1. Non-medical factors related to maternal mortality Birgitta Essén, MD, associate professor Senior Lecturer in International Maternal Health Care Department of Women’s and Children’s Health IMCH, Uppsala University

2. outline RH history (SRHR) MM: medical factors, classification MM: non medical factors UN, WHO policy

3. How did it start?

4. Biafra 1967-1970

5. Main PH focus: Population ! => FP ” Maternal and child health” ”Reproductive Health” ”Reproductive Health” Maternal health Maternal health FP

6. Reproductive health - International focus/attention Bucharest 1974 – UN Population Conf. Mexico City 1984 – same focus: population Cairo 1994 – International Conference on Population and Development (=>”RH”) Beijing – UN Conference on Women WHO strategy approved 2004 Safe Mootherhood UN MDG 5 WHO Continum of Care 2010

7. Sexual & reproductive health & rights Sexual & reproductive health & rights FP Violence against women Violence against women Child- lessness Child- lessness Cx cancer Cx cancer HIV/AIDS STD Abortion Adolescent SRHR Adolescent SRHR Maternal newborn health Maternal newborn health ”Reproductive Health” ”Reproductive Health” Maternal health Maternal health FP

8. MGD 5 1990 to 2015 Reduce maternal mortality with 3/4

9. Maternal mortality MDG 5 Hill K, et al. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet. 2007;370. Disparities poor-rich Graham WJ, et al. The familial technique for linking maternal death with poverty. Lancet. 2004;363 Lifetime risk (WHO 2007) Ethiopa:1 in 10 Norway: 1 in 15,000

10. Trends in strategies to reduce maternal mortality Safe Motherhood Initiative, Nairobi 1987 AbouZahr C. Safe motherhood: a brief history of the global movement 1947–2002. Br Med Bull. 2003. Other MDGs: 1eradicating powerty 2primary education 3 gender equity …however, most strategies have been vertical programs focusing on single interventions ! Starrs AM. Safe motherhood initiative: 20 years and counting. Lancet. 2006.

11. Maternal mortality ratio per 100 000 livebirths, 2008 Hogan et al., Lancet 2010 Norge: 8/100 000 Afghanistan: 1575/100 000 Etiopia: 590/100 000 Dem rep Kongo Nigeria Pakistan India

12. Yearly reduction MM (%), 1990-2008 Hogan et al., Lancet 2010

13. “Big five” Haemorrhage Sepsis Preeclampsia/eclampsia Obstructed labour Unsafe abortions

14. Why?

15. Socioeconomic factors contributing No power to decide Inequality Low education/illiteracy Poverty Early marriages Harmful practices No access to delivery care No access to family planning and antenatal care Infrastructure

17. Halving MMR Sri LankaMalaysia www.worldbank.org ”Investing effectively in maternal health”

18. History: Sri Lanka & Malaysia How did they do it ? Expanding access to effective maternity care by midwives and doctors Improving utilization and quality of care with emphasis on making life-saving care free. The World Bank, 2003

19. Maternal mortality, time trend (100 000/deliveries) År Death women

20. Maternal mortality where?

21. Shifting from Unskilled Care

22. To Skilled Care

23. 4 models of delivery care Koblinsky, Bull WHO Traditional birth attendants (TBA) Skilled birth attendants –at home Skilled birth attendants –at health center Hospital

25. Trends in strategies to reduce maternal mortality – health care seeking behaviour “Consequently, increased attention with regard to the utilization of obstetric care has been directed toward understanding the motivations and behaviours of pregnant women and their social network” Rööst et al 2009.

26. WHO 4. august 2010 Contiuum of care Interventions at home/community level Interventions at first level health facilities Interventions at referral facilities

27. WHO Policy, 2010 Family planning (Safe abortion, STI prevention) ”Reduce MM with 30%” ANC ”Reduce MM with 50 % and NM 15%” Emergency Obsteric Care, Skilled BA ”Reduce MM 95%”

28. Countdown report to 2015 Afghanistan Etiopia India

29. Interventions in 68 “Countdown Countries” Bhutta ZA et al., Lancet 2010

30. Conclusions Maternal newborn health Maternal & newborn survival extra dependent on functioning health care (less on general living conditions) Public awareness through reporting is fundamental Infrastructure and Education Skilled birth attendance is key – midwives! As well as backup for obstetric emergencies

31. Thanks for listening! Any questions? Give me a break…