Between 1990 and 2010, the maternal mortality ratio declined by nearly half—from 543,000 deaths to 287,000 deaths. While the first decade saw a rate of decline of approx 3.1% per year, the 2000-2010 decade rate increased to over 4% globally. But to reach a MMR of 50 by 2035—the upper limit of the MMR among OECD countries—the the ann rate of reduction worldwide must increase to 5.6%
Given the variation in rates of decline in the reduction of preventable Mat mort by region to achieve any aggressive but plausible target set for the future, the question is just how do we achieve such a target. The draft strategies we have laid out follows the format of A Promise Renewed—as eventually we would like to see the maternal, newborn, child strategies better linked to ensure a continuum of care. -- Geog focus--…-- High burden pop speaks to ensuring that the vulnerable receive quality respectful care for both mothers/newborn—that barriers to access (such as cost, transport, cultural factors) are addressed and interventions are implemented at scale. -- High impact Care is provided based on the local causes of maternal and newborn death—and it starts with 1. family planning to ensure all women have a voluntary intended birth, That quality respectful intrapartum and immediate post natal care is available with effective referralThat prevention and treatment is available throughout the maternity period to address not only the ob complications (hem, PeE, sepsis, unsafe abortion and ob/prolonged labor) but also for co-infections, and poor nutrition. To do this policies and programs need to build on and strengthen if needed the various initiatives or situations that health systems find themselves in recently—financing initiatives (CCT, vouchers, fee exemptions, national or social insurance programs) , decentralization, privatization—and in Arusha we heard that nearly half of people in developing countries now live in urban areas
A supportive enviroment is needed for both immediate an sustainabile resultsMutual accountability-- Needs to build on global and national commitments already publicly made as well as subnational efforts to set goals, fund programs and closely monitor progress with involvement of communities.
Geographic focus: over half of all maternal deaths take place in just 8 countries –with 3 in Asia and 4 in SSA—with nearly equivalent numbers of maternal deaths-between 78-83,000 deaths/year. For USAID, the major focus is on 24 countries ( x in SSA, y Asia) that contribute to nearly 75% of the deaths annually.
High burden population: While there have been increases in use of facility births and births with a skilled attendant over the decade between 1998-2008 in both SSA and Asian countries, the use of maternal health services –whether it be ANC 4 or use of a SBA for birth—shows the widest gap in equity as measured by the quintiles 1 and 5. The poor continue to use fewer services than the richest quintile by nearly a factor of 2??? Ck.When we look at maternal death, we know from national studies in both Ghana and Bangladesh and several smaller studies , that those women with higher education are far less likely to die than their counterparts without education. Empowering women with cash or with education is likely to contribute to improved use of services as well as reduce mortality.
2. High impact interventions: the direct causes of maternal death are well-known and have been for the 2 decades of the SMI. We often think there has been little progress in addressing them–but in effect there has been progress—in determining what works and in implementing such. Perhaps the biggest advance has been to address the major obstetric killer, postpartum hemorrhage. AMTSL using oxytocin has been widely accepted and recent research has led to the potential of a simplified regimen and guidelines have been promulgated to this effect (true?),; , the interest and excitement caused by misoprostol has led to… Even so, hemorrhage remains the largest contributor to maternal death.What has become increasingly obvious over the last decade is the escalating impact of co-infections on maternal health. The numbers of deaths due to these indirect causes of maternal death (HIV/AIDS, malaria, TB) has increased –but there are few data we can rely on…. Nutrition—specifically anemia—has continued to be recognized as a ….
Malaria is also implicated in maternal deaths. And even in areas of endemic malaria, where it is anticipated that pregnant women will not die from malaria, reports are now available questioning this ….
Given the varying contributing factors to maternal death, the care required must be adjusted to address the causes. For example, provision of basic and emergency obstetric care with family planning has contributed to the reduction of MMR , but in other sites where the causes of maternal death go beyond the direct obstetric complications, more care is needed to address the co-infections—HIV/AIDS, malaria, TB and more. IT is likely that in those areas with this higher morbidity burden, more providers per 1000 births will be needed as their workload will be higher. Yet according to the State of the World’s Midwives, it is in just those countries where the work force available is less. (think we should revers the services—with FP in circle at center
A bold endgame:Ending preventable maternaldeaths worldwide by 2035CORE MeetingBaltimore, MDApril 26, 20131
850535901404005004524080210-100200300400500600700800900Sub-Saharan Africa Eastern Asia(excluding China)Southern Asia(excluding India)LAC WorldMMR:maternaldeathsper100,000livebirthsWhile maternal mortality has declined globally between 1990 &2010, there has been considerable regional variation1990 201041%AAR: 2.6%59%AAR = 4.4%41%AAR: 2.6%41%AAR: 2.6%47%AAR: 3.1%Source: WHO/UNICEF/UNFPA/World Bank. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva, World Health Organization, 2012.
MDG 5 Assessment of Progress for 24 prioritycountries: Maternal Mortality Ratio Average AnnualRate of Reduction (%) 1990-2010Zambia, 0.4Kenya, 0.5Sudan, 1.6Liberia, 2.4Ghana, 2.6Nigeria, 2.6DR Congo, 2.7Haiti, 2.7Pakistan, 3.0Senegal, 3.0Mozambique, 3.1Tanzania, 3.2Uganda, 3.2Mali, 3.5Malawi, 4.4Madagascar, 4.7Ethiopia, 4.9Indonesia, 4.9Rwanda, 4.9Afghanistan, 5.1India, 5.2Yemen, 5.3Bangladesh, 5.9Nepal, 7.30.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0OnTrackInsufficientProgress5.4% (on target)Little/NoProgressSource: Trends in Maternal Mortality 1990-2010
Countries require different rates of reduction toend preventable maternal deaths by 2035 –reaching MMR = 505010020030040050060070080090010001990 1995 2000 2005 2010 2015 2020 2025 2030 2035MaternalMortalityRation(per100,000livebirths)Asia, excl. India andChinaIndiaSub-Saharan AfricaGlobal MMROECD Countries - Upper LimitAsia: Afghanistan, Bhutan, Cambodia, Indonesia, Iran, Iraq, Kyrgyzstan, Lao, Morocco, Myanmar, Nepal, Pakistan, PapuaNew Guinea, Philippines, Solomon Islands, Tajikistan, Turkmenistan, Uzbekistan, VietNam, YemenAfrica: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Cote dIvoire,Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau,Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Sao Tome andPrincipe, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Togo, Uganda, Tanzania, Zambia, Zimbabwe22550CurrentAAR 2000-2010AAR toReachMMR = 50Sub-SaharanAfrica -3.7% -8.9%India -6.5% -5.4%Asia, excludingIndia and China -4.8% -5.1%Global -4.1% -5.6%
6KenyaMalawiMozambique NigeriaRwandaSudanTanzaniaUgandaZambiaGhanaLiberiaMaliDR CongoEthiopiaBangladeshSenegalAfghanistanMadagascarIndonesiaNepalPakistanYemenIndiaHaiti0.02.04.06.08.010.012.00.0 2.0 4.0 6.0 8.0 10.0RequiredAnnualRateofReductionbetween2010and2035toReachMMR=50in2035Observed Rate of MMR Reduction between 2000 and 2010Bubble size = Number ofMaternal Deaths in 2010SSA with High HIV PrevalenceSSA with Low HIV PrevalenceAsiaHaitiCountries above the diagonal line need to accelerate theirrate of MMR reduction to reach an MMR of 50 by 2035
Ending Preventable Maternal Mortality requires …Geographic FocusHigh Burden PopulationsHigh Impact Practices• Intensify programs where most maternal deaths occur• Address barriers and scale up access towards equity andrespectful maternal and newborn care for those nowunderserved• Base the maternal health strategy on the local causes ofmaternal and newborn death• Strategy should emphasize1. Family planning2. Quality respectful intrapartum and immediatepostnatal care with effective referral3. Provide prevention and treatment for obstetriccomplications and co-morbidities that increasematernal deaths—HIV/AIDS, malaria, tuberculosis, and poornutrition—during the full spectrum of maternitycare.• Build on and strengthen emerging health system changes-- financing initiatives, decentralization, privatization
Mutual Accountability• Promote transparency and shared accountability forfinancing and results• Monitor progress against a common set of metrics• Ensure communications – electronic and mobiletechnology – and improve documentation/surveillance andmapping to improve the continuum of care and use ofknowledge in programmingSupportive Environment• Educate girls and women—as well as men• Empower women to demand quality services• Enact smart policy for inclusive economic growth• Leverage public, private and professional partnershipsEnding Preventable Maternal Mortality requires……
Over half of all maternal deathsoccur in just eight countriesIndia 56,00020%Nigeria 40,00014%DRC 15,0005%Sudan* 10,0003%Indonesia9,600 3%Ethiopia 9,0003%Tanzania 8,5003%Other 126,90045%Pakistan 12,000* Sudan and South SudanSource: WHO, UNICEF, UNFPA and the World Bank estimates. Trends in Maternal Mortality: 1990-2010Geographic Focus
Maternal coverage indicatorsshow widest gap in equity0102030405060708090100Early startofbreastfeedingDPTimmunizationFullyimmunizedVitamin A OralrehydrationtherapyFamilyplanningneedssatisfiedAntenatalcare with askilledproviderAntenatalcare (≥ 4visits)Skilled birthattendantPercentCoverageQuintile 1 Quintile 5Child Health Indicators Maternal Health IndicatorsBarros, Ronsmans, Axelson et al. 2012High Burden Population
Proven interventions can addressthe leading causes of maternaldeath, both direct and indirectPreeclampsiaEclampsia18% Hemorrhage35%Unsafe Abortion 9%Sepsis8% Indirect and OtherDirect30%Source for Causes: Countdown to 2015• Active management of thethird stage of labor• Uterotonics: oxytocin &misoprostol•Blood transfusion• Family Planning• Diet, supplementationand fortification• Prevention andtreatment of infections• Iron folate supplements• De-worming• Malaria intermittent treatment• Anti-retrovirals• Tetanus toxoid• Clean delivery• Antibiotics• Family planning• Post-abortion care• Calcium• Magnesium Sulfate• Aspirin• Anti-hypertensives• Cesarean sectionUnderlying causes:• Unintended pregnancy• Under-nutrition• Co-infectionsHigh Impact Practices
HIVAIDS programs need to be tailored to diverse epidemics andintegrated into maternal newborn programsIndirect Causes of Maternal Mortalityare growing
HIDN/MCH AFRICA PRIORITY COUNTRIESESTIMATED HIV PREVALENCE AMONG TOTAL POPULATION 2011The boundaries and names used on thismap do not imply official endorsementor acceptance by the U.S. Government.ESTIMATED HIV PREVALENCE AMONGTOTAL POPULATION 2011Data Source: UNAIDS, 2011Map Source: OST/GeoCenter, January 2013*Natural Breaks (Jenks)1% - 2%3% - 4%5% - 7%8% - 13%No DataCountry HIV burden MMRMozambique 490Zambia 440Malawi 460Kenya 360Uganda 310Tanzania 460Nigeria 630DRCongo 540Rwanda 340Senegal 370Ethiopia 350Rwanda 340Mali 540Ghana 350Source: MMRs: Trends in Maternal Mortality: 1990 to 2010WHO, UNICEF, UNFPA and The World Bank Estimates, WHO 2012In SSA, the proportion of indirect vs. obstetric causes is greaterthan in South Asia – reflecting the important contribution ofinfectious diseases to maternal mortality in Africa
Country MMRMozambique 490Zambia 440Malawi 460Kenya 360Uganda 310Tanzania 460Nigeria 630DRCongo 540Rwanda 340Senegal 370Ethiopia 350Rwanda 340Mali 540Ghana 350Liberia 770Senegal 370Madagascar 240Maternal mortality is also high in areasof epidemic and endemic malariaSource: 2010 Malaria Atlas Project, available under theCreative Commons Attribution 3.0 Unported License.Clinical burden of Plasmodium falciparum,2007
767062605338 3831222059485001020304050607080%USAID Priority Countries with Natoinal Data by RegionPrevalence of Anemia in Pregnant Women22% of maternal deaths are associated with iron deficiency anemiaSource: Stolfus et al, Iron deficiency anemia, “Comparative quantification of health risks,” WHO, 2002.
Integrated care duringpregnancy, childbirth and beyondCare for Mothers with TB and otherinfectious diseasesCare for Mothers and Newborn inAreas With MalariaCare for HIV Positive Mothers andNewbornsEmergency Care for Mothers andNewbornsStandard Care for Maternal andNewborn HealthFamily Planning•TB screening and treatment•STI screening and treatment•Screening and treatment for other infections like Hepatitis•Use of ITNs•Intermittent Preventative Treatment•Case management for malaria illness and anemia• ART initiation or continuation• Couples counseling and testing• Prevention of opportunistic infections• Extra monitoring and treatment for HTN, pre-eclampsia/eclampsia and anemia• On-going case management for mother and newborn•Referral networks•Surgery and Medical care•Availability of Blood•Focused Antenatal Care and improved nutrition•Intrapartum Care•Postnatal Care•Voluntary access to modern contraceptive methods•Healthy Timing and Spacing of Pregnancies•Post-abortion care
• Weak health systems –especially inadequatenumber of midwives andsurgeons, poor qualitydrugs, poor quality ofcare, financialbarriers, measurementchallenges, and so forth• Urbanization• Privatization• DecentralizationContextual Challenges
Innovations– mHealth has potential to be apowerful accelerator of progressCommunications to improve referral systems, and so forth
Quality of care is critical:an important part is respect• A “veil of silence” has obscuredwidespread humiliation and abuseof women in facilities duringchildbirth, a time of intensevulnerability for women.• In many settings, disrespect ofwomen in childbirth has been“normalized” and is sometimesaccepted by women themselves.• Institutional disrespect and abuseof women can significantly deterwomen’s use of facility skilledcare for normal and emergencybirth care.USAID promotes
In summary….1. Target setting— a work in progress2. Reaching the target – Strategies based on local causes of maternaldeath and contextual factors3. More data needed — including reporting death, includingcause, time and place of death4. Implementation research on untested strategies and innovationswill guide more effective investment for better outcomes.5. We have an unprecedented opportunity for accelerated progress -- building on reduced fertility rates, increased rates of femaleeducation, and economic growth