7/01. source: who/unicef/unfpa estimates of maternal mortality in 1995, who 2001. number of maternal...

Organizing Delivery Care for a Safer Motherhood

Marge Koblinsky Director, NGO Networks for HealthNovember 5, 2001

Lessons Learned

Source: WHO/UNICEF/UNFPA estimates of Maternal Mortality in 1995, WHO 2001.Number of maternal deaths in 1995:world estimate (515,000)N=515,000

Chart5

0.5

0.42

0.04

0.01

Chart4

0.5

0.42

0.04

0.01

Sheet1

Africa (273,000)50%

Asia (217,000)42%

Latin America and Caribbean (22,000)4%

More Developed Countries (2,800)1%

Sheet1

0

0

0

0

Sheet2

Sheet3

Proportion of Maternal DeathsBy Direct CauseSource: WHO wall chart Maternal Health Around the World WHO, Geneva, 1997.N=515,000

Chart6

0.34

0.21

0.18

0.16

0.11

Sheet1

Hemorrhage34%

Infections21%

Abortions18%

Eclampsia16%

Obstructed Labor11%

Sheet2

Sheet3

PREGNANCY

DELIVERY

POST NATAL

PRE- PREGNANCY

0

22 Weeks

BIRTH

7 Days

28 Days

42 Days

Timing of Maternal and Perinatal Mortality

* Dashed line indicates that there are no data available to delineate exactly when these deaths occur.

Perinatal Death

3-14 Days if Tetanus

Maternal Death

What Can be Done to Improve Maternal/Perinatal Health and Survival?Antenatal CareIntrapartum CarePostpartum/ Newborn CarePreconception CareNutritionInfection ControlFamily PlanningNutritionInfection ControlDanger SignsIdentify/Manage ProblemsSafe Delivery EOCEmOCNutritionInfection ControlFamily PlanningIdentify/Manage ProblemsPREGNANCYDELIVERYPOST NATALPRE- PREGNANCY022 WeeksBIRTH7 Days28 Days42 Days

Essential Obstetric Care (EOC), Basic(BEOC) and Emergency Care (EmOC)

EOC (also Comprehensive EOC)

Comprehensive EOC

Basic EOC

EMOC

Surgical obstetrics

X

X

Anesthesia

X

X

Blood replacement

X

X

Management of problem pregnancies

X

X

Medical Treatment

X

X

X

Manual procedures

X

X

X

Monitoring of labor

X

X

Neonatal special care

X

X

Successful Models of Safe Motherhood:Features of Service Delivery Configurations

Who Delivers

-----------------Where Delivers---------------

Home

Limited EOC Facility

Full EOC Facility

Non-professional

Model 1:

Home deliveries by community member trained briefly

transport

referral support

Professional

Model 2:

Home deliveries by professional;

Transport

referral support

Model 3:

Professional provision of Basic EOC

Transport

referral support

Model 4:

Professional provision of Basic and Comprehensive EOC

MODEL 1: Rural China:MMR 115 (1995)MODEL 2: Malaysia: MMR 50 (1970s)MODEL 3: Malaysia: MMR 43 (1980-90s)MODEL 4: US: MMR 12; Mexico City: MMR 114 (1988)

Program/project Examples and MMR

Who Delivers

-----------------Where Delivers----------------

Home

Limited EOC Facility

Full EOC Facility

Non-professional

Model 1:

China (rural)(115)

Fortaleza, NE Brazil (120)

Professional

Model 2:

Malaysia (1970s-early 1980s) (39)

The Netherlands (1955-1970)(70-12)

Model 3:

Malaysia (mid-1980s)(47)

Sri Lanka (30)

Model 4:

Sweden

United Kingdom (9)

United States (12)

Mexico City (114)

Causes of Direct Obstetric Maternal DeathsMexico City, 1988-1989MMR=114Source: Bobadilla, et al, 1996

Preventable Maternal Deaths by Responsible Factor and Health Institutions (%) Mexico City, 1988-1989Source: Bobadilla, et al, 1996

Institution

(n=deaths)

Responsible Factor

Physician

Hospital

Patient

PA1 (68)

93

16

37

PA2 (33)

82

33

38

SS1 (79)

80

8

10

SS2 (25)

68

16

12

Total (205)

83

16

22

Types of Physician Errors in Preventable DeathsMexico City, 1988-1989Source: Bobadilla, et al, 1996

Type of error

Percent

Wrong therapy

Error of surgical judgement

Error of diagnosis

Belated treatment

Error in administration of anesthesia

Poor prenatal care

Other

31

24

19

5

5

3

18

Total

100

Push and Pull of Maternity CareMidwife1Model----------------------------

Lessons Learned: Quality of Safe Motherhood Care and Maternal MortalityReducing maternal mortality takes timeMany changes are involved, including quality of servicesSocioeconomic inputs have been underestimatedNo evidence that model 1 can result in MMR

MotherCare FrameworkReduced Maternal & Perinatal MortalityImproved knowledge & decision-making in communityIncreased % of pregnant women receiving skilled care during antenatal, delivery and postpartum periodsImproved quality of servicesIncreased availability and access to servicesGOAL(IMPACT)STRATEGIES TO REACH OBJECTIVE (PROCESS)OBJECTIVE(OUTCOME)

Strategy: Increased availability and accessIndicators:1 CEOC + 4 BEOC sites/500,000 pop% hospitals with C section+ Blood transfusion% poorest quintile using SBA

Target: Every woman have access to skilled birth attendantContext specific

Provider-oriented interventions to improve Quality of Maternal Care:Clinical skills training

Training in client/provider interaction

Critical self-review or feedback via case review, routine monitoring, criterion-based clinical audit.

Options for Training to improve maternal care:In-service training in specific skills;

Pre-service training in specific skills;

Distance education/ programmed self-instruction.

Common objectives:Increase knowledge of specific subjects;Develop or increase competence for specific skills;

Less frequently stated objectives:Maintenance of skills over time;Routine implementation of newly acquired skillsTraining Objectives:

Frequency Distribution of Correct Answers in Knowledge Test, MotherCare GuatemalaSource: Training Evaluation Report, MotherCare Guatemala, June 1999

Quality of Care Skills Assessment1999Significant P

Absolute (%) Mean Scores in Application of Skills by Training Status, MotherCare GuatemalaSource: Training Evaluation Report, MotherCare Guatemala, June 1999

Lessons Learned Quality of CareBut, some skills remain weak:Guatemala: breech; newborn resuscitation; internal bimanual compression; manual removal of the placenta

Bolivia: partograph; bimanual compression

Lesson:Key skills can be improved via in-service competency-based training

Lessons Learned-Quality of Care

Score for skills began low and were still low post-training:Bolivia:trained 57 -74%; untrained 39-52%Guatemala:trained 41-92%; untrained 25-58%

Participation of doctors remains crucial although they are difficult to involve in trainingDoctors affect others performance (e.g. use of the partograph)Doctors rotate among different services (Guatemala, Bolivia)Separate group of doctors covers night shifts (Guatemala)

Staff turnover is highGuatemala:All staff rotate due to personnel shortageBolivia:Approximately 72% turnover in providersConclusion: In-service training program is not a substitute for two to three year midwifery training program

Strategy: Improved knowledge and decision-makingIndicators of coverage (facility registers)

% women with skilled birth attendant (excludes TBA)

C section rate (pop based)

Met Need: % women with complications being treated at EOC facility

Strategy: Improved knowledge and decision-makingProcess indicators (pop-based):% women/men with knowledge of obstetric danger signs

% women who intend to use skilled birth attendant

Community Strategies: use of skilled birth attendant Constraints and Interventions--MotherCare Guatemala

Baseline Levels of Awareness of Danger SignsSources: MotherCare & PMM Network, 1996-8

Barriers to Improving RecognitionPregnancy is considered a normal event in most countries

Some obstetric complications lack distinguishing characteristics along a continuum between normalcy and emergency that triggers alarm, and

Beliefs associated with major obstetric complications in different settings affect the interpretation of their severity and the decisions to respond appropriately

Questions to Measure Knowledge of Danger SignsCan you tell me what kind of problems can happen to a woman during labor and during the birth?Unprompted responses

Have you also heard of these things happening?Prompted responses

Possible AnswersWaters break too earlyBleeds a lot during birth after baby bornShe has a feverTakes too long before she can push the baby outShe faintsShe has fits or convulsionsThe afterbirth (placenta) does not come outBaby dies before coming outOther (specify)

Improving Pregnant Womens Knowledge of Danger Signs through Counseling at Health Centers & Posts, MotherCare GuatemalaSource: Patsy Bailey (FHI), 2001

Coverage: Guatemala, Bolivia, Indonesia 1995-1999Guatemala

Met Need:Guatemala & BoliviaGuatemalaBolivia

Conclusions: Use of Skilled Birth Attendant and Met NeedThe pattern of birthing is slow to change when use is low. Structural efforts seem to increase use of skilled birth attendants and met need more than communications efforts (but this could be dependent on base levels).From the Guatemalan experience, building a referral system with TBAs does not appear as useful as communicating danger signs and where to go directly to women.However, there is the suggestion that trained TBAs can be more selective in whom they refer.

CHINA

MODEL 1 MODEL 3 & 4

Maternal-related statistics, Tonghai and Huaning, Yunnan, China 1999

-1990

1999-2000

Yunnan (GDP $536, 1999)

MMR

149 (1989)

101 (1999)

TFR

2.47 (1990)

2.20 (2000)

Tonghai (GDP= $700, 1999)

MMR

52

TFR

2.29 (1990)

2.10 (2000)

Huaning (GDP= $272, 1999)

MMR

84

TFR

2.40 (1990)

2.16 (2000)

Hospital Delivery Rate in Huaning and Tonghai Counties, Yunnan, ChinaSource: County MCH Station, MIS, Tonghai and Huaning County, 1990-1999

1

69.3749.28

66.5250.72

73.0356.67

78.360.78

80.750.61

85.1557.81

86.357.7

89.358.71

92.4959.95

92.4561.54

Tonghai

Huaning

Year

HDR(%)

Sheet1

%%%

1980

1981

1982

1983

1984

198555.0160.0

198660.5863.0

198766.7368.0

198866.7470.0

198967.6972.0

1990

199177.421865151100.0100.00100.098.045.944.9498.3996.002.983.04

199284.0114018479100.094.05100.091.146.124.9099.6484.813.093.00

199384.0812735756100.098.24100.0100.006.335.20100.00100.003.172.90

199486.2812106464100.0100.00100.0100.006.295.6099.8395.313.153.03

199593.57980277277100.0100.00100.099.286.435.34100.0098.923.213.05

199695.72957402402100.0100.00100.0100.006.705.20100.00100.003.203.10

199797.931159458453100.098.91100.0100.006.785.49100.00100.003.103.11

199898.671055373373100.0100.00100.0100.007.024.95100.00100.003.123.12

199997.43661304304100.0100.00100.0100.006.965.85100.00100.003.953.47

2000301300100.0099.676.3199.673.12

Sheet2

/

1973179116231332046

19741822892325037.0114.641093

1975185042240351237

197618829423571

197719163923563

197819449623604

197919659124675

198019873225459

198120200323406

198220523525478

1983207642288973538

1984210834299731888471.9186.25

1985213875331892099072.2772.34290

1986216998326742232575.7575.84436

1987221068353472300078.8675.072798

1988225850351612482987.4287.45637

1989229776179433396393137885.2183.15889

1990233385181434424202840279.479.416251

1991237079183268432782960580.980.985313

199224078118421344455306388282.005381

1993244503185477457233175486.3786.405024

1994247437186851475033376486.2786.2749023841580.87

1995250254188286489263415187.1887.181480

1996252866189746508813618288.1788.17321169531775

1997255630191150525713773687.6187.61159374432954

1998258451192554529493824985.5388.5886252033038

1999260617194897537573888986.3688.2253545933629351684.08

20003887087.12

-

Sheet2

014.64

086.25

077.9

083.98

075.07

077.78

080.18

081

085.01

083.48

086.47

087.44

088.37

087.82

087.33

086.38

086.5

Tonghai

Huaning

Year

CCR(%)

Sheet3

198069.9031.85

198151.7932.83

198274.9547.29

198381.0975.05

1984100.00100.004.182.8386.2139.10

1985100.005.11100.004.604.203.022.902.9487.9039.325.20

1986100.005.67100.005.564.222.992.983.0092.1344.875.58

1987100.0015.3899.1814.435.183.203.422.6496.7045.6117.42

1988100.0035.9397.2729.875.403.233.082.5897.6847.9036.03

1989100.0049.9199.4347.915.364.093.002.7296.9650.0062.07

199054.1152.314.532.5899.1197.7269.3749.2877.2754.1177.2756.74

1991100.0053.5398.3252.375.584.552.912.8999.0874.9666.5250.7282.4358.4482.4354.89

199283.5360.7288.7659.5884.7899.1573.0356.6788.5372.7375.7660.72

199391.8774.2292.3573.5989.2380.3378.3060.7891.8774.4977.9074.22

199492.4472.9792.7071.8792.6680.3780.7050.6192.4473.2779.3372.97

199593.3777.0992.9376.4094.9179.8885.1557.8193.3777.0935.6779.12

199695.6581.3795.4280.9995.8986.2486.3057.795.6580.8653.465.53

199796.2382.5596.2782.3597.2887.6989.3058.7196.2382.1665.7420.31

199896.1981.0796.1981.0398.7590.0692.4959.9596.1980.3170.7524.50

199996.2087.0396.2087.0397.8399.7492.4561.5496.5387.3672.9732.99

200087.2487.0093.1368.4587.2454.29

Sheet3

00

00

00

00

00

00

00

00

00

Tonghai

Huaning

Year

New Method Delivery Rate%

Sheet4

00

00

00

00

00

00

00

00

00

Tonghai

Huaning

Year

HDR(%)

Figure Hospital Delivery Rate in Huaning and Tonghai Counties

00

00

00

00

00

00

00

00

00

%

00

00

00

00

00

00

00

00

00

00

%

00

00

00

00

00

00

00

00

00

00

TonghaiCounty

Huaning County

Year

SMR(%)

Figure Systemic Management Rate in Tonghai and Huaning County, 1990-1999

00

00

00

00

00

00

00

00

00

00

Tonghai

Huaning

Year

HDR(%)

Figure Hospital Delivery Rate in Huaning and Tonghai Counties

1973

1974

1975

1976

1983

1985

1986

1987

1988

19896364721931697581412113915906739272539764

19907034826102792521560125716538086260033295

1991713090010445101291605139511507797272743278

1992738294510550105171720142211637906285044455

1993763299010835105361777148612098284297445723

1994780698611433107431853157613168549375448016

19958127102211742109461927161214248745338148926

19968509108312167113151967161215279150350150831

19978674112912472117572016166716229631360352571

19988864115112630117672035169417229692324152796

19999074112512654119542111172815439826374353758

2000

Policy Guides the Way, China MMRto be halved by 2000 Promotes increased coverage for maternal and child health Increasing hospital delivery for rural women Health education for at least 85% of pregnant women Use of modern delivery method for 95% of births with village doctor (clean perineal area, clean hands, clean cord care)

Policy Guides the Way, China RegulationsNational and provincial Established responsibilities of the MCH institutes Quality of care standards Equipment necessary for family delivery Personnel allowance Medical aid to the poor

China: MCH Network

Three-tiered maternal and child health care network in rural China

: Administrative relationship; : Professional relationship

County Health Bureau

County

MCH Station

Specialist

County

Hospital

Specialist

Township/Town Health Center,

Doctors

Village Clinic

Village doctors

Health Care Infrastructure, Tonghai and Huaning, Yunnan, China 1999

Tonghai

Huaning

Health Care infrastructure

#

Per pop

Pop= 260,000

#

Per pop

Pop= 195,000

County Hospitals

2

130,000

2

97,500

THC

8*

32,500

5

39,000

Village VC

44

5,909

76

2,566

Village Doctor

153

1,699

207

942

TBAs

42

6190

115

1726

*T: 4 of 8 THCs- comprehensive hospitals

H: 2 of 5 THCs- comprehensive hospitals

Accountability for performance, Tonghai and Huaning, Yunnan, ChinaAccountability Contracts based on indicators of performance (preventive/curative)Systematic Management Rate (SMR)% systematic management pregnant women (SMPW) = 5 ANC, 3 PNC, 3 cleans + booklet to women% hospital deliverydecreased MMR

Scores related to employment, promotion, subsidies

Ensuring financial accessibility, Yunnan, ChinaMCH Prepay Scheme (at marriage registration)

Prepay for 5 ANC + 3 PNC + child health exams (complication coverage) Fee = 1 visit if not on scheme

Medicaid for Poor and High-Risk Pregnant Women Experimental stageinsurance for delivery (Delivery: $30 THC, $72 County MCH station, $124 County hospital)

Yunnan, China: Summary- MMR

How to transition to Model 2 and 3Develop strong policyMMR makes a difference! Bolivia, China, Egypt, Honduras, Indonesia, JamaicaIncrease availabilityCEOC facility 1/100,000 ChinaBEOC facility 1/30,000 China, Indonesia, ZimbabweSkilled birth attendant 1/1000 -1500 Indonesia, ZimbabweWell-connected front-line provider 1/1000-1500 ChinaMaternity waiting home 1/50,000 Zimbabwe, Honduras Increase financial accessibility Bolivia, China

How to transition to Model 2 and 3

Ensure referralUse risk approach based on clinical signs/symptoms China, Honduras, Indonesia, JamaicaLink levels of care through supervision ChinaPromote accountability ChinaTarget resources to needy areasBirthing centers, maternity waiting centers Honduras

MODEL 1 MODEL 2

INDONESIA

Assistance During Delivery, Indonesia 1991-1997Source: DHS 1991, 1994, 1997

Chart5

4.930.959.64.4

6.734.854.43.7

7.443.846.12.7

Doctor

Trained nurse/midwife or other health professional

Birth Attendant

Relative or other

Year

percentage

Chart7

2178.5

18.281.6

21.678.4

Health Facility

At home

Year

percentage

Place of Delivery, Indonesia 1991-1997

Chart9

2.25.26.1

0.91.93.5

1.22.84.2

1991

1994

1997

percentage

Characteristics of Delivery, Indonesia: Caesarian Sections 1991-1997

Sheet1

Health FacilityAt home

19912178.5

199418.281.6

199721.678.4

DoctorTrained nurse/midwife or other health professionalBirth AttendantRelative or other

19914.930.959.64.4

19946.734.854.43.7

19977.443.846.12.7

199119941997

Doctor4.96.77.4

Trained nurse/midwife/other health professional30.934.843.8

Birth Attendant59.654.446.1

Relative or other4.43.72.7

Urban: Delivery by caesarian sectionRural: Delivery by caesarian sectionTotal deliveries by caesarian section

19912.20.91.2

19945.21.92.8

19976.13.54.2

Sheet2

Sheet3


Chart5

4.930.959.64.4

6.734.854.43.7

7.443.846.12.7

Doctor


Birth Attendant

Relative or other

Year

percentage

Assistance During Delivery, Indonesia 1991-1997

Chart7

2178.5

18.281.6

21.678.4

Health Facility

At home

Year

percentage

Chart9

2.25.26.1

0.91.93.5

1.22.84.2

1991

1994

1997

percentage


Sheet1


19912178.5

199418.281.6

199721.678.4


19914.930.959.64.4

19946.734.854.43.7

19977.443.846.12.7

199119941997

Doctor4.96.77.4





19912.20.91.2

19945.21.92.8

19976.13.54.2

Sheet2

Sheet3


Chart5

4.930.959.64.4

6.734.854.43.7

7.443.846.12.7

Doctor


Birth Attendant

Relative or other

Year

percentage

Assistance During Delivery, Indonesia 1991-1997

Chart7

2178.5

18.281.6

21.678.4

Health Facility

At home

Year

percentage


Chart9

2.25.26.1

0.91.93.5

1.22.84.2

1991

1994

1997

percentage

Sheet1


19912178.5

199418.281.6

199721.678.4


19914.930.959.64.4

19946.734.854.43.7

19977.443.846.12.7

199119941997

Doctor4.96.77.4





19912.20.91.2

19945.21.92.8

19976.13.54.2

Sheet2

Sheet3

Trends in Proportion C-Sections Among All BirthsS. Kalimantan, 1997-99

Chart1

000

000

000

1997

1998

1999

A

Monthly admissions

South KalimantanBy district

All districtsBanjar BaruBKHSS

DateAll admissionsAbortionsDeliveriesMajor OCMOI/AMI+eclSectioAdmissionsMajor OCMOI/AMI+eclSectioAdmissionsMajor OCMOI/AMI+eclC-sectionAdmissionsMajor OCMOI/AMI+eclC-section

35400.05507438330341703518913262821341104555

35431.0422772572243142155681113221745564053

35462.040354261197274214871713201433452741

35490.0489703232322847202911124281942522823

35521.0500593522565177213962329138026144913

35551.050262330273517521290111932277114738511

35582.0449563072274452216912028161221503235

35612.0500523312514168220951624231347543649

35643.051062357255436822210417302316346135210

35674.04937730124332532351071623191343713427

35704.04956929726638423661122229461133902612

35735.04747629224126583638581839182212428110

35765.044459290214264016269610181422422944

35796.04626029325736741669114243020699247315

35827.0381442381893459141811423251643433147

35855.0435732622193953150771217221535514016

35886.047648297231356418892162918902544447

35916.0398422572003053135611121181443513937

35947.04696330724739691789013253117324734210

35977.0424682802232960166771024161511353243

36008.0419542802093661189921934201311423333

36039.0379632402144264156771825231734292334

36069.0456872592413142184861014231634543921

36100.043974256211314816973813241645442823

36130.043569139207245216176919271023433201

36161.0407591412023052148691118322145432201

36192.041378149216264415780713301832412904

36220.042482151226305815483725311722231423

36251.0469861602493054191881224241700221501

36281.048467167243275219198112114801473412

36312.06271142243253264204998191913021338148

36342.0616902753154770216106182626173411874710

36373.0528962062782855216101824422621795204

36404.04432313754166811121352476483423

36434.05242643362206951127342042422223

36465.0491249265718696921281424603818

Three-monthly admissions

South KalimantanBy district

All districtsBanjar BaruBKHSS

DateAll admissionsAbortionsDeliveriesMajor OCMOI/AMI+eclAdmissionsMajor OCMOI/AMI+eclSectioAdmissionsMajor OCMOI/AMI+eclSectioAdmissionsMajor OCMOI/AMI+eclSectio

Dec96-Feb97137520590172499154654228315270521012211112149000000000

Mar97-May97149119110057611301996272774572735411151601101627000000000

Jun97-Aug97145917099573312818865829053826241912165103924000000000

Sep97-Nov971462222890750961539643044670104429828588419000000000

Dec97-Feb981287163821660961734692413457735012141771071126000000000

Mar98-May98130916381665010417047323039675838710156123820000000000

Jun98-Aug981312185867679104190533259428367455412499916000000000

Sep98-Nov9812742247556661041545092363652704910131279078000000000

Dec98-Feb99125520642962580148466225275089499101278306

Mar99-May991377235478718871645362693070694223926336

Jun99-Aug99177130070591810718963630634698756573302071122

Sep99-Nov991458007449617355827231699758131215094514

Trends in met need

Major obstetric complications

BanjarBarito KualaHSS

19971099189413

1998966182419

19991072205447

Births1309760635036

1271963345374

1372864675474

19978%3%8%

19988%3%8%

19998%3%8%

Life threatening complications


19971753943

19981513435

19991222919

Births1309760635036

1271963345374

1372864675474

19971.34%0.64%0.85%

19981.19%0.54%0.65%

19990.89%0.45%0.35%

sectio


19972764779

19982594170

19992583248

Births1309760635036

1271963345374

1372864675474

19972.11%0.78%1.57%

19982.04%0.65%1.30%

19991.88%0.49%0.88%

A

5503034170

4222243142

4031972742

4892322847

5002565177

5022735175

4492274452

5002514168

5102554368

4932433253

4952663842

4742412658

4442142640

4622573674

3811893459

4352193953

4762313564

3982003053

4692473969

4242232960

4192093661

3792144264

4562413142

4392113148

4352072452

4072023052

4132162644

4242263058

4692493054

4842432752

6273253264

6163154770

5282782855

4432313754

5242643362

4912492657

All admissions


MOI/AMI (+ eclampsia)

C-sections

Month/Year

Number of admissions

Trends in admissions in 7 hospitalsSouth Kalimantan (Dec 96-Nov 99)

351891326

155681113

14871713

202911124

213962329

212901119

216912028

220951624

2221041730

2351071623

3661122229

36385818

16269610

166911424

141811423

150771217

188921629

135611121

178901325

166771024

189921934

156771825

184861014

16973813

16176919

148691118

15780713

15483725

191881224

191981121

20499819

2161061826

216101824

166811121

206951127

18696921

Deliveries


MOI/AMI (+eclampsia)

C-section

Month/Year


Trends in hospital admissionsBanjar (Dec 96 - Nov 99)

282134

221745

201433

281942

13802

3227711

161221

231347

231634

191343

461133

391822

181422

302069

251643

221535

18902

181443

311732

161511

201311

231734

231634

241645

271023

322145

301832

311722

241700

14801

191302

261734

422621

352476

342042

281424

Deliveries



C-section

Month/Year


Trends in hospital admissionsBarito Kuala (Dec 96 - Nov 99)

1104555

564053

452741

522823

6144913

4738511

503235

543649

6135210

713427

902612

12428110

422944

9247315

433147

514016

544447

513937

4734210

353243

423333

292334

543921

442823

433201

432201

412904

231423

221501

473412

1338148

11874710

795204

483423

422223

603818

Deliveries



C-section

Month/Year


Trends in hospital admissionsHSS (Dec 96 - Nov 99)

137572499

1491761130

1459733128

146275096

128766096

1309650104

1312679104

1274666104

125562580

137771887

1771918107

145874496

All admissions


Life threatening obstetric complications

Three-month period


Figure 5: Trends in admissions in 7 hospitalsSouth Kalimantan (Dec 96 - Nov 99)

22831654

27745627

29053658

30446964

24134469

23039473

25942533

23636509

22527466

26930536

30634636

27231558



All admissions

Three-month period


Figure 6: Trends in admissions in 7 hospitals Banjar (Dec 96 - Nov 99)

000

000

000

000

000

000

000

000

000

000

000

000



All admissions

Three-month period


Figure 7: Trends in admissions in 7 hospitalsBatola (Dec 96 - Nov 99)

000

000

000

000

000

000

000

000

000

000

000

000



All admissions

Three-month period


Figure 8: Trends in admissions in 7 hospitalsHSS (Dec 96 - Nov 99)

74

77

54

70

59

62

56

52

62

77

69

76

59

60

44

73

48

42

63

68

54

63

87

74

69

59

78

82

86

67

114

90

96

Month/Year

Number of abortions

Abortion admissions in 7 hospitalsSouth Kalimantan (Dec 96 - Aug 99)

000

000

000

1997

1998

1999

District

Major obstetric complications in hospital as a proportion of all births

Figure 9: Trends in coverage of obstetric care for major obstetric complications (Dec 1996-Nov 1999)

000

000

000

1997

1998

1999

District

Life threatening obstetric complications in hospital as a % of all births

Figure 10: Trends in coverage of obstetric care for life threatening obstetric complications (Dec 1996-Nov 1999)

000

000

000

1997

1998

1999

District

Caesarean sections as a proportion of all births

Figure 11:Trends in proportion c-sections among all births

Skills Assessment: Village MidwifeIndonesia, 1999

Significant P

Indonesia: Challenges Ahead...Ensure strong policy guidanceto increase coverage --financial options? --partnering with traditional systems --improved communicationsto maintain quality --pre-service competency-based training --partnering with professional associations for continuing education (e.g. IBI, POGI, Perinasia)to increase accountability of professionals, andto ensure normal deliveries remain with BDD, BidansWhat is sustainability of BDD Program?

Cost of Model 2Indonesia: Village midwife training + 1 year service, 1998US$Initial training2000 - 3500Basic salary/year400__________2400-3900X 55,000 midwives=132 - 215 millionSource: Hull et al 1998; P Daly, pers comm.

MODEL 1 MODEL 3 & 4ZIMBABWE

Maternal Mortality Trends, Zimbabwe 1988-1989Sources: Mbizvo 1994; DHS 1994, 1999; Census Data 1992; NHIS 1988-1997

Chart1

77.11988

100.091989

81.53168

91.651991

66.74395

1401993

131.32283

105.421995

169.91996

145.231997

1999695

MMR

Year

MMR

Sheet1

19881989199019911992*19931994**1995199619971999

MMR77.1100.0981.5391.6566.74140131.32105.42169.9145.23

168395283695

Sheet2

Sheet3

Zimbabwe: Birth-related statistics, 1994 and 1999

Ref: DHS, 1994; DHS, 1999

_1057483463.xls

Chart1

69.172.2

68.472.5

66.7

1994

1999

% of births

Sheet1

Facility-based birthSBAC-Section

199469.168.46

199972.272.56.7

Sheet2

Sheet3

_1057483572.xls

Chart1

69.172.2

68.472.5

66.7

1994

1999

% of births

Sheet1


199469.168.46

199972.272.56.7

Sheet2

Sheet3

_1057396722.xls

Chart1

69.172.2

68.472.5

66.7

1994

1999

% of births

Figure 2. Zimbabwe: Birth-related statistics, 1994 and 1999

Sheet1


199469.168.46

199972.272.56.7

Sheet2

Sheet3

Zimbabwe: Impact of AIDS, 1999% Adults (15-49 years)25%% ANC clientsUrban30%31 sentinel sites30%% STD clients72%Source: UNAIDS, 2000

Zambia: Causes of Maternal Death, University Teaching Hospital, 1996-1997Causes%Direct42Indirect58Malaria30AIDS-relatedTuberculosis25Unspecific chronic respiratory infection221982- MMR 1181996-1997- MMR 921Source: Ahmed et al, 1999

Zimbabwe: Successful program elements, 1997Increased hospitals and clinics37% (1980-1997)1 clinic/10,000 popIncreased staffing (1997)1 midwife/1,500 popFP Program (1999)CPR54%Waiting Mothers Shelters1/50,000 popMaternal audits - district, provincial, national levelsTBA training - practical training with local midwifeSource: Feresu S. et al, 2000

Zimbabwe: Summary- MMR

- Indirect causes, especially AIDS, suspected.

- Maternity care alone is not the answer in such circumstances.

Here, you can see the baseline levels of awareness of danger signs in four countries.If you look at the green bars, you will notice that less than 30 percent of women in Bolivia, Indonesia, and Pakistan spontaneously mentioned danger signs of ante- and post-partum hemorrhage. In addition, in the same countries, the pattern of orange bars demonstrates that less than 5% of women spontaneously mentioned convulsions.High levels of awareness can be deceptive, as can be seen by the blue bar for sepsis in Bolivia and the green bar for hemorrhage in Nigeria. Even though awareness of the severity of sobreparto, a locally defined condition similar to puerperal sepsis is high in Bolivia, the cultural interpretation of its etiology makes women and families turn to the traditional system. Awareness of awareness of hemorrhage was also high in Nigeria, but cultural beliefs influenced the actions of families that turned to the traditional system for care.

You may ask . . .why is it challenging when we have been providing information to communities on danger signs for quite some time now. It is not as simple as that because:Pregnancy is considered a normal event in most countriesSome obstetric complications lack distinguishing characteristics along a continuum between normalcy and emergency that triggers alarm, andBeliefs associated with major obstetric complications in different settings affect the interpretation of their severity and the decisions to respond appropriately.

Therefore, recognizing of major obstetric complications at the time of occurrence does not easily translate into being aware of medically defined danger signs. Compounding this is the fact that complications are rare events, and messages facilitating diagnosis and action need to be retained and recalled.

7/01. source: who/unicef/unfpa estimates of maternal mortality in 1995, who 2001. number of maternal...

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