Global Strategies on Maternal Health

Tulsi Ram Bhandari Ph D Scholar, AMC, SCTIMST

Thought & Action for Change

Outline of Presentation • Objective• Literature search• Introduction• Why strategies?• Historical Glimpse• Strategy Players…• Discussion & Lesson Learnt• Remaining Issues• Conclusion• Future Actions

“Every day we hear about the dangers of cancer, heart disease and AIDS. But how many of us realize that, in much of the world, the act of giving life to a child is still the biggest killer of women of child-bearing age?”

– Liya Kebede

Objective of the Seminar:

Review global strategies on maternal health.

Literature Search• Online Search by using Key words: – Global strategy on maternal health,– Global/International health conventions on maternal

health and reproductive health, – Global/International conventions/declarations on

women’s health and right.Web search: PubMed, Medline, who.int, Google Scholar.

• Grey-literature and desk review: For published and unpublished materials

• For referencing: Zotero Standalone

5

StrategyIntroduction:–A plan of action

designed to achieve a vision or putting a plan into operation in a skilful way.

– Derived from the Greek "στρατηγία" (strategia); which means command or general-ship [1]

Strategy [cont]

• Definition:–Defined as "…the direction and scope over

the long-term: which achieves advantage through its configuration of resources within a challenging environment, to meet the needs and to fulfil expectations". [2]

– In gist: an approach that has to be followed to achieve a goal.

Why Need Global Strategy?• More than 7 million pregnancy- related deaths:

mothers, newborns and stillbirths occur annually;

• 99% deaths occur in developing countries,

• Out of the total deaths 75% can be prevented-by access of SBA care and EmOC,

• Deaths are more common in rural, illiterate, poor and remote communities,

• Reduce maternal deaths and achieve MDG 5 by 2015.[6-7]

Causes of Maternal Deaths- [5]

Direct Causes – 80%

Haemorrhage - 24%, Obstructed labour- 8%,

Eclampsia -12%, Sepsis - 5% ,

Unsafe abortion -13%, Other direct causes – 8%(ectopic pregnancy, embolism and anaesthesia-related causes)

Indirect causes - 20%.(E.g. Anaemia, TB, Malaria, HIV/AIDS etc )

Causes [cont…][5]

Timing of Maternal Death

• Antenatal: 24%

• Intra-natal: 15%

• Postnatal: 61% (most occur within 24 hours of delivery)

Courtesy: Kirti Iyengar, 2005

Historical Glimpse

Before 1948-

–There was lack of global and regional strategies for health including maternal health.

–After establishment of United Nations, there was felt and generated global effort for health.

–WHO was established in 1948.

Universal Declaration of Human Rights, 1948• Article -25

1. Everybody has health and well-being right…

2. Motherhood and childhood are entitled to special care and assistance…[5]

First time, maternal mortality estimates by WHO- 1984 [ 11]

–WHO first time released maternal mortality estimates. During this time, the main strategies for reduction of maternal mortality were-• Trained TBAs,• Identified high risk pregnancy.

The First International Safe Motherhood Conference, Nairobi-1987 [13]

–Defined and developed the concept of “safe motherhood”

–Launched safe motherhood initiatives with aim to reduce the burden of maternal death and ill-health in low income countries.

Safe Motherhood Strategies mainly consisted of-–Family planning and access to other

reproductive health services including safe abortion;–Skilled care during pregnancy and delivery, –Emergency Obstetric Care, and –Postnatal Care. [5]

The “Four Pillars” of Safe Motherhood Program [5]

1st 2nd 3rd 4th

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Three Delays in Maternal Care [6]

1st delay: Delay in decision to seek care– Failure to recognise complications– Acceptance of maternal death– Low status of women– Socio-cultural barriers, etc

2nd delay: Delay in reaching care– Poor roads, mountains,

islands, rivers, etc3rd delay: Delay in receiving care– Inadequate facilities, supplies and personnel– Poor training and de-motivation of personnel– Lack of financial resources, etc

Source: Family Care International

International Conference on Population and Development-1994 [14]

Highlighted points of Maternal Health-• Reduce maternal mortality, … • Ensure universal access to RHC-FP, • Assisted childbirth, • Prevention of STIs including HIV/AIDS

Note: Maternal health should be seen with in the Sexual and Reproductive Health issues.

The 10th Anniversary Meeting of Safe Motherhood Initiatives in Sri Lanka-1997 [16]

Three core action messages were developed, for shaping the future work:1. Shift from “High Risk Approach” to “Every Pregnancy

Faces Risks”;2. Shift from TBA to “Ensure skilled attendants at delivery”;3. Improve quality and access of maternal care; EmOC is

the utmost importance .

Before pregnancy: emphasis on empowerment of women and strengthening of sexual and reproductive health.

ICPD+5—1999

Prioritised Safe Abortion within Programs of Maternal Health-

Reproductive health care and unmet need for contraception including safe abortion for maternal mortality reduction[17]

The WHO, UNICEF, UNFPA and World Bank Joint Statement on the Reduction of Maternal Mortality, 1999 [18]

–Recommend to reduce Maternal and Child Health problems/mortality by-1. A societal commitment to ensuring safe

pregnancy and birth.2. Improve access to the quality health care.3. A commitment to the special needs of girls

and women throughout their lives.

Millennium Development Goals (MDGs)-2000 [21]

Goal 5: Improve maternal health• Target:

reduce the maternal mortality ratio by three-quarters between 1990 and 2015, • Indicators: –Maternal mortality ratio–Proportion of birth attended by skilled

health personnel

“Working with Individuals, Families and Communities to Improve Maternal Health 2010”[29]

–Published, Department of Making Pregnancy Safer: WHO,– Edited by Carlo Santarelli - consultant,

Making Pregnancy Safer focuses on –1)Advocacy, 2) Technical support to countries, 3) Partnership building, 4) Norms, standards

and tools development, 5) Research, and6) Monitoring and evaluation of global efforts.

Prioritized Areas For Organizing Interventions- [29]

1. Developing capacities

2. Increasing awareness

3. Strengthening linkages

4. Improving quality

Making Pregnancy Safer-

Interventions in the Priority Areas [29]

1. Developing Capacities-

–Self-care (nutrition, rest, plan for delivery, hygiene …)

–Care-seeking

–Birth and emergency preparedness...

2. Increasing Awareness-

–Human and reproductive rights

–The role of men and other influentials

–Community epidemiological surveillance and maternal-perinatal death audits

(needs, diseases and deaths) ...

Interventions… [cont]

3. Strengthening Linkages-

–Community financing and transport schemes to reduce second delay–Maternity waiting homes for hard-to-reach

areas to reduce second delay–Roles of TBAs within the health system • Improve hygiene during delivery• Recognize complications & refer• Provide emotional support to mother ...

Interventions… [cont]

4. Improving Quality

–Community involvement in the quality of care

–Social support during childbirth

–Inter-personal & inter-cultural competency of health care providers

Interventions… [cont]

–To promote universal access to safe, legal abortion,

–To support women's autonomy to make their own decision.

International Campaign for Women's Right to Safe Abortion, May- 2012, Belgium [30]

Global Players: Maternal Health Strategy-• Crucial:

WHO, UNICEF, UNFPA, UNAIDS and World Bank• Others:

UNDP, IPPF (International Planned Parenthood Federation),Population Council, DFID, FCI, Dutch Ministry of Foreign Affairs, Norwegian Agency for Development Corporation, The Partnership For Maternal, Newborn and Child Health … [13 and 18]

DiscussionContent and quality of care?

• In spite of all the efforts being put on maternal health, still, it seems that the quality of maternity care in poor-resource settings is often very low.

• Essential interventions are not carried out in a timely and there are many problems with referrals onwards…

Vignette of 3rd delay

Discussion cont…

• For the improvement of maternal and reproductive health outcomes, there is need to focus and take account the macroeconomic environment efforts in national as well as international level by government and non-governmental agencies. [35]

• Need to address cross-cutting issues for the succeeding of strategies. [38]

• According to Marge-2012, In the poorest countries, women may have more pressing health needs even than for maternity care-– access to any affordable health care, – Education, – Enough food to eat, – Employment, – Sanitation and potable water, …

Discussion cont…

• Lesson Learnt from: Sweden, Sri-Lanka , Malaysia, … [38, 40]

For addressing the maternal health challenges and issues there should strategically address cross-cutting issues, like -• Education, •Gender empowerment/ independence, • Political commitment/willingness•Women’s rights

Maternal Care Model in Sri Lanka

Source: Repot of High Level Consultant Meeting on MDG 4&5 , India 2008 Source: Repot of High Level Consultant Meeting on MDG 4&5 , India 2008

Public health Midwife with client

When should strategies focus?Conception Pregnancy

Delivery

InfancyPreschool Age

Adolescence

Under-5 Clinic Services

School Age

Post Partum

AntenatalClinic

MaternityCare

School HealthServices

Source: Based on New Model of ANC, WHO Source: Based on New Model of ANC, WHO

Maternal Health Strategies: Paradigm Shift

Identification of high risk pregnancy by trained TBAs

Every pregnancy faces risk and SBA care

Cross- cutting issues

Social determinants of healthSocial determinants of health

1980sEarly1990s

Late 1990s

2000

Identification of high risk pregnancy by trained TBAs

1980s

Remaining Challenges and Issues

• MDG -5 is further off-track than any of the other MDGs. Only 12 out of the 68 identified countries seem on track. [38]

• Increase political commitment and willingness among the under developing countries.

• Raising inter- sectoral co-ordination to address the cross-cutting issues of maternal health. [39]

• Establish up to date databank in low income countries . [40]

• Making agreement between socio-cultural and religious practices with maternal health care.e.g. use of FP services and abortion practices

• Maternal health care of affected and displaced women during conflicts and wars.

• Continuation of financial incentives/support and the involvement of private-sector in maternal health care.

Remaining Issues [cont..]:

Conclusion:

• Inequalities in the risk of maternal death exist everywhere, both between and within countries.

• Single strategy will not be enough to optimize maternal health worldwide.

• Urgently required public health strategy to reduce maternal mortality, particularly in under developing countries.

• International consensus and multi-sectoral efforts are inevitable parts of global maternal health strategy.

• Need to establish data-bank, particularly in developing countries to formulate evidence-based strategies.

Conclusion Cont…

Future Actions• Prevention of unwanted pregnancies by family

planning & safe abortion, • Provision of institution delivery and EmOC,• Antenatal and postnatal quality care: to detect

and treat complications early,

• Investigations into maternal deaths,

• Ensure 24 hour professional care at all levels,

• Strengthen financing schemes including case transfer initiatives by inter-sectoral involvement.

Acknowledgement

• Writers, editors and publishers of the reviewed literature & Kirti Iyengar,

• Doctorial Advisory Committee (DAC) Members for their consistent guidance from the inception of this presentation.

Thank You.

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