Ghia Fdn overview-strategy update january 2017 (presentation resaved sept 14_...
Maternal Health 2014 nazmul
1. Inequalities in Access to Maternal Health
Care and Role of Transport Intervention:
Mom’s Van as an Example.
Nazmul Alam, MPH, DrPH
Université de Montréal
November 22, 2014
Ryerson University
Quebec, Canada
2. Outline of the Presentation
• Maternal mortality: causes and consequences
• Maternal care services: persistent inequality
• Interventions to address inequality
• Role of transport intervention: The walk
• Mom’s van intervention
3. Maternal Mortality: A Global Tragedy
• In 2013, 289 000
women died from
complications of
pregnancy or
childbirth.
– 99% in developing
world
– >50% of them in
Africa
• http://gamapserver.who.int/gho/interactive_charts/mdg5_mm/atlas.html
5. 5
Progress towards Millennium
Development Goal 5
Countdown of 75 countries, account for 95% of all deaths.
Nine countries are on track; 25 made insufficient or no progress.
Count down to 2015: briefing note
6. Causes of Maternal Mortality
*Malaria, HIV, accident etc..
**Obstructed labor, ambolism etc..
Source: Countdown to 2015, 2010.
7. Three Delays Model
• 1st delay: delay in decision to seek care
• Lack of understanding of complications
• Acceptance of maternal death
• Low status of women
• Socio-cultural barriers to seeking care
• 2nd delay: delay in reaching care
• Mountains, islands, rivers
• Distance to health centres and hospitals
• Availability of and cost of transportation
• 3rd delay: delay in receiving care
• Supplies, personnel
• Poorly trained personnel with punitive attitude
* 3 delay model, Thaddeus 1994
8. 8
Maternal Health Care
Prenatal care
Antenatal care
Skilled attendent
at Birth
Emergency
obstetric care
Postnatal care
9. EmOC is fundamental
Screening
TBA
Training
Antenatal
Care
Skilled
Attendant Referral
Risk
Social
Mobilization
Waiting
Homes
Emergency Obstetric Care
10. Coverage of care
• Good quality maternal health
services are not universally
available and accessible
– > 35% receive no antenatal
care
– ~ 50% of deliveries
unattended by skilled
provider
– ~ 70% receive no
postpartum care during 1st 6
weeks following delivery
11. Maternal care services and MMR
R2 = 0.74
2000
1800
1600
1400
1200
1000
800
600
400
200
0
Y Log. (Y)
0 10 20 30 40 50 60 70 80 90 100
% skilled attendant at delivery
Maternal deaths per 1000000 live births
12. Prenatal care, skilled birth attendance and MMR
in India.
Praveen et. al., PLoS One. 2010 Oct 27;5(10):e13593.
18. 18
Mothers education and SBA
Trends in the percentage of skilled birth attendance by (A) woman’s education, (B) partner’s
education, (C) wealth index, 1993–2008. BMJ Open 2013 3:
19. Interventions to reduce maternal
mortality
Health systems improvements
• Antenatal care
• Skilled attendant at delivery
• Functional EmOC
• Referral
Structural interventions
- Girls education
- Infrastructure
- Health care financing
23. 23
Health Voucher scheme
Demand side financing: maternal health voucher scheme in Bangladesh, Ahmed, Soc. Sci & Med, 2011
24. In Burkina Faso, household costs related to maternal care has been
progressively reduced: i. abolition of ANC user fees, 2002; ii. subsidy for
C-sections, 2006; iii. subsidy for all deliveries, 2007. (De Allegri, Valerie, 2012)
24
User fee abolitions
25. Referral and transport intervention
Poor transport specially in rural areas in LMIC is one
of the avoidable factors.
• scarcity of transportation
• distance
• cost of transport
• poor road conditions
26. Referral and transport intervention
The Walk video:
Every Mother Counts
http://youtu.be/8HZuMmU778I
27. Three wheeler motor van (Mom’s van)
for transportation of women with
obstetric emergency
28. Existing transport intervention:
Mostly in Africa, where it needs more….
- RESCUER project in Uganda
- Yellow flag initiative in Nigeria
- Safe motherhood transport plan- Malawi
But existing transport intervention are either inadequate,
urban focused, facing management or sustainability
problem
29. Goal: Contribute in reduction of maternal mortality to
achieve MDG targets
Objectives
• to understand availability transportation and
referral network during obstetric emergencies in
rural areas
• to assess acceptability, feasibility and utilization
of ‘Mom’s van’ intervention
31. 31
Study Area
Bangladesh, Mymensingh District, Nandail Upazila: approximately
328,847 population
Kaya district in Burkina Faso: approximately 66,851 population
32. Formative research
Qualitative and quantitative methods have
been used:
Those methods included:
• Literature review,
• Survey with a semi structured
questionnaire,
• In-depth interviews with key informants,
• Focus group discussions (FGDs),
32
35. 35
Place of delivery and experience to travel
Burkina Faso Bangladesh
36. 36
Care seeking during pregnancy and delivery,
Bangladesh
Characteristics Number, N=300 %
Complications during last
pregnancy/delivery
137 45.7
Sought care for complications 128 42.7
Mode of transportation to go health
centres
Ambulance/micro-bus
CNG/Auto
Rickshaw/ Rickshaw van
Boat
On foot
(n=187)
26
80
71
3
7
13.9
42.8
38.0
1.6
3.7
Time needed to go a health facility
(range) 1h24m (30m-3h30m)
Cost for one visit (range) 752.7 (1500-3500)
37. Care seeking during pregnancy and delivery, Burkina
Faso
37
Characteristics Number (N=340) %
Complications during last
preg./delivery
247 73.2
Sought care for complications 229/247 92.7
Available transportation
Motor cycle
On foot
Moto ambulance
208
69
2
75.0
20.3
0.6
Ave. time to reach health facility (range) 1h:30m (10m-10h)
Cost (FCFA*) for each visit (range) 750 (0-3750)
38. Van modeling
38
Allwells Marketing company and Rasendic
motors Inc..
39. Key features/innovations:
• A three wheeler, suitable for rural roads, safer than two
wheeler.
• Cell phone connectivity to help rapid communication
with families and service providers.
• Manage by community support group to promote sense
of ownership, included women in committee
• Adopted a business model for limited income generation
for sustainability.
• Will carry women from poor families for free to promote
equity.
40. How it helps:
•Availability of Mom’s van in the community will help
reduce 1st delay (decision making)
•Women with complications can reach facilities in
less 60 minutes (2nd delay).
• Mobile connectivity will help reduce delay at the
facility (3rd delay).
41. Major outcomes:
• Acceptability: acceptability will be assessed by
interviewing women who received services and their
family head .
• Feasibility: feasibility will be assessed by measuring cost,
management and administrative issues
• Effectiveness: measuring distal outcome like met need,
travel time, referral rate, etc..
46. Major challenges:
- Sustainability vs. affordability
- Creating demand
- Risk of accident
- Monitoring and supervision
47. Singh A, Mavalankar DV, Bhat R, Desai A, Patel SR, et al. (2009) Providing skilled birth attendants and emergency obstetric
care to the poor through partnership with private sector obstetricians in Gujarat, India. Bulletin of World
Health Organization 87: 960–964.
Houweling TAJ, Ronsmans C, Campbell OMR, Kunst AE (2007) Huge poorrich inequalities in maternity and child care in
developing countries. Bulletin of the World Health Organization 85(10): 745–754.
Freedman LP, Graham WJ, Brazier E, Smith JM, Ensor T, et al. (2007) Practical lessons from global safe motherhood
initiatives: time for a new focus on implementation. Lancet 370: 1383–91.
Pathak PK, Singh A, Subramanian SV. Economic inequalities in maternal health care: prenatal care and skilled birth
attendance in India, 1992-2006.PLoS One. 2010 Oct 27;5(10):e13593.
McIntyre D, Thiede M, Birch S: Access as a policy-relevant concept in low- and middle-income countries. Health Economics,
Policy and Law 2009, 4:179–193.
MATERNAL HEALTH INEQUALITIES OVER TIME: IS THERE A COMMON PATHWAY? Andrew Amos Channon, Sarah
Neal, Zoe Matthews and Jane Falkingham University of Southampton, UK October, 2012
Målqist M, Lincetto O, Du NH, Burgess C, Hoa DT. Maternal health care utilization in Viet Nam: increasing ethnic inequity.
Bull World Health Organ. 2013 Apr 1;91(4):254-61.
The World Health Organization, Department of Reproductive Health and Research (2007) Maternal mortality in 2005:
estimates developed by WHO, UNICEF and UNFPA. Geneva: World Health Organization.
United Nations. 2012b. The Millennium Development Goals Report. New York.
Barros AJ, Ronsmans C, Axelson H, et.al. Equity in maternal, newborn, and child health interventions in Countdown to 2015:
a retrospective review of survey data from 54 countries.Lancet. 2012 Mar 31;379(9822):1225-33.
Maternal health inequalities over time: is there a common pathway? Andrew Amos Channon, Sarah Neal, Zoe Matthews and
Zere E, Kirigia JM, Duale S, Akazili J: Inequities in maternal and child health outcomes and interventions in Ghana. BMC
Pub Health 2012, 12(252):1–10.
Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994 Apr;38(8):1091-110.
De Allegri M, Ridde V, et al. The impact of targeted subsidies for facility-based delivery on access to care and equity -
evidence from a population-based study in rural Burkina Faso.J Public Health Policy. 2012 Nov;33(4):439-53.
Arsenault C, Fournier P, Philibert A. et. al. Emergency obstetric care in Mali: catastrophic spending and its impoverishing
effects on households. Bull World Health Organ. 2013 Mar
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47
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