April 18, 2023

Delivering safer motherhood – sharing the evidenceVincent De Brouwere

Institute of Tropical

Medicine, Antwerp

On behalf of all

Immpact teams

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Acknowledgements

• The ITM Antwerp Immpact team- Hilde Buttiëns- Bruno Marchal- Yvette Jacob

• Wendy Graham, PI, and Aberdeen team• The Centre Muraz (Burkina Faso), Centre for Family Welfare

(Indonesia), Nogutchi (Ghana) teams who produced the results in collaboration with teams from north institutions (University of Aberdeen, London School of Hygiene and Tropical Medicine, Johns Hopkins, Institute of Tropical Medicine Antwerp)

• Carine Ronsmans (especially for the slides of the Lancet series presentation graciously provided)

• Donors: Bill & Melinda Gates Foundation, DFID, USAID, EU

- Pascale Baraté- Anne Vriens

- Dominique Dubourg

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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

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1 in 30,000 die in Sweden compared to 1 in 16 in sub-Saharan Africa

Maternal death in SwedenMaternal deaths in sub-Saharan Africa

Women who survive Maternal deaths in sub-Saharan Africa Maternal death in Sweden

5 <100 100-299 300-499 500-999 1000+

Maternal deaths per 100,000 live births, 2000

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Have we made progress?

MDG 5 Target

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Immpact Framework Of Objectives

SUPERGOALMaternal mortality and morbidity reduced

GOALWomen receive timely care which is appropriate, effective and acceptable to their

needs arising from pregnancy, childbirth and the puerperium

PURPOSE Policy makers and programme managers practise evidence-based decision-making

for safe motherhood

OUTPUT 2New evidence of effective

and cost-effective strategies

OUTPUT 3Stronger capacity for

evidence-based decision-making and rigorous outcome evaluation

OUTPUT 1Enhanced methods and tools for measuring & attributing outcomes

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Output 1: Methods and Tools

•About 30 different tools generated to measure:- Maternal outcomes- Perinatal outcomes- Process - Factors influencing health systems- Outcomes after pregnancy- Economic outcomes- Policy making process- Functionality of health centres

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OP1: Methods and Tools, focus on

Measuring Maternal Mortality

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Guiding principles for maternal mortality work programme

1. Promote multiple measurement approaches (to increase the armoury of tools)

2. Increase efficiency of data capture (to address in-country capacity constraints & large

sample sizes needed)

3. Improve reliability of data (to promote awareness that quality matters)

4. Focus research and development effort (to build on promising existing tools & innovate)

© Immpact

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Work programme innovations in phase I

POPULATION BASED ESTIMATES

INSTITUTIONAL ESTIMATES

CAUSE OF DEATH

CAPACITY STRENGTHENING

1. Sampling at service sites (SSS-health facilities; SSS-markets)

2.MADE-IN/MADE-FOR

Rapid Ascertainment Process for Institutional Deaths (RAPID)

Barriers and facilitators to reporting facility and community deaths

Computer algorithm for causes (InterVAM)

E.g. CALpackages

Census workshop

Secondary research:

Familial Technique;

Profiles;

Meta-analytic methods

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Innovation in sampling, hence called

Sampling at Service Sites (SSS)

© Immpact

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Exploring alternative sampling sites – Burkina Faso

“Sampling at shopping sites”- market places

Proof of principle trial of SSS-M compared to household survey

Market survey was quicker and also cheaper (3US$ compared to 11US$)

© Immpact© Immpact

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Results from SSS-M compared to alternatives

MM ratio(per 100,00 live birth)

% maternal deaths among all deaths to women of reproductive age

SSS-M (Ouargaye; 2003/04) 397(254 - 540)

26.9%

Immpact census: deaths in household (Ouargaye; 2003/04)

400(343 – 457)

26.4%

Immpact census: direct sisterhood method(Ouargaye part; 2003/04)

332(246 - 418)

18.0%

DHS (National; 1999)

WHO/UNICEF/UNFPA (National, modelled; 2000)

484

1000(630 -1500)

22%

37%

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Work programme innovations in phase I

POPULATION BASED ESTIMATES

INSTITUTIONAL ESTIMATES

CAUSE OF DEATH

CAPACITY STRENGTHENING

1. Sampling at service sites (SSS-health facilities, SSS-markets);

Rapid Ascertainment Process for Institutional Deaths (RAPID)

Barriers and facilitators to reporting facility and community deaths

Computer algorithm for causes (InterVAM)

E.g. CALpackages

Census workshop

Secondary research:

Profiles;

Meta-analytic methods

2. MADE-IN/ MADE-FOR

Familial Technique;

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What is MADE-IN/MADE-FOR?

Maternal Death from Informant (MADE-IN)

Village-based informants identify maternal deaths among women of reproductive age

Maternal Death Follow On Review (MADE-FOR)

Follow-up interviews with families confirm cause of death

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Familial technique

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Work programme innovations in phase I

POPULATION BASED ESTIMATES

INSTITUTIONAL ESTIMATES

CAUSE OF DEATH

CAPACITY STRENGTHENING

1. Sampling at service sites (SSS-health facilities, SSS-markets);

2. MADE-IN/ MADE-FOR

Rapid Ascertainment Process for Institutional Deaths (RAPID)

Barriers and facilitators to reporting facility and community deaths

Computer algorithm for causes (InterVAM)

E.g. CALpackages

Census workshop

Secondary research:

Familial Technique;

Profiles;

Meta-analytic methods

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Computer algorithm for causes (InterVAM)

InterVAMa model for determining pregnancy-related causes of death from verbal autopsies

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Evaluation questions in Ghana, Indonesia and Burkina

OP2: New evidence on strategies

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Ghana: Delivery Fee Exemption policy

• 2003: pilot trial in four regions

• 2005: extension to the whole country in public, private-for profit and private not for profit sectors

• Results:- 11% increase of skilled care utilisation- Better access of poor women

• ButBut: erratic funding is a threat to sustainability and credibility of the policy

• Other barriers still remain i.e. geographic, transportation and cultural

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Quality of care before and after the introduction of the free delivery policy (average score in 2003 and 2005)

Before fee exemptions After fee exemptions

Maximum score: 44

Ghana

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• Reduction of geographic barriers:

- By 1996: 54.000 village midwives posted in each village

- Immpact 2005: • Urban area well covered• Only 29% of villages covered• Where there is a village

midwife, this halves MMR

Indonesia: Village midwifes

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Village midwifes efficacious, but…

• Identify on time obstetric complications

• Facilitate the decision to refer early

• Help the family to organise the transfer

• But knowledge, skills and quality of care still insufficient

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0,0%

2,0%

4,0%

6,0%

8,0%

10,0%

12,0%

14,0%

richest poorest Rural area

C-s

ect

ion

s ra

te

1997 2003

Indonesia: contrasted improvement

Better strategy can be to combine reduction of

geographic and financial barriers to

skilled care

C-Sections

Accouchements professionnels

0%

20%

40%

60%

80%

100%

richest poorestRural area

Pro

po

rtio

n

Of

del

ive

ries

wit

h h

ealt

h

pro

fess

ion

als

1997 2003

Institutional deliveries

Caesarean sections

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Trends of institutional deliveries

Year

% o

f In

stitu

tio

na

l B

irth

s

2001 2002 2003 2004 2005

01

02

03

04

05

06

07

0

DiapagaOuargaye FCIOuargaye non FCI

30%

Burkina: Community mobilisation

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Access to life saving interventionsCaesarean rates per 100 births in the two

districts under study

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OP2: Summary findings

Ghana• Removing financial barriers increased institutional

deliveries but financing must be sustained• Accompanying measures required

Indonesia• Addressing geographic barriers increased skilled

attendance at delivery• Financial barriers remain

Burkina Faso• Community mobilisation increased institutional deliveries• Geographic and financial barriers remain for hospital

care In all settings, quality of care is an issue

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OP3: Capacity strengthening

• Involvement of country technical partners has improved national research capacities

• Key policymakers and stakeholders must be involved in setting health and research priorities and translating results

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Capacity-Strengthening Challenges

• Balancing international research and national interests

• Managing the tension between the need for fast results and the need to establish new competencies.

• Balancing short-term need of research with long-term need of partner institutions for sustainability

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Conclusion

• Direct causes of maternal deaths are avoidable provided there is a functioning health care system and a comprehensive approach of maternal health

• Main challenge is the human resources: competent, available in an appropriate working environment

• This health care system depends on the societal development

- Pressure to get quality care- Functioning logistics- Women’s empowerment- Equity

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