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Global strategies to improve maternal health

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  • 1. Global Strategies on Maternal Health Tulsi Ram Bhandari Ph D Scholar, AMC, SCTIMST Thought & Action for Change
  • 2. Outline of Presentation • Objective • Literature search • Introduction • Why strategies? • Historical Glimpse • Strategy Players… • Discussion & Lesson Learnt • Remaining Issues • Conclusion • Future Actions
  • 3. “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
  • 4. Objective of the Seminar: Review global strategies on maternal health.
  • 5. 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 • Grey-literature and desk review: For published and unpublished materials • For referencing: Zotero Standalone 5
  • 6. Strategy Introduction: –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]
  • 7. 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.
  • 8. 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]
  • 9. 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 )
  • 10. Causes [cont…][5]
  • 11. Timing of Maternal Death • Antenatal: 24% • Intra-natal: 15% • Postnatal: 61% (most occur within 24 hours of delivery) Courtesy: Kirti Iyengar, 2005
  • 12. Historical Glimpse
  • 13. 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.
  • 14. 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]
  • 15. 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.
  • 16. 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.
  • 17. 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]
  • 18. The “Four Pillars” of Safe Motherhood Program [5] 1st 2nd 3rd 4th Cleansafe Delivery Essential ObstetricCare
  • 19. 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, etc 3rd 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
  • 20. 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.
  • 21. 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.
  • 22. 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]
  • 23. 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.
  • 24. 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
  • 25. “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, and 6) Monitoring and evaluation of global efforts.
  • 26. Prioritized Areas For Organizing Interventions- [29] 1. Developing capacities 2. Increasing awareness 3. Strengthening linkages 4. Improving quality Making Pregnancy Safer-
  • 27. Interventions in the Priority Areas [29] 1. Developing Capacities- –Self-care (nutrition, rest, plan for delivery, hygiene …) –Care-seeking –Birth and emergency preparedness ...
  • 28. 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]
  • 29. 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]
  • 30. 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]
  • 31. –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]
  • 32. 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]
  • 33. Discussion Content 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
  • 34. 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]
  • 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…
  • 36. • 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
  • 37. Maternal Care Model in Sri Lanka Source: Repot of High Level Consultant Meeting on MDG 4&5 , India 2008 Public health Midwife with client
  • 38. When should strategies focus? Conception Pregnancy Delivery InfancyPreschool Age Adolescence Under-5 Clinic Services School Age Post Partum Antenatal Clinic Maternity Care School Health Services Source: Based on New Model of ANC, WHO
  • 39. 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 health 1980sEarly 1990s Late 1990s 2000 Identification of high risk pregnancy by trained TBAs 1980s
  • 40. 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]
  • 41. • 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..]:
  • 42. 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.
  • 43. • 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…
  • 44. 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.
  • 45. 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.
  • 46. Thank You.
  • 47. References 1. Liddell HG, Scott R. A Greek-English Lexicon, στρα^τηγ-ία. [cited 2012 May 10]; Available from: http://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atext%3A1999.04.0057%3Aent ry%3Dstrathgi%2Fa 2. Johnson PG, Scholes PK. Exploring Corporate Strategy: Text and Cases. 7th ed. Financial Times/ Prentice Hall, 2006. 3. Thames K. Why Have a Health Strategy? [cited 2012 May 10]. Available from: http://www.kingston.gov.uk/browse/health/health_in_kingston/health_strategy/strategy_w hy.htm 4. WHO. Global Strategy for Women’s and Children’s Health, 2010. [cited 2012 Apr 17]. Available from: http://www.who.int/pmnch/activities/jointactionplan/201009_globalstrategy_6lang/en/inde x.html 5. WHO. District planning tool for maternal and newborn health strategy implementation, 2011. [cited 2012 May 16]. Available from: http://www.who.int/maternal_child_adolescent/documents/9789241500975/en/
  • 48. References cont… 6. AMDD. Our work is urgent. [cited 2012 May 18]. Available from: http://www.amddprogram.org/d/content/about-us 7. WHO. Maternal mortality, 2012. [cited 2012 May 13]. Available from: http://www.who.int/mediacentre/factsheets/fs348/en/index.html 8. The Universal Declaration of Human Rights, 1948. [cited 2012 Apr 26]. Available from: http://www.un.org/en/documents/udhr/ 9. International Covenant on Civil and Political Rights, 1966. [cited 2012 Apr 28]. Available from: http://unispal.un.org/UNISPAL.NSF/0/DDA106BF303C3CEE85256368005960A0 10. World Conference on Women, Mexico City, 1975. [cited 2012 Apr 28]. Available from: http://www.5wwc.org/conference_background/1975_WCW.html 11. WHO. The conference on Primary Health Care in Alma-Ata, 1978. [cited 2012 Apr 30]. Available from: http://apps.who.int/iris/bitstream/10665/39228/1/9241800011.pdf 12. Convention on the Elimination of All Forms of Discrimination against Women New York, 1979. [cited 2012 Apr 28]. Available from: http://www2.ohchr.org/english/law/cedaw.htm 13. United Nations: Key Conference Outcomes on Gender and Equality. [cited 2012 Apr 28]. Available from: http://www.un.org/en/development/devagenda/gender.shtml
  • 49. References cont… 14. Safe Motherhood Timeline - International Women’s Health Program [Internet]. [cited 2012 Apr 27]. Available from: http://iwhp.sogc.org/index.php?page=safe-motherhood- timeline&hl=en_US 15. 3rd World Conference on Women, Nairobi 1985. [cited 2012 Apr 28]. Available from: http://www.earthsummit2002.org/toolkits/women/un-doku/un-conf/narirobi-2.html 16. Safe Motherhood and Newborn Health - International Women’s Health Program. [cited 2012 Apr 27]. Available from: http://iwhp.sogc.org/index.php?page=inetvu-mobile- solutions&hl=en_US 17. UNFPA. Master Plans for Development: ICPD - International Conference on Population and Development, 1994. [cited 2012 Apr 29]. Available from: http://www.unfpa.org/public/home/sitemap/icpd/International-Conference-on-Population- and-Development 18. The 10th Anniversary Meeting of Safe Motherhood Initiatives is held in Sri Lanka,1997. [cited 2012 May 12]. Available from: http://iwhp.sogc.org/index.php?page=safe-motherhood- timeline&hl=en_US 19. Implementing the Decisions of the International Conference on Population and Development, ICPD+5: Information from the United Nations Regional Commissions, 1999. [cited 2012 May 12]. Available from: http://www.un.org/popin/icpd5.htm
  • 50. References cont… 20. World Health Organization. Reduction of maternal mortality. Geneva: World Health Organization; 1999. 21. WHO. Maternal, newborn, child and adolescent health. [cited 2012 May 2]. Available from: http://www.who.int/maternal_child_adolescent/en/ 22. Millennium Development Goals, 2000 . [cited 2012 Apr 29]. Available from: http://www.ilo.org/global/topics/millennium-development-goals/lang--en/index.htm 23. United Nations Millennium Development Goals, 2000. [cited 2012 May 11]. Available from: http://www.un.org/millenniumgoals/ 24. ILO. Maternity Protection Recommendation, 2000. [cited 2012 May 2]. Available from: http://www.ilo.org/ilolex/cgi-lex/convde.pl?R191 25. The first International Safe Motherhood Conference is held in Nairobi; the concept of “safe motherhood” is defined and developed.,1987. [cited 2012 May 11]. Available from: http://iwhp.sogc.org/index.php?page=safe-motherhood-timeline&hl=en_US 26. Women Deliver: Global Conference Set for London, 2007. [cited 2012 May 18]. Available from: http://www.mdgasiapacific.org/node/138 27. Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. The Lancet 12;371:1247–58. Available from: http://www.sciencedirect.com/science/article/pii/S0140673608605590
  • 51. References cont… 28. WHO. Global Strategy for Women’s and Children’s health, 2011. [cited 2012 Apr 17]. Available from: http://www.who.int/pmnch/topics/maternal/201009_globalstrategy_wch/en/index.html 29. WHO. Working with individuals, families and communities to improve maternal and newborn health, 2010. [cited 2012 Apr 16]. Available from: http://www.who.int/maternal_child_adolescent/documents/who_fch_rhr_0311/en/index.ht ml 30. WHO. Commission on Information and Accountability for Women’s and Children’s Health, 2011. WHO. [cited 2012 Apr 25]. Available from: http://www.who.int/pmnch/media/membernews/2011/20110620_commission_on_account ability/en/index.html 31. Sundari Ravindran T. Understanding Health Sector Reforms and Sexual and Reproductive Health Services: A Preliminary Framework. Reprod Health Matters 2002;10:16–8. 32. Berg CJ. From Identification and Review to Action—Maternal Mortality Review in the United States. Semin Perinatol 2012;36:7–13. 33. WHO. Three-year study identifies key interventions to reduce maternal, newborn and child deaths,2011. [cited 2012 Apr 16]. Available from: http://www.who.int/mediacentre/news/releases/2011/reduce_maternal_deaths_20111215/ en/index.html
  • 52. References cont… 34. Carvalho N, Salehi AS, Goldie SJ. National and Sub-National Analysis of the Health Benefits and Cost-Effectiveness of Strategies to Reduce Maternal Mortality in Afghanistan. Health Policy Plan 2012;1-13. 35. Clark SL. Strategies for Reducing Maternal Mortality. Semin Perinatolo 2012;36:42–7. 36. Fonn S, Sundari Ravindran T. The macroeconomic environment and sexual and reproductive health: a review of trends over the last 30 years. Reprod Health Matters 2011;19:11–25. 37. Falconer AD. Millennium Goal 5. Obstet Gynaecol Reprod Med 2010;20:369–71. 38. Strategy to Accelerate Progress towards the Attainment of International Development Goals and Targets Related to Reproductive Health. Reprod Health Matters 2005;13:11–8. 39. Bullough C, Meda N, Makowiecka K, Ronsmans C, Achadi EL, Hussein J. REVIEW: Current strategies for the reduction of maternal mortality. BJOG 2005;112:1180–8.