no goals at half-time: what next for the millennium development goals? mdg 5: improve maternal...
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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
• Maternal mortality is the public health indicator with the greatest gap between rich and poor countries
Source: http://www.who.int/whosis/mme_2005.pdf
<100 100-299 300-499 500-999 1000+
Maternal deaths per 100,000 live births, 2005
99% of deaths in developing world
The poor are hardest hit
0
100
200
300
400
500
600
700
800
900
Tanzania 1996 Indonesia 2002 Peru 2000
Mat
erna
l mor
talit
y ra
tio
Poorest 20% Richest 20%
Source: Graham et al. 2004 Lancet 363(9402):23-27
Why act: maternal deaths considered preventable, subnational & national studies
64
75
68
51
85
55
35
0 10 20 30 40 50 60 70 80 90 100
Zambia
Vietnam
United States
Turkey
Tanzania
Portugal
Jamaica
PercentOverall, 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 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?
MDG 5 Target
Source: WHO http://www.who.int/reproductive-health/publications/maternal_mortality_2005/mme_2005.pdf
Epidemiology
0
100
200
300
400
500
600
700
800
900
1000
Sub-Saharan Africa South Asia
Ma
tern
al m
orta
lity
ra
tio
Haemorrhage Hypertensive diseases Sepsis/Infection Obstructed labour
Other direct Abortion Indirect causes Unclassif ied
Causes of death should drive interventions
Excessive bleeding is the main cause of death
Most problems can not be predicted or prevented
Most life-saving interventions require considerable skill
Source Ronsmans C& Graham W 2006; Lancet (9542):1189-200.
0
20
40
60
80
100
120
140
160
Dea
ths
per
1000
per
son
year
Timing of death is critical
Most deaths cluster around labour or within 24 hours after delivery
Matlab, Bangladesh
Time since pregnancy
Source Ronsmans C& Graham W 2006; Lancet (9542):1189-200.
What Should We Do?
• Content of Services
• Organization of Services - Delivery Mechanisms
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
Fertility componentFamily planning servicesAbortion services
Obstetric componentDelivery CareANCPostpartum Care
General Health Services
Strategies for providing family planning
Clinic-based Mobile clinics Community-based distribution Social marketing Target special groups: postpartum, post
abortion, adolescents, workplace.
Abortion Policies
Source: http://www.reproductiverights.org/pub_fac_abortion_laws.html
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?
• 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
• Where women deliver and who attends them, is paramount
WHO?
• Skilled Attendant (midwife or doctor)
Emergency Obstetric Care (EmOC)
Component CEmOC (Hospital)
BEmOC (Health Centre)
Surgery (CS, anaesthesia)
X
Blood Transfusion X
Manual Procedures (Vacuum Aspiration, Removal of retained placenta, Instrumental delivery)
X X
Medical Treatments ( MgSO4, IV Antibiotics, Oxytocics)
x x
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
• 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
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
Where are we now?
0
5
10
15
20
25
Overall Urban Rural
On track (>70%)
Watch (31- 69%)
High alert (<30%)
Progress in coverage looks very different in rural and urban areas
Derived from data in DHS Comparative Reports (2005). The context of women's health: results from the Demographic & Health Surveys 1994-2001.
32 priority countries by coverage of births with a health professional
“Countdown to 2015”
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
• 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
Country/
year
Normal delivery
Complicated delivery
Benin, 2002 3-7 11-51
Ghana, 2002 5-6 16-35
Bangladesh (rural)
2000-01
11 90-138
Bangladesh (urban) 1995
12 42
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
So what is needed?
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
• Policy makers must make strategic human resource decisions to ensure 100% coverage with health professionals
• Implement plans now for 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
2—More health professionals for delivery
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• 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
0
1
2
3
4
5
6
7
8
9
Mat
erna
l & p
erin
atal
cond
ition
sC
hild
hood
clu
ster
& d
iarr
hoea
l
dise
ases
HIV
/AID
S
TB
Mal
ari
a
Pe
rce
nt
of
DA
LY
s
Source:http://www.who.int/healthinfo/global_burden_disease/en/index.html
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
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
0
100
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600
700
1960
1962
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2002
2004
Mat
ern
al d
eath
s p
er 1
0000
0 liv
e b
irth
s
Sri Lanka Thailand MalaysiaHonduras Egypt Matlab, BangladeshBangladesh MM Survey 2001 China India
Progress is Possible
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
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