7. Ending Preventable Maternal Mortality requires âŚ
Geographic Focus
High Burden Populations
High Impact Practices
⢠Intensify programs where most maternal deaths occur
⢠Address barriers and scale up access towards equity and
respectful maternal and newborn care for those now
underserved
⢠Base the maternal health strategy on the local causes of
maternal and newborn death
⢠Strategy should emphasize
1. Family planning
2. Quality respectful intrapartum and immediate
postnatal care with effective referral
3. Provide prevention and treatment for obstetric
complications and co-morbidities that increase
maternal deathsâ
HIV/AIDS, malaria, tuberculosis, and poor
nutritionâduring the full spectrum of maternity
care.
⢠Build on and strengthen emerging health system changes
-- financing initiatives, decentralization, privatization
8. Mutual Accountability
⢠Promote transparency and shared accountability for
financing and results
⢠Monitor progress against a common set of metrics
⢠Ensure communications â electronic and mobile
technology â and improve documentation/surveillance and
mapping to improve the continuum of care and use of
knowledge in programming
Supportive Environment
⢠Educate girls and womenâas well as men
⢠Empower women to demand quality services
⢠Enact smart policy for inclusive economic growth
⢠Leverage public, private and professional partnerships
Ending Preventable Maternal Mortality requiresâŚ
âŚ
9. Over half of all maternal deaths
occur in just eight countries
India 56,000
20%
Nigeria 40,000
14%
DRC 15,000
5%
Sudan* 10,000
3%
Indonesia
9,600 3%
Ethiopia 9,000
3%
Tanzania 8,500
3%
Other 126,900
45%
Pakistan 12,000
* Sudan and South Sudan
Source: WHO, UNICEF, UNFPA and the World Bank estimates. Trends in Maternal Mortality: 1990-2010
Geographic Focus
10. Maternal coverage indicators
show widest gap in equity
0
10
20
30
40
50
60
70
80
90
100
Early start
of
breastfeeding
DPT
immunization
Fully
immunized
Vitamin A Oral
rehydration
therapy
Family
planning
needs
satisfied
Antenatal
care with a
skilled
provider
Antenatal
care (⼠4
visits)
Skilled birth
attendant
PercentCoverage
Quintile 1 Quintile 5
Child Health Indicators Maternal Health Indicators
Barros, Ronsmans, Axelson et al. 2012
High Burden Population
11.
12. Proven interventions can address
the leading causes of maternal
death, both direct and indirect
Preeclampsia
Eclampsia
18% Hemorrhage
35%
Unsafe Abortion 9%
Sepsis
8% Indirect and Other
Direct
30%
Source for Causes: Countdown to 2015
⢠Active management of the
third stage of labor
⢠Uterotonics: oxytocin &
misoprostol
â˘Blood transfusion
⢠Family Planning
⢠Diet, supplementation
and fortification
⢠Prevention and
treatment of infections
⢠Iron folate supplements
⢠De-worming
⢠Malaria intermittent treatment
⢠Anti-retrovirals
⢠Tetanus toxoid
⢠Clean delivery
⢠Antibiotics
⢠Family planning
⢠Post-abortion care
⢠Calcium
⢠Magnesium Sulfate
⢠Aspirin
⢠Anti-hypertensives
⢠Cesarean section
Underlying causes:
⢠Unintended pregnancy
⢠Under-nutrition
⢠Co-infections
High Impact Practices
13. HIVAIDS programs need to be tailored to diverse epidemics and
integrated into maternal newborn programs
Indirect Causes of Maternal Mortality
are growing
14. HIDN/MCH AFRICA PRIORITY COUNTRIES
ESTIMATED HIV PREVALENCE AMONG TOTAL POPULATION 2011
The boundaries and names used on this
map do not imply official endorsement
or acceptance by the U.S. Government.
ESTIMATED HIV PREVALENCE AMONG
TOTAL POPULATION 2011
Data Source: UNAIDS, 2011
Map Source: OST/GeoCenter, January 2013
*Natural Breaks (Jenks)
1% - 2%
3% - 4%
5% - 7%
8% - 13%
No Data
Country HIV burden MMR
Mozambique 490
Zambia 440
Malawi 460
Kenya 360
Uganda 310
Tanzania 460
Nigeria 630
DRCongo 540
Rwanda 340
Senegal 370
Ethiopia 350
Rwanda 340
Mali 540
Ghana 350
Source: MMRs: Trends in Maternal Mortality: 1990 to 2010
WHO, UNICEF, UNFPA and The World Bank Estimates, WHO 2012
In SSA, the proportion of indirect vs. obstetric causes is greater
than in South Asia â reflecting the important contribution of
infectious diseases to maternal mortality in Africa
15. Country MMR
Mozambique 490
Zambia 440
Malawi 460
Kenya 360
Uganda 310
Tanzania 460
Nigeria 630
DRCongo 540
Rwanda 340
Senegal 370
Ethiopia 350
Rwanda 340
Mali 540
Ghana 350
Liberia 770
Senegal 370
Madagascar 240
Maternal mortality is also high in areas
of epidemic and endemic malaria
Source: 2010 Malaria Atlas Project, available under the
Creative Commons Attribution 3.0 Unported License.
Clinical burden of Plasmodium falciparum,
2007
16. 76
70
62
60
53
38 38
31
22
20
59
48
50
0
10
20
30
40
50
60
70
80
%
USAID Priority Countries with Natoinal Data by Region
Prevalence of Anemia in Pregnant Women
22% of maternal deaths are associated with iron deficiency anemia
Source: Stolfus et al, Iron deficiency anemia, âComparative quantification of health risks,â WHO, 2002.
17. Integrated care during
pregnancy, childbirth and beyond
Care for Mothers with TB and other
infectious diseases
Care for Mothers and Newborn in
Areas With Malaria
Care for HIV Positive Mothers and
Newborns
Emergency Care for Mothers and
Newborns
Standard Care for Maternal and
Newborn Health
Family Planning
â˘TB screening and treatment
â˘STI screening and treatment
â˘Screening and treatment for other infections like Hepatitis
â˘Use of ITNs
â˘Intermittent Preventative Treatment
â˘Case management for malaria illness and anemia
⢠ART initiation or continuation
⢠Couples counseling and testing
⢠Prevention of opportunistic infections
⢠Extra monitoring and treatment for HTN, pre-eclampsia/eclampsia and anemia
⢠On-going case management for mother and newborn
â˘Referral networks
â˘Surgery and Medical care
â˘Availability of Blood
â˘Focused Antenatal Care and improved nutrition
â˘Intrapartum Care
â˘Postnatal Care
â˘Voluntary access to modern contraceptive methods
â˘Healthy Timing and Spacing of Pregnancies
â˘Post-abortion care
18. ⢠Weak health systems â
especially inadequate
number of midwives and
surgeons, poor quality
drugs, poor quality of
care, financial
barriers, measurement
challenges, and so forth
⢠Urbanization
⢠Privatization
⢠Decentralization
Contextual Challenges
19. Innovationsâ mHealth has potential to be a
powerful accelerator of progress
Communications to improve referral systems, and so forth
20. Quality of care is critical:
an important part is respect
⢠A âveil of silenceâ has obscured
widespread humiliation and abuse
of women in facilities during
childbirth, a time of intense
vulnerability for women.
⢠In many settings, disrespect of
women in childbirth has been
ânormalizedâ and is sometimes
accepted by women themselves.
⢠Institutional disrespect and abuse
of women can significantly deter
womenâs use of facility skilled
care for normal and emergency
birth care.
USAID promotes
21. In summaryâŚ.
1. Target settingâ a work in progress
2. Reaching the target â Strategies based on local causes of maternal
death and contextual factors
3. More data needed â including reporting death, including
cause, time and place of death
4. Implementation research on untested strategies and innovations
will guide more effective investment for better outcomes.
5. We have an unprecedented opportunity for accelerated progress -
- building on reduced fertility rates, increased rates of female
education, and economic growth
Between 1990 and 2010, the maternal mortality ratio declined by nearly halfâfrom 543,000 deaths to 287,000 deaths. While the first decade saw a rate of decline of approx 3.1% per year, the 2000-2010 decade rate increased to over 4% globally. But to reach a MMR of 50 by 2035âthe upper limit of the MMR among OECD countriesâthe the ann rate of reduction worldwide must increase to 5.6%
Given the variation in rates of decline in the reduction of preventable Mat mort by region to achieve any aggressive but plausible target set for the future, the question is just how do we achieve such a target. The draft strategies we have laid out follows the format of A Promise Renewedâas eventually we would like to see the maternal, newborn, child strategies better linked to ensure a continuum of care. -- Geog focus--âŚ-- High burden pop speaks to ensuring that the vulnerable receive quality respectful care for both mothers/newbornâthat barriers to access (such as cost, transport, cultural factors) are addressed and interventions are implemented at scale. -- High impact Care is provided based on the local causes of maternal and newborn deathâand it starts with 1. family planning to ensure all women have a voluntary intended birth, That quality respectful intrapartum and immediate post natal care is available with effective referralThat prevention and treatment is available throughout the maternity period to address not only the ob complications (hem, PeE, sepsis, unsafe abortion and ob/prolonged labor) but also for co-infections, and poor nutrition. To do this policies and programs need to build on and strengthen if needed the various initiatives or situations that health systems find themselves in recentlyâfinancing initiatives (CCT, vouchers, fee exemptions, national or social insurance programs) , decentralization, privatizationâand in Arusha we heard that nearly half of people in developing countries now live in urban areas
A supportive enviroment is needed for both immediate an sustainabile resultsMutual accountability-- Needs to build on global and national commitments already publicly made as well as subnational efforts to set goals, fund programs and closely monitor progress with involvement of communities.
Geographic focus: over half of all maternal deaths take place in just 8 countries âwith 3 in Asia and 4 in SSAâwith nearly equivalent numbers of maternal deaths-between 78-83,000 deaths/year. For USAID, the major focus is on 24 countries ( x in SSA, y Asia) that contribute to nearly 75% of the deaths annually.
High burden population: While there have been increases in use of facility births and births with a skilled attendant over the decade between 1998-2008 in both SSA and Asian countries, the use of maternal health services âwhether it be ANC 4 or use of a SBA for birthâshows the widest gap in equity as measured by the quintiles 1 and 5. The poor continue to use fewer services than the richest quintile by nearly a factor of 2??? Ck.When we look at maternal death, we know from national studies in both Ghana and Bangladesh and several smaller studies , that those women with higher education are far less likely to die than their counterparts without education. Empowering women with cash or with education is likely to contribute to improved use of services as well as reduce mortality.
2. High impact interventions: the direct causes of maternal death are well-known and have been for the 2 decades of the SMI. We often think there has been little progress in addressing themâbut in effect there has been progressâin determining what works and in implementing such. Perhaps the biggest advance has been to address the major obstetric killer, postpartum hemorrhage. AMTSL using oxytocin has been widely accepted and recent research has led to the potential of a simplified regimen and guidelines have been promulgated to this effect (true?),; , the interest and excitement caused by misoprostol has led to⌠Even so, hemorrhage remains the largest contributor to maternal death.What has become increasingly obvious over the last decade is the escalating impact of co-infections on maternal health. The numbers of deaths due to these indirect causes of maternal death (HIV/AIDS, malaria, TB) has increased âbut there are few data we can rely onâŚ. Nutritionâspecifically anemiaâhas continued to be recognized as a âŚ.
Malaria is also implicated in maternal deaths. And even in areas of endemic malaria, where it is anticipated that pregnant women will not die from malaria, reports are now available questioning this âŚ.
Given the varying contributing factors to maternal death, the care required must be adjusted to address the causes. For example, provision of basic and emergency obstetric care with family planning has contributed to the reduction of MMR , but in other sites where the causes of maternal death go beyond the direct obstetric complications, more care is needed to address the co-infectionsâHIV/AIDS, malaria, TB and more. IT is likely that in those areas with this higher morbidity burden, more providers per 1000 births will be needed as their workload will be higher. Yet according to the State of the Worldâs Midwives, it is in just those countries where the work force available is less. (think we should revers the servicesâwith FP in circle at center