No Goals at Half-time: What Next for the Millennium Development Goals?
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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 Development Goals?

  • 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 Development Goals?

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 Development Goals?

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 several & national studiesMillennium 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? & national studies

MDG 5 Target

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


Epidemiology
Epidemiology & national studies


Causes of death should drive interventions & national studies

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.


Timing of death is critical & national studies

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? & national studies

  • 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 maternal & neonatal mortality

 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 maternal & neonatal mortality

  • Clinic-based

  • Mobile clinics

  • Community-based distribution

  • Social marketing

  • Target special groups: postpartum, post abortion, adolescents, workplace.


Abortion policies
Abortion Policies maternal & neonatal mortality

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


Strategies for abortion
Strategies for abortion maternal & neonatal mortality

  • 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? maternal & neonatal mortality

    • 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 maternal & neonatal mortality

    • Where women deliver and who attends them, is paramount


    WHO? maternal & neonatal mortality

    • Skilled Attendant (midwife or doctor)


    Emergency Obstetric Care (EmOC) maternal & neonatal mortality


    Quality health centre strategy focuses on
    Quality Health Centre Strategy focuses on maternal & neonatal mortality

    • 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


    Where are we now? survival

    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 survivalGabrysch 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 costs hugeas 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 huge

    • 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 huge

    • 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 huge

    • 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 huge

    • 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 huge

    • 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 translated into programmes

    • 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


    Progress is Possible translated into programmes


    The health centre strategy is key
    The Health Centre Strategy is key translated into programmes

    • 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


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