[email protected] 16/6/10 reducing maternal mortality what are the gaps in progress towards...

[email protected] 16/6/10

Reducing Maternal Mortality

What are the gaps in progress towards achieving MDG 5?

Eilish McAuliffe, Centre for Global Health, TCD


Global Action on Maternal Health

• Safe Motherhood – since 1987• MDG 5 - 75% reduction in the maternal mortality ratio (MMR) from 1990 to

2015• White Ribbon Alliance• Women Deliver – launched 2007• Obama’s Global Health Initiative• The Countdown to 2015 for Maternal, Newborn, and Child Survival (an independent supra-institutional organisation, health-care professionalassociations, donors, and governments, with The Lancet as a key partner.)

Yet 500,000 pregnancy-related deaths occur annually.

Without HIV this would have reduced to 281,500 by 2008

Latest estimates are for the first time showing significant decline from 526,300 in 1980 to 342,900 in 2008 (Hogan et al, 2010).


Hogan et al. 2010 review

• 1980 526,300 (446,400 – 629,600) 422/100,000 live births

• 2008 342,900 (302,100 – 394,000) 251/100,000 live births

• yearly rate of decline of 1·5%.

• To reach MDG 5 target by 2015 needs a decline rate of 5.5% per annum

• Without HIV would have a decline rate of 2.2% and Global MMR estimate of 206/100,000 in 2008


What’s happening in Africa?

• The proportion of global maternal deaths in sub-Saharan Africa increased from 23% (18–27) in 1980 to 52% (45–59) in 2008, resulting from both the accelerated increase in the number of maternal deaths in the early 1990s and declines in Asia.

• Trends in MMRs, excluding deaths from HIV infection, showed decreases during 1980–2008 in eastern and southern Africa, and a slower decline in central and western Africa.


In 1990–2008, countries with substantial

declines in MMR included:

Egypt

Romania

Bangladesh

India

China


What accounts for improvements?

Four Drivers of Maternal Mortality are improving in most countries.

1. global TFR has dropped from 3·70 in 1980, to3·26 in 1990 and 2·56 in 2008.2. income per head (affects nutritional status of mothers & physical

andfinancial access to health care) has been risingparticularly in Asia and Latin America. 3. Maternal educational attainment, another strong correlate ofmaternal mortality, has been rising—eg, average years of schooling ofwomen aged 25–44 years in sub-Saharan Africa increased from 1·5 in 1980 to 4·4 in 20084. the steady, slow, rise in coverage of skilled birth attendance could

have contributed to maternal mortality declines


But…

Nairobi Study (Ziraba et al. Maternal mortality in the informal settlements of Nairobi city: what do we know? Reproductive Health, 2009, 6:6 http://www.reproductive-health-journal.com/content/6/1/6)

used data from verbal autopsy interviews conducted on nearly all female deaths aged 15–49 years between January 2003 and December 2005 in two slum communities covered by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS).

Findings• Over 86% of maternal deaths and 96% late maternal deaths had sought

care at least once from a professional health care worker prior to death.• About 62% of maternal deaths occurred in a health care facility compared to

only 31% of late maternal deaths

• definition of maternal death, "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes"definition of late maternal death "death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy"

http://www.reproductive-health-journal.com/content/6/1/6


“these numbers should now act as a catalyst, not a brake, for accelerated action on MDG-5, including scaled-up

resource commitments.” (Richard Horton, Lancet, 2010)


FundingAlthough overseas development assistance for maternal, newborn, and

child health has increased, funding for this sector accounted for only 31% of all development assistance for health in 2007.

(Bhutta et al, Lancet, 2010: 375-2032-44)

calls to integrate maternal and child survival programmes into vertical funding mechanisms for the MDGs, such as the Global Fund to fight AIDS, TB, and Malaria. Editorial “The Global Fund: replenishment and redefinition in 2010”. Lancet 2010; 375: 865

“Maternal, newborn, and child health offer a unique opportunity to give the Global Fund a fresh and expanded mandate, rewarding its

already great success. New evidence of progress towards MDG-5 only underlines the importance of this more comprehensive

approach—a replenished Global Fund for all the health MDGs”. (Richard Horton, 2010)


Systems approach

Countdown assesses progress every 2-3 yearsuses WHO health-systems framework,6 linked and overlapping components of a healthsystem • service delivery,• health workforce, • information,• medical products,• vaccines and technologies, • And financing and leadership or governance


Supported by IrishAid and Ministry of Foreign Affairs Denmark.


• Health Systems Strengthening for Equity

(HSSE)

Ultimate aim – to improve quality and coverage of EmOC.


MMR estimates by country

Country 1980 1990 2000 2008

Malawi 632

(395-966)

743

(457-1127)

1662

(1034-2551)

1140

(675-1813)

Mozambique 411

(228-668)

385

(241-591)

505

(311-796)

599

(359-957)

Tanzania 603

(380-925)

610

(375-940)

714

(411-1162)

449

(273-721)


Sampling

Country No. of Facilities No. of Providers

Malawi 84(near national sample)

631

Mozambique 138 535

Tanzania 90 811


System components

INPUTSOUTCOMES/RESULTSPROCESSES


The Enabling Environment

•Resources (WI) staff infrastructure drugs equipment

•Management support (WI)•Workplace relationships (WI)•Fair and just treatment (OJ) Supervision In-service trainingPromotion• Matching capability and workload (Burnout)

INPUTS OUTCOMES/RESULTSPROCESSES

•Job Satisfaction

•Performance

•Organisational Commitment

WI = Work Index

OJ = Organisational Justice


Malawi


•Light for tasks at night•Access to running water (piped or storage container)

Malawi


• Cord ties•Sterile gloves


Malawi


•Tetracycline ointment•Lignocaine



Malawi


•Sterile gloves•Soap•antiseptics

•Tetracycline ointment•Lignocaine



Malawi


Availability of items required for management of obstetric complications, by facility

Malawi


Most common missing items for management of obstetric complications

Malawi


Main providers of EmOC are NPCs/MLPs

• 80% all CS in districts by NPCs• Across all three countries NPCs are providing all

of the CEmOC signal functions, although not all NPCs provide all of the signal functions

• No significant difference in post-operative complications

• High Retention levels: Retention after 7 yrs: 88% for NPCs vs. 0% for MDs (Mozambique)

• NPCs 3x more cost-effective (Moz)


Cadres performing EmOC signal functions in past 3 monthsCountry Cadres Assisted Vaginal

DeliveryRemoval of

retained products

Malawi Clinical Officers 88% 85%

Reg. Nurse Midwives 67% 22%

Mozambique Técnicos de cirurgia

76% 94%

MCH nurse middle level 73% 85%

Tanzania Assistant Medical Officers

60% 82%

Reg. Nurse Midwives 24% 33%


5.45

11.5

15.75

45.45

21.81

3.9

11.8

15.4

43.2

25.7

8.9

8.2

9.5

50.6

22.8

2.76.1

21.8

41.5

27.9

28.6

14.3

42.9

14.3

0%10%20%30%40%50%60%70%80%90%

100%

RGNS &Midwives

Enrollednurses

Assistants &Aides

CO/AMOs Doctors

Strongly agree AgreeNeither agree nor disagree DisagreeStrongly Disagree

Tanzania: Cadres Actively Seeking other Employment


Availability of supervision by type

32.337.9

60.3

6 3.6 4.1

29.6

15.28.9

19.814.515.8

3.60.74.1

8.6

28

6.8

0

10

20

30

40

50

60

70

Formal On request No

superv ision

Negativ e

superv ision

Other No response

Malawi Tanzania Mozambique


Views on current supervision

• “The way of doing supervision of health workers who are providing emergency services during delivery is not good, to be honest, we don’t have that close supervision to tell them that you are supposed to do 1,2,3. There is no good mechanism…” District Health Secretary

• “Sometimes with shortage of workers you go to supervise but end up joining staff to work with them…You have to be there with them to know their problems, and stay with them to give them the feedback, then help them to solve problems…but you are just rushing the work.” RCH Co-ordinator


Factors affecting job satisfaction

In Malawi, Mozambique and Tanzania, substantial portion of job satisfactionlevels explained by providers’ perceptions of:

– Adequate supervision

– Support from management

– Adequate pay for work done

– Opportunities for career advancement


Factors affecting job satisfaction

Management and formal supervisory support

outweighed concerns relating to pay

threefold

in their contribution to job satisfaction levels


Facility attractiveness

• Facility index dissatisfaction score is formed from combined standardized average scores for each facility on five scales:

• (i) job satisfaction (reversed), • (ii) intention to leave, • (iii) satisfaction with supervision (reversed), • (iv) management support (reversed),• (v) emotional exhaustion.

• High dissatisfaction facilities (in green): e.g. Edingeni Rural Hospital, Machinga District Hospital,, Nkhatabay District Hospital,

• Middling facilities (closest to mean line): e.g. Embangweni Hospital, Ekwendini Rural Hospital, Kasunga District Hospital, Mchinji District Hospital.

• High satisfaction facilities (in black): Kaseye Community Hospital, Mua Hospital, Phalombe District Hospital


In Summary

• Much can be done to improve the provision of EmOC

• Addressing problems in the delivery system may have more immediate effect than addressing socio-cultural issues or attempting to manage migration.

• Many interventions required to improve care are not expensive.


What next?

• Development and sustainability of a supportive supervision system (planned Tanzania & Mozambique study)

• Targeted interventions (e.g. Resources, SCM, HRM) to ensure equity in access to and quality of EmOC.

• Review of pay structures and incentives for NPCs and entire team

• Assessment of obstetric team dynamics, decision making and impact on quality of care (planned Malawi study)


With Thanks

• HSSE Team:– Centre for Global Health, Trinity College, University of Dublin

– AMDD, Mailman School of Public Health, Columbia University, USA

– Centre for Reproductive Health, College of Medicine, Malawi

– Ifakara Health Institute, Tanzania

– Dept. of Community Health, Eduardo Mondlane University, Mozambique

– Realizing Rights: Ethical Globalization Initiative, USA

– Regional Prevention of Maternal Mortality Network, Ghana

• Funders:• IrishAid

• Ministry of Foreign Affairs, Denmark

[email protected] 16/6/10 reducing maternal mortality what are the gaps in progress towards...

Documents

maternal mortality declines

number of maternal deaths

drivers of maternal

maternal mortality ratio

reproductive health

professional health

nairobi urban health

female deaths