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No Goals at Half-time: What Next for the Millennium Development Goals? MDG 5: Improve maternal health Oona Campbell. The problem of maternal death is large. A woman dies each minute -- day in, day out

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No Goals at Half-time: What Next for the Millennium Development Goals?MDG 5: Improve maternal health Oona Campbell

the problem of maternal death is large
The problem of maternal death is large
  • A woman dies each minute -- day in, day out
  • Maternal mortality is the public health indicator with the greatest gap between rich and poor countries
maternal deaths per 100 000 live births 2005
Maternal deaths per 100,000 live births, 2005

99% of deaths in developing world

<100

100-299

300-499

500-999

1000+

Source: http://www.who.int/whosis/mme_2005.pdf

the poor are hardest hit
The poor are hardest hit

Source: Graham et al. 2004 Lancet 363(9402):23-27

why act maternal deaths considered preventable subnational national studies
Why act: maternal deaths considered preventable, subnational & national studies

Overall,

WHO estimates

98% preventable

Source: Maine D. Safe Motherhood Programs: Options and Issues, Center for Population and Family Health, 1993.

maternal survival is tied to several millennium development goals
Maternal survival is tied to severalMillennium Development Goals
  • Is Goal of MDG 5: reduce maternal deaths by 75% by 2015
  • Linked to MDGs for poverty reduction, female empowerment, and infectious diseases
  • Strengthens efforts to promote newborn survival and improve the health of the child (MDG 4)
  • Improves the welfare of the whole family
  • Supports health systems strengthening
have we made progress
Have we made progress?

MDG 5 Target

Source: WHO http://www.who.int/reproductive-health/publications/maternal_mortality_2005/mme_2005.pdf

slide9

Causes of death should drive interventions

Most life-saving interventions

require considerable skill

Most problems can not be

predicted or prevented

Excessive bleeding

is the main cause of death

Source Ronsmans C& Graham W 2006; Lancet (9542):1189-200.

slide10

Timing of death is critical

Most deaths cluster

around labour or

within 24 hours after

delivery

Time since pregnancy

Matlab, Bangladesh

Source Ronsmans C& Graham W 2006; Lancet (9542):1189-200.

what should we do
What Should We Do?
  • Content of Services
  • Organization of Services - Delivery Mechanisms
many sources of effective single interventions that reduce maternal neonatal mortality
Many sources of effective single interventions that reduce maternal & neonatal mortality
  • Lancet Series
  • Disease Control Priorities Project DCPP (World Bank)
  • World Health Report; BMJ
  • Cochrane Collaboration (RH Library)
  • Many single interventions but none alone can reduce maternal or neonatal mortality
organization of services
Organization of Services

 Fertility component

Family planning services

Abortion services

 Obstetric component

Delivery Care

ANC

Postpartum Care

General Health Services

strategies for providing family planning
Strategies for providing family planning
  • Clinic-based
  • Mobile clinics
  • Community-based distribution
  • Social marketing
  • Target special groups: postpartum, post abortion, adolescents, workplace.
abortion policies
Abortion Policies

Source: http://www.reproductiverights.org/pub_fac_abortion_laws.html

strategies for abortion
Strategies for abortion
  • Legalize abortion
  • Ensure legal services provided
      • Medical Abortion
      • Vacuum Aspiration
  • Reduce barriers
  • Irrespective of legality:
    • Provide post-abortion care
      • prompt emergency care
      • appropriate care (VA)
      • comprehensive RH services
why not achieving promise
Why not achieving promise?
  • Family planning
    • Fatigue/ widening of focus
    • Lack of political will
    • US withdrawal from provision of commodities
  • Safe Abortion
    • Lack of political will/ champions
    • Anti abortion politics
    • Training
delivery care
Delivery care
  • Where women deliver and who attends them, is paramount
slide19
WHO?
  • Skilled Attendant (midwife or doctor)
quality health centre strategy focuses on
Quality Health Centre Strategy focuses on
  • Monitoring woman and baby during labour and for 24 hours postpartum
  • Safety and primary prevention
  • Early detection and basic management of problems
  • Referral to hospital for emergency care
quality health centre strategy is best bet for maternal survival
Quality Health Centre strategy is best bet for maternal survival
  • Most effective because skilled attendants can deliver proven interventions
  • More efficient than skilled attendants in the home or hospital
  • Alternative strategies are not as effective or efficient and may not be sustained
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Where are we now?

Half the world’s women currently give birth with a professional

In SA & SSA, most urban women deliver with a professional

But only a third of rural women have a professional at birth

slide with unpublished data gabrysch s 2008
Slide with unpublished data Gabrysch S (2008)

Slide shows data from a census of Zambian health facilities.

It shows limited capability of providing Basic Emergency Obstetric Care functions

the shortage of human resources in developing countries is huge
The shortage of human resources in developing countries is huge
  • Need to double the supply of health professionals for deliveries
  • Over 300,000 more needed by 2015 to achieve a coverage of 75%
  • 24,000 health centres also are needed
payments hurt the poor household costs as percent of gdp capita
Payments hurt the poor: household costsas percent of GDP/capita

Removing financial barriers encourages care-seeking

A promising approach is to remove fees and fund through general taxes

The poor may need additional support

Source Borghi et al. Lancet, 2006; 368(9545):1457-65

1 a new era of strategic thinking
1—A new era of strategic thinking
  • Care during delivery is the priority
  • All women should be able to deliver in health centres, with midwives working in teams
  • Target the women in greatest need: poor and rural women in sub-Saharan Africa and South Asia
2 more health professionals for delivery
2—More health professionals for delivery
  • Policy makers must make strategic human resource decisions to ensure 100% coverage with health professionals
  • Implement plans nowfor training and deployment of sufficient numbers of health professionals
  • Ensure skills and competencies to provide evidence-based care: Quality counts
  • Invest in efforts to retain existing staff
3 greater financial resources
3—Greater financial resources
  • Protect poorest families from the catastrophic consequences of unaffordable emergency care
  • Maternal mortality reduction requires a consistent and significant effort over the next 10 years and beyond
  • National governments need to invest greater resources
  • Donors need to increase financial contributions in low income countries to fill the resource gap
financial resources have not been adequate
Financial resources have not been adequate
  • Maternal & newborn health not given financial priority despite a burden of disease larger than HIV, TB, or Malaria
  • Global development assistance to maternal and neonatal health in 2003 was US$ 663 million
  • To achieve universal coverage with a health professional, an additional US$1 billion is needed now, increasing to US$6.1 billion in 2015

Percent of DALYs

Malaria

TB

HIV/AIDS

Maternal & perinatal conditions

Childhood cluster & diarrhoeal diseases

Source:http://www.who.int/healthinfo/global_burden_disease/en/index.html

4 robust tracking of progress and accountability
4—Robust tracking of progress and accountability
  • Better data and information systems needed to track progress in improved services and maternal health
  • This is to encourage and monitor government and donor commitments
5 political commitment is critical for implementation
Necessary to ensure this new era of strategic thinking is translated into programmes

Governments, donors, and civil society need to work in concert

5—Political commitment is critical for implementation
cross cutting issuess
Cross-cutting issuess
  • Geographic focus: where problems are
  • Policy change: communication of successful strategies rather than interventions
  • Mechanisms for distributing interventions (delivery mechanisms)
  • Human resource constraints (rural areas)
  • Training
  • Access in remote areas/communication/ referral
  • Financial constraints/ competition for vertical resources
  • Lack of data for routine monitoring
the health centre strategy is key
The Health Centre Strategy is key
  • Too many women are dying in their prime years
  • Maternal mortality is an MDG that 189 countries have signed up to
  • We need to get on with what works
ad