams and projects in19 sub-Saharan African countries CARE: projects in Ethiopia, Rwanda, Tanzania, Peru and Tajikistan Save the Children: projects in Mali and Vietnam Reproductive Health for Refugees (RHR) Consortium: projects in 12 countries

45. AMDD Partners Technical Partners: Family Health International John Snow International Indian Institute of Management at Ahmedabad (IIMA) JHPIEGO Engender Health (formerly AVSC International)

46. RESOURCES UNICEF/WHO/UNFPA, Guidelines for Monitoring the Availability and Use of Obstetric Services, UNICEF, New York, October 1997 Maine, Deborah, Safe Motherhood Programs: Options and Issues, Columbia University, New York, 1991 UNFPA and AMDD, Reducing Maternal Deaths: Selecting Priorities, Tracking Progress, Distance Learning Courses on Population Issues, Turin, UN System Staff College, 2002 Loudon, Irvine, “On Maternal and Infant Mortality 1900-1960”, Social History of Medicine, April 1991, Vol. 4, No.1, pp 29-73

47. Created by Nadia Hijab & Czikus Carriere