1. 04_DirectorReport_PCC/1 9/2004 Rita Kabra_/1 Access to essential medicines for Maternal and Newborn Health Dr Rita Kabra Making Pregnancy Safer WHO/EDM Technical Briefing Seminar Salle G, WHO/HQ 27 September – 1 October 200 4

2. 04_DirectorReport_PCC/2 9/2004 Rita Kabra_/2 Outline of the presentation current situation: maternal and newborn health current situation: maternal and newborn health Making pregnancy safer, Integrated management of pregnancy and childbirth Making pregnancy safer, Integrated management of pregnancy and childbirth Examples of two medicines Examples of two medicines The way ahead The way ahead

3. 04_DirectorReport_PCC/3 9/2004 Rita Kabra_/3 Current scenario Every minute a woman dies from complications of pregnancy or childbirth Every minute a woman dies from complications of pregnancy or childbirth All but 1% of these deaths occur in developing countries All but 1% of these deaths occur in developing countries Most deaths occur due to poor service provision, lack of access to and use of these service s Most deaths occur due to poor service provision, lack of access to and use of these service s Most of these deaths could be avoided only if appropriate care was available throughout pregnancy, childbirth and the post-natal period. Most of these deaths could be avoided only if appropriate care was available throughout pregnancy, childbirth and the post-natal period.

4. 04_DirectorReport_PCC/4 9/2004 Rita Kabra_/4 Causes of maternal death 529,000 : 99 % in developing countries

5. 04_DirectorReport_PCC/5 9/2004 Rita Kabra_/5 World Health Organization Making Pregnancy Safer WHO’s contribution to the Safe Motherhood initiative Health sector strategy aimed to assist countries to identify and implement affordable strategies to address maternal and newborn health.

6. 04_DirectorReport_PCC/6 9/2004 Rita Kabra_/6 World Health Organization To ensure safe pregnancy and childbirth through the availability, access and use of quality skilled care for all women and their newborns The central objective of the Making Pregnancy Safer

7. 04_DirectorReport_PCC/7 9/2004 Rita Kabra_/7 Essential component of skilled care A skilled attendant/skilled professionals supported by an appropriate environment with access to basic supplies, essential medicines and relevant emergency services A skilled attendant/skilled professionals supported by an appropriate environment with access to basic supplies, essential medicines and relevant emergency services Skilled care should be provided within a continuum of care at all levels of the health system Skilled care should be provided within a continuum of care at all levels of the health system

8. 04_DirectorReport_PCC/8 9/2004 Rita Kabra_/8 What is the continuum of care? FAMILY and COMMUNITY FIRST LEVEL CARE REFERRAL LEVEL CARE

9. 04_DirectorReport_PCC/9 9/2004 Rita Kabra_/9 (Arabic)(Portuguese)EnglishFrenchSpanishRussianLaotianVietnameseIndonesianChineseFarsi Evidence-based practice guidelines for maternal and newborn health care: according to level of care

10. 04_DirectorReport_PCC/10 9/2004 Rita Kabra_/10 Essential medicines are selected on basis of evidence on efficacy and safety Integrated Management of Pregnancy and Childbirth (IMPAC) Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice (PCPNC) ADAPTATION GUIDE A guide to identify necessary adaptations of clinical policies and guidelines A. The Adaptation Process December 2003 Working Draft: for Limited Distribution Only World Health Organization Department of Reproductive Health and Research

11. 04_DirectorReport_PCC/11 9/2004 Rita Kabra_/11 World Health Organization The midwifery modules Using Human Rights to improve Maternal and Neonatal Health Beyond the numbers Reviewing maternal deaths and complications to make pregnancy safer Making Pregnancy Safer Planning Guide 2004 Integrated management of Pregnancy and Childbirth IMPAC

12. 04_DirectorReport_PCC/12 9/2004 Rita Kabra_/12 Essential medicines for maternal and Essential medicines for maternal and newborn health Postpartum haemorrhageOxytocin injectable/ Postpartum haemorrhageOxytocin injectable/uniject IV fluids Eclampsia/Pre-eclampsiaMagnesium sulphate Calcium gluconate Hydralazine Sepsis/InfectionAmpicillin GentamicinMetronidazole Tetanus toxid vaccine HIVNevirapine or HIVNevirapine orZidovudine AnaemiaIron/folic acid Blood

13. 04_DirectorReport_PCC/13 9/2004 Rita Kabra_/13 Access to essential medicines is a pre requisite to improved maternal and newborn health Access to essential medicines is a pre requisite to improved maternal and newborn health Essential medicines are those that satisfy the priority health care needs of the population. (report to WHO Executive Board, January 2002) Essential medicines are those that satisfy the priority health care needs of the population. (report to WHO Executive Board, January 2002) Selection criteria: Essential medicines are selected with due regard to disease prevalence, evidence on efficacy and safety, and comparative cost effectiveness Selection criteria: Essential medicines are selected with due regard to disease prevalence, evidence on efficacy and safety, and comparative cost effectiveness

14. 04_DirectorReport_PCC/14 9/2004 Rita Kabra_/14 Oxytocin for preventing and treating postpartum hemorrhage (PPH) 150,000 maternal deaths per year 150,000 maternal deaths per year Active management of third stage of labour reduces the risk of PPH by about 60% reduces the need for extra oxytocic by 70%, reduces the risk of postpartum anaemia Active management of third stage of labour reduces the risk of PPH by about 60% reduces the need for extra oxytocic by 70%, reduces the risk of postpartum anaemia Management of PPH: Management of PPH: oxytocin oxytocin prostaglandins : misoprostol prostaglandins : misoprostolErgometrine blood transfusion surgery

15. 04_DirectorReport_PCC/15 9/2004 Rita Kabra_/15 Table 3 Cost estimates for using oxytocin for prevention of post-partum hemorrhage in Uganda P opulation Pregnancies Incidence of PPH Potential cases Intervention’s effectiveness Unit cost of treatment for PPH Cost of treatment for cases of PPH Savings Total programme cost Potential savings 1,094,000 64,863 10% 6486 50% (3243 fewer cases) Scenario 1: no preventive intervention $56 $364,011 Scenario 2: with preventive intervention $56 $182,006 $1,800,000 10% Rounded to nearest whole numbers. Figures taken from two Districts Iganga and Mbarara. *Actual savings depend on factoring, such as additional costs, savings from all types of complications averted, etc.

16. 04_DirectorReport_PCC/16 9/2004 Rita Kabra_/16 Magnesium sulphate for preventing and treating eclampsia 50,000 maternal deaths women per year 50,000 maternal deaths women per year The Collaborative Eclampsia trial: lowers risk of recurrent convulsions by 67%, lower risk for ventilation, pneumonia, and need for intensive care The Collaborative Eclampsia trial: lowers risk of recurrent convulsions by 67%, lower risk for ventilation, pneumonia, and need for intensive care The Magpie trial : Lowers risk of eclampsia by 58% for women with pre eclampsia. The Magpie trial : Lowers risk of eclampsia by 58% for women with pre eclampsia.

17. 04_DirectorReport_PCC/17 9/2004 Rita Kabra_/17 Added to the WHO EML Access to magnesium sulphate: a long way to go

18. 04_DirectorReport_PCC/18 9/2004 Rita Kabra_/18 Challenges Availability: Every pregnancy faces risk, essential medicines should always be available at every health centre Availability: Every pregnancy faces risk, essential medicines should always be available at every health centre Accessibility: geographical distribution of medicines, and at loer level facilities Accessibility: geographical distribution of medicines, and at loer level facilities Quality and safety : Storage, stability, avoid overuse and misuse Quality and safety : Storage, stability, avoid overuse and misuse Policy: Regulations on who can prescribe, training of health workers, rational selection, evidence based guideline Policy: Regulations on who can prescribe, training of health workers, rational selection, evidence based guideline Political will Political will

19. 04_DirectorReport_PCC/19 9/2004 Rita Kabra_/19 Key points for policy makers Most maternal deaths are avoidable Most maternal deaths are avoidable Most maternal health problems can be treated with a few essential medicines Most maternal health problems can be treated with a few essential medicines Access to essential medicine is a prerequisite to improve maternal and newborn health Access to essential medicine is a prerequisite to improve maternal and newborn health Procurement, reimbursement, training and donations of drugs should be based on proper use of these few medicines Procurement, reimbursement, training and donations of drugs should be based on proper use of these few medicines

20. 04_DirectorReport_PCC/20 04_DirectReport_PCC/20 The future is promising International commitment :The Millennium Development Goals reduce maternal mortality by three quarters reduce under-five mortality by two thirds WHO s commitment :Making Pregnancy Safer Department for country implementation MPS commitment: strengthening of integrated health systems. A co-ordinated response to essential maternal and perinatal health care. malaria, HIV programme. Close collaboration with EDM on reproductive health/ maternal health medicines.

21. 04_DirectorReport_PCC/21 9/2004 Rita Kabra_/21 ….women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving. Dr. M. Fathalla

22. 04_DirectorReport_PCC/22 9/2004 Rita Kabra_/22 Web site: www.who.int/reproductivehealth Web site: www.who.int/reproductivehealth Documentation centre: Documentation centre:lambertsue@who.int