vikki chambers: new approaches to maternal mortality in africa
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Vikki Chambers (Research Officer in Africa Power and Politics Programme, Overseas Development Institute): A comparative perspective of the political factors which shape maternal health outcomes in Malawi, Niger, Rwanda and UgandaTRANSCRIPT
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Safe motherhood:A case study of rural Rwanda
Vikki Chambers Overseas Development InstitutePresentation for New Approaches to Maternal Health conference, Cambridge University, 3 July 2012
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APPP local governance research
Research question: What sorts of governance arrangements enable a ‘better’ provision of public goods (enabling key bottlenecks to be tackled) in sub-Saharan Africa?
Public goods: Water and sanitation, facilitation of markets, public security and maternal health
In-depth country studies
Multiple case studies: Malawi, Niger, Rwanda, and Uganda
Single case studies: Ghana, Sierra Leone, Senegal, and Tanzania
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Methods and approach
Scope of fieldwork: Two rural districts (Nyamagabe and Musanze), five months fieldwork in each, team of four researchers (incl. 3 Rwandans)
Research methods: ethnographic techniques (participant and non-participant observation, casual conversations, informal interviews), semi-structured interviews, review of official documents.
Assumptions about key components of safe motherhood: physical and financial access to maternal healthcare facilities, ante- and post-natal care, family planning use, assisted childbirth, efficient transfer between first and second level health care facilities.
Bottlenecks taken as entry point.
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What works and why?
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Rwanda maternal health: observed results 1
Households are increasingly limiting and spacing family size - condom distribution to young people, vasectomy uptake, contraceptive range equivalent to London (female condoms!), women demand ‘better’ methods with no side effects and change methods.
Low MMR - Villagers struggle to recall women who have died in childbirth, no recorded maternal deaths in health centers since 2008
Family planning methods available to women at Bisate health centre, Musanze district
Health infrastructure exist, are reasonably well equipped and staffed with professionals and offer full range of maternal health services. Community health workers in every village.
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Rwanda maternal health: observed results 2
Local authority staff – no evidence of absenteeism, contactable
Women and men attend the 1st ANC. Both are tested for HIV. HIV+ women are integrated into PMTCT programmes.
Women give birth at health centres. Many use waiting facilities to avoid accidental home births. No evidence of ‘TBAs’ practicing.
Men and women attending the maternity wing of Kinigi health centre, Musanze district
Women using the maternity waiting facilities at Jenda health centre, Nyamagabe district
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Quantitative data
Rwanda 1992 2000 2005 2008 2010 MDG
MM per 100,000 1,071 750 540 476 268
Births at a health facility (%) 25 26 28 45 69 100
Total fertility rate (TFR) 6.2 5.8 6.0 5.5 4.6
Modern contraception prevalence (%)
13 7 10 24 45
% of women receiving: at least one ANC four ANCs
94 92 9413.3
9624
99.835
* Source Demographic Health Surveys
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How have bottlenecks been overcome?
The coherence of the policy environment at all levels.
Consistent national/local development objectives
Coherent policy reforms accompanied by the strategies necessary for implementation, with clear lines of responsibility.
Effective coordination and management of development partners avoids overlaps ensuring that interventions plug real resources gaps.
Political commitment in pushing reforms through has been key
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How have bottlenecks been overcome?
Performance disciplines exist and function to ensure professional standards are respected and that policy is implemented
Regular and effective supervision and monitoring of all actors (health providers are evaluated, imihigo objectives and reporting for local officials, CHW monthly reports). Upward accountability
There are real consequences for poor performance
The incentive structures (rewards/sanctions) faced by different actors, at all levels, are consistent. (PBF, CHW cooperatives, imihigo rankings, user enforcement measures i.e. fines/public education).
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How have bottlenecks been overcome?Collaborative space for local actors exists and is facilitated/encouraged by the stateAdvisory and oversight committees exist (i.e.
health committees, collaborative public education campaigns).
State has facilitated local problem-solving initiatives (particularly those which address specific bottlenecks). Feedback mechanisms exist so that lesson-learning feeds back into policy.
Local population are involved in collective action activities (CHW, traditional ambulances, mutuelle committees, poverty reduction strategies, CHW).
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Quantitative outcomes compared - 1
Source: Computed from Demographic and Health Survey data, various years.
Maternal mortality ratios (MMR)Malawi: Reduction in the MMR only just recover losses in 1990sNiger: Almost no progress in MMR since 1992Uganda: Modest decrease in MMR Rwanda: Consistently falling MMR
Health centre deliveries Malawi: significant increase since 2000Niger: slight reduction since 1998Uganda: only a very small increase since 1995 Rwanda: spectacular improvement since 2005
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Contraceptive useMalawi: Consistent increases since the early 90s with a slow-down in the early 2000sNiger: Consistent but small increase over timeUganda: Sharp increase between 1995 and 2000, followed by a reduction Rwanda: Decrease post-1992, followed by consistent and drastic increase post-2005
Quantitative outcomes compared - 2
Source: Computed from Demographic and Health Survey data, various years.
Ante-natal visits (4)Malawi: almost consistent decrease since high levels in the 1990sNiger: small but consistent increaseUganda: stagnating use with a small dip in 2000Rwanda: important increase since 2005
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SimilaritiesSimilarities:
General resource scarcity
Cost recovery in the 1990s with recent shift towards some form of user fee exemption.
Health service delivery decentralised to local level
So what explains the difference?
Levels of health expenditure appear to indicate a relationship between health expenditure per capita and maternal health outcomes but this is not sufficient.
Uganda has seen the greatest increase with little improvement in outcomes.
APPP research indicates that the extent to which countries have overcome particular bottlenecks can explain many of these differences.
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Common obstacles (bottlenecks) to safe motherhood
Local choices about health-care (=delays in seeking medical assistance)
Lack of accessible health infrastructure and failings in emergency evacuation procedures (=delays in transferring women to adequate health care facilities)
Shortage of trained staff, stock-outs of blood/medicine, low staff morale and keeping of professional standards (=shortcomings in quality of care
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Observed differences (in addressing bottlenecks)Use of modern services :
Uganda: uptake of maternal health services appears nominal.
Banning of TBAs in Malawi, Niger and Uganda has not been effective.
Rwanda: evidence of real behavioural change due to effective public education campaigns supported by enforcement.
Timely transfers:
Niger: Ambulances exist but fuel expenses are prohibitive
Rwanda: community health insurance has increased financial accessibility; ‘waiting rooms’ help prevent accidental home births.
Better quality care:
Uganda: Staff absenteeism; health centres don’t respect hours
Malawi: Severe overcrowding; low staff morale affects service
Niger: poorly trained staff, demeaning treatment of patients
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Lessons from Rwanda
Focusing on material resources alone can ignore the potential of institutional factors to overcome service-delivery blockages in resource-constrained environments.
Addressing key service-delivery bottlenecks is not just about ‘supply’ and ‘demand’ but the interaction between the two. Top-down policy drive and grass-roots engagement have both been crucial.
Collaborative spaces in which actors come together can provide key arenas in which service delivery bottlenecks can be overcome.
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The Africa Power and Politics Programme is a consortium research programme funded by the UK Department for International Development (DFID) and Irish Aid for the benefit of developing countries.