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

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400

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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

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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

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1960

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Mat

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eath

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0 liv

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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