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                                                        Campaign on Accelerated Reduction of Maternal Mortality in Africa

                           No woman should die giving life. It’s within our reach. It’s in our hands.




         Stirring
       Continental                                                            success in
        Conscience VE
               IMPRO                                                          maternal
       into Action L T H
               MATERNAL
               HEA                                                              death
                                                                              reduction
                                                                              Africa is winning




African Union Commission                                                                                United Nations Population Fund
FULL NAME                                        Vision/Mission                Connections/Linkages

        Campaign on Accelerated     CARMMA : Our vision                               >   UN Secretary General’s Global Strategy
        Reduction of Maternal Mortality Continental should die giving
                               Stirring      No Woman                                     on Women’s and Children’s Health
        in Africa              Conscience and Action
                                             life
                                                                                      >   Commission on Information and
                                                                                          Accountability for Women’s and
                                                   Our mission is to                      Children’s Health
       DATE OF BIRTH                SuCCeSSreduce maternal, newborn
                                               on MAteRnAl
                                          accelerate action across Africa
                                          to
        2009                        deAth ReduCtion : > The UN Commission on Life-Saving
                                          and child mortality.
                                                                          Commodities for Women and
                                 Africa is winning                                        Children

       Initiators                              Our strategic
                                               actions                                >   Family Planning Summit on
                                                                                          repositioning family planning
        African Union in collaboration
        with UNFPA and others                  1. Build on existing efforts to        >   The Global and Regional Partnerships
                                                   improve maternal, newborn              on Reproductive, Maternal, Newborn
                                                   and child health across Africa         and Child Health
       countries of Launches                       – particularly by sharing best
                                                   practice.                          >   The Thematic Think Piece for Health
                                                                                          in the post 2015 UN Development
                                                                                          Agenda
2012




        South Africa
                                                   2. Generate and share data on
                                                   maternal, newborn and child        >   The Save the Mother and Save the
                                                   health.                                Child Initiative of the Prevention
        Botswana, Liberia, Democratic Republic                                            and Elimination of Mother-to-Child
        of Congo, Gabon, Tanzania, Equatorial                                             Transmission of HIV
2011




        Guinea, Burundi, Burkina Faso, Tunisia
        and Niger.                                 3. Advocate for increased          >   Safe Motherhood Initiative
                                                   political commitment, and
                                                   mobilize domestic resources in     >   White Ribbon Alliance Initiative
                                                   support of maternal, newborn
        Ethiopia, Sierra Leone, Central            and child health.                  >   The Continental Policy Framework
        African Republic, Uganda, Cameroon,                                               for Sexual and Reproductive Health
2010




        Mauritania, Lesotho, Zambia,                                                      and Rights
        Zimbabwe, Guinea Bissau, Senegal,
        Gambia, Eritrea, Angola, Togo, Benin,      4. Communicate with the            >   The Maputo Plan of Action
        Congo Brazzaville and Kenya.               wider African public and inspire   >   The African Health Strategy
                                                   action.
                                                                                      >   The Abuja Declaration on HIV/AIDS,
        Mozambique, Malawi, Rwanda, Nigeria,                                              tuberculosis and other related
2009




        Swaziland, Ghana, Namibia and Chad.                                               infectious diseases
2                                                  CARMMA Report 2013
CONTENTS




Page 5                 : CARMMA in numbers

Pages 6-7              : CARMMA stirs continental conscience into action

Page 9                 : Success in maternal death reduction:

                          report shows Africa is on a winning track

Page 10                : Trends in maternal mortality in Africa

Page 11                : Steps towards achieving results

Pages 12-30            : Country highlights

Page 31                : CARMMA - main challenges

Page 32-33             : Intersecting views: UNFPA African and Union

Pages 34               : Youth for carmma


This document was produced by Akinyele Eric Dairo, Olive Bonga, Adebayo Fayoyin, Lindsay Barnes.


                                          CARMMA Report 2013
                                                                                                   3
Her Excellency, Dr. Nkosazana
                          Dlamini-Zuma, AUC Chairperson
                          Women constitute more than 50 per cent of the continent’s population
                          and their engagement in all spheres of human endeavour is imperative.
                          Africa has unacceptably high maternal and infant mortality rates. What
                          women in other countries – especially in the developed world – take
                          for granted as a normal physiological function of giving birth and
                          ensuring the continuation of the human race, on our continent means
                          putting your life at risk. The death of a mother is not just the death of
                          an individual. It means the survival of the young children that she may
                          be leaving behind is not guaranteed, and if they survive, they may not
                          reach their full potential in life. And of course, the loss of a mother is
                          a loss to the family and the community.




                          Africa has many accomplishments in which to take pride and
                          confidence, including a 41 per cent reduction in maternal mortality.
                          Progress on many fronts is dramatic with a new sense of optimism
                          found right across the continent. But if the continent is to make the
                          most of its rich potential, there are many challenges still to overcome.
                          And none is bigger than further improving Africa’s still unacceptably
                          high record on maternal health. While Africa has only 14 per cent of
                          the world’s population, it accounts for well over half of all maternal
                          deaths worldwide – deaths that are overwhelmingly avoidable. For it is
                          not untreatable diseases but the lack of access to family planning, basic
                          care around childbirth, skilled attendance, health checks and advice in
                          pregnancy that are the main reasons for this loss of human life.

                          It is a mark of the new determination across Africa, to remove
                          obstacles to progress, that we are seeing a major drive to end this
                          unnecessary death toll. The Campaign on Accelerated Reduction of
                          Maternal Mortality in Africa (CARMMA) was launched three years ago
                          by the African Union, with the support of UNFPA, the United Nations
                          Population Fund, which I am privileged to head. CARMMA has enjoyed
                          tremendous support at the highest levels. We see success stories right
                          across the continent, with strengthened health systems, increased
                          funding and new partnerships between the public, private and voluntary
    Dr. Babatunde         sectors. However, despite some remarkable results, over 450 women
                          and girls continue to die in Africa every day from complications in
    Osotimehin,           pregnancy or childbirth. If the continent is to continue the remarkable
                          economic and social progress achieved over the last decade, then
    Executive Director,   reducing child and maternal deaths must be a top priority. It is within
    United Nations        our reach that no woman should die giving life. The realization of this
                          commitment is also in our hands.
    Population Fund
    (UNFPA)



4                                   CARMMA Report 2013
CARMMA in numbers

                                      37
                                      countries have


            92%
                                      launched the
                                      campaign so far

              of countries have
          carried out activities
            that have fostered


                                      50%
         political commitment


                                      of member states have strengthened
                                      their health systems, developed a
                                      monitoring and evaluation system or

                41%
reduction in maternal deaths in
                                      integrated HIV, reproductive health
                                      and family planning services

       Africa from 1990 to 2010
                                     17%
                                      of member states have allocated or
                                      increased funding for maternal, newborn
                                      and child health (MNCH) and sexual and
                                      reproductive health and rights (SRHR)




                                      57.5%
                                      of maternal deaths
                                      worldwide occur among
                                      women on the African
                                      continent


                       452
             women are dying
               every day from
            pregnancy-related
               causes in Africa




                            CARMMA Report 2013
                                                                                5
CARMMA Stirs Continental
              Conscience into Action




    The aim of
    CARMMA is to
    use the vehicles of
    policy dialogue,
    advocacy and
    community social
    mobilization to                      Maps; provision of sustainable       become an integral part of the
    enlist political                     funding; the strengthening of        health sector landscape and the
    commitment                           health systems; development          maternal and neonatal health
                                         of monitoring and evaluation         road map in Africa.
    throughout the                       mechanisms;      promotion      of
                                                                              Such integration of CARMMA into
    continent, increase                  integrated HIV and AIDS, and
                                                                              existing Maternal and Newborn
                                         strengthening of reproductive
    resources and boost                  and family planning services.
                                                                              Health (MNH) strategies is
    Maternal Health                                                           critical because of the need to
                                         Continentally, the campaign has


    A
                                                                              ensure government ownership of
    success continental launch,
         t the                           made tremendous progress
                                                                              the campaign, so as to boost its
            in     2009,      countries since those early days, with
                                                                              sustainability and visibility.
            were urged to launch several            countries      adopting
                                                                              Countries such as Zimbabwe,
    the campaign and to develop National Road Maps and
                                                                              Namibia and Sierra Leone
    mechanisms for implementation developing            Strategic    Health
                                                                              now have extensive MNH
    and monitoring progress.             Development Plans. CARMMA
                                                                              programmes. In Namibia, inter-
                                         has also become the platform
    Since the first national launch, by                                       sectoral collaboration at the
                                         for mobilizing commitments and
    Mozambique on 3 August 2009,                                              national level is marked by the
                                         support for the UN Secretary
    37 countries have now launched                                            involvement of various ministries
                                         General’s Global Strategy on
    the campaign: eight in 2009; 18 in                                        and civil society in the national
                                         Women’s and Children’s Health
    2010; 10 in 2011, and one in 2012.                                        coordination mechanism.
                                         and the implementation of
    With launching comes the                                                  In Sierra Leone, access to care at
                                         the recommendations for the
    implementation of commitments,                                            health facilities increased with free
                                         Commission on Information and
    policies and activities that include                                      health care services for pregnant
                                         Accountability (COIA) of the
    community mobilization; the                                               and lactating women and under-
                                         Global Strategy. CARMMA has
    development of National Road                                              five children. The involvement

6                                               CARMMA Report 2013
of civil society organizations in   kits, and resuscitation equipment also becoming institutionalized
monitoring RH commodities has       for the adult and child.            in many countries. In Namibia,
also improved accountability and    Cameroon has also begun a pilot maternal death review tools
transparency.                       project in which obstetric kits are have been launched, and reviews
In most countries that have         being made available to pregnant are being put in operation in all
launched the campaign, there        women at a fixed price. It is district hospitals. Swaziland holds
is broad engagement of all          notable that as a result of this, quarterly review meetings as well
stakeholders,    and     growing    the number of monthly deliveries as an annual one; while in Gambia,
collaboration among maternal,       increased by about 70 per cent since 2010, hospitals have been
newborn and child health            in participating health facilities carrying out maternal death audits
partners.                           within six months.                  with the assistance of UNFPA.
                                    Through      CARMMA, Malawi In Uganda, the government has
The strengthening of health
                                    is also aiming to bring MNH made maternal death a notifiable
systems, including the training
                                    services closer to the community condition, and Maternal and Peri-
of health workers, is being
                                    and promote access to Sexual natal Death Review (MPDR)
emphasized in many countries,
                                    and Reproductive Health (SRH) has been institutionalized, with
including Uganda, Botswana,
                                    services, including the provision notification to the Ministry of
Gambia and Eritrea. With the
                                    of Depo-Provera to clients by Health required within 24 hours.
support of partners,
including      UNFPA,           With launching comes the                           “One of our priorities is
Uganda        operates                                                             Millennium Development
a bursary scheme          implementation of commitments, Goal 5 – improving
for the training of policies and activities that include                           maternal health,” said
midwives,        while    mobilization; the development of Mr. Bunmi Makinwa,
Botswana has broad                                                                 Director of UNFPA’s
training programmes         National Road Maps; provision                          East and Southern Africa
for            doctors,        of sustainable funding; the                         Regional Office. The
midwives, and nurses.
UNFPA, WHO and
                           strengthening of health systems; “2012 Status Newborn   on Maternal,
                                                                                                     Report

the Global Fund are            development of monitoring                           and     Child     Health”
supporting similar            and evaluation mechanisms;                           points to unacceptably
processes in Gambia.                                                               high maternal and child
Eritrea is providing
                              promotion of integrated HIV                          mortality and morbidity,
in-service training         and AIDS, and strengthening of                         despite some progress
to midwives and           reproductive and family planning in improving the health
other health care                                                                  of women and children:
providers, as well as                        services.                             “Despite the progress
to young doctors, in                                                               recorded, Africa is still
                                    health surveillance assistants;
the provision of Comprehensive                                          confronted        with    formidable
                                    while Nigeria is using anti-
Emergency        Obstetric     and                                      challenges as it strives towards
                                    shock garments, Misoprostol
Neonatal Care (CEmONC)                                                  the attainment of the MDGs,
                                    and magnesium sulphate in the
services, with Intrauterine Device                                      especially MDGs 4 and 5 by
                                    management of post-partum
(IUD) and Norplant insertions                                           2015,” says the report.
                                    haemorrhage and eclampsia.
introduced following the launch
                                                                        Continentally, Africa has woken
of CARMMA in the country.           One of the most important
                                                                        up to the wise words of Former
Many        countries,    including dimensions of the work that
                                                                        Zambian         president    Rupiah
Swaziland, Ghana and Malawi, are is going on throughout Africa
                                                                        Bwezani         Banda:     “Maternal
going ahead with the provision on maternal mortality is the
                                                                        mortality is not only an injustice,
of facilities and equipment aimed remarkable use of partnership and
                                                                        it is also a tragedy.”
at providing the best care for collaboration. Rwanda decided to
pregnant women and newborns. merge CARMMA with the White
                                                                        On account of the commitment
Swaziland has equipped a Ribbon Alliance (WRA) Initiative
                                                                        of African leaders and their
regional hospital with basic in national efforts to reduce
                                                                        development        partners, “No
MNH equipment such as a digital maternal mortality and morbidity.
                                                                        Woman Should Die Giving Life”.
Doppler, scanner, and delivery Maternal mortality review is

                                           CARMMA Report 2013
                                                                                                               7
CARMMA Timeline
                                                                                                                               2013
                                                                                                                               Carmma
                                                                                                                               special event
                                                                                                                               on “Reinforcing
                                                                                                                               the Campaign
                                                                2011
                                                                At the 5th session of the
                                                                                                                               on Accelerated
                                                                                                                               Reduction in
                                                                                                                               Maternal Mortality
                                                                Pan African Parliament                                         in Africa” at the

    2006
                                                                                                                               twentieth
                                                                in Johannesburg, it was
                                                                stressed that maternal,                   2012                 Ordinary Session
    Africa, through
    the Maputo
    Plan of Action,
                                   2010
                                   The African Union
                                                                newborn and infant
                                                                health is critical to
                                                                overall human and social
                                                                                                          Launch of
                                                                                                          the CARMMA
                                                                                                                               of the Assembly of
                                                                                                                               the African Union,
                                                                                                                               organized by the
                                                                                                                               Department of
                                   Summit in Uganda             development in Africa,                    website (www.        Social Affairs of
    declared the                                                and governments were                      carmma.org) by
    equivalent                     was convened                 urged to devote greater                   the Department of    the African Union
    of a state of                  under the theme:             financing towards the                     Social Affairs of    Commission, in
    emergency on                   “Maternal, Infant            health of women and                       the African Union    collaboration
    maternal and                   and Child Health             children.                                 Commission.          with UNFPA
    child health.                  and Development in                                                                          and the African
                                   Africa.”                                                                                    Development Bank.




    2009                                                                                                                 2013
    Launch of 2011                             The African Union
                                                                                            2012
                                                                                            UNFPA,
                                                                                                                        Expected outcomes:
    Carmma                                     Conference of Ministers
                                               of Health expanded
                                                                                            the World Health
                                                                                            Organization (WHO) and
                                                                                                                        - Reinforcing commitment
                                                                                                                          to Maternal Health
                                                                                                                        - Increase in financial
                                               CARMMA to include                            the United Nations
                                               newborn and child                            Children’s Fund (UNICEF)      resources for Maternal 		
                                               health, asthmandated                         held a regional workshop      Health
                                               by the 15 Ordinary                           on maternal death review    - Intensified actions on 		
                                               Session of the AU                            with representatives          Maternal and Neonatal
                                               Assembly.                                    from 26 sub-Saharan           Health.
                                                                                            African countries,
                                                                                            in Burkina Faso and
                                                                                            Tanzania.



                                                                                                         Countries that are preparing
                                                                                                               to launch CARMMA
         Côte d’ivoire


                         Comoros




                                                    Mauritius



                                                                 South sudan
                                        Mali




                                                                                    Sudan




8                                                                              CARMMA Report 2013
Success in maternal death reduction
Report Shows Africa is on a Winning Track




                                                            Among the more prominent success
                                                            stories for Africa, the report shows that
                                                            Equatorial Guinea has achieved MDG5,
                                                            one of 10 countries worldwide that
                                                            did so during the period. Its maternal
                                                            death rate dropped by 81 per cent,
                                                            from 1200 to 240 per 100,000 live
                                                            births, between 1990 and 2010.

W       ith the majority of
        African countries having
implemented CARMMA, 2012
                                       Africa had the highest maternal
                                       mortality ratio at 500 maternal
                                       deaths per 100,000 live births. In
                                                                              increments, with the biggest drop
                                                                              recorded between 2005 and 2010
                                                                              - from 630 to 500 deaths per
bore good news in the form of an       Africa, a woman still faces a one-     100,000 live births (see Trends in
impressive 41 per cent decline in      in-39 lifetime risk of dying due to    Maternal Mortality: 1990 to 2010,
maternal mortality in Africa from      pregnancy or childbirth-related        Page 56).
1990 to 2010, according to the         complications; that risk is one in     Five countries in sub-Saharan
report Trends in Maternal Mortality:   3,800 in developed countries.          Africa - Botswana, Lesotho,
1990 to 2010 by the World              Among the more prominent               Namibia, South Africa and
Health Organization (WHO),             success stories for Africa, the        Swaziland - showed an increase
United Nations Children’s Fund         report shows that Equatorial           in maternal deaths from 2000
(UNICEF) and the United Nations        Guinea has achieved MDG 5, one         to 2005 on account of HIV,
Population Fund (UNFPA).               of 10 countries worldwide that         but their maternal mortality
While there were 850 deaths per        did so by 2010. Its maternal death     rates are currently dropping
100,000 live births in 1990, that      rate dropped by 81 per cent, from      as antiretroviral treatment has
rate had declined to a regional        1200 to 240 per 100,000 live births.   become more available.
average of 500 deaths per 100,000      Eritrea is considered on track to      While substantial progress has
live births by 2010, with no fewer     achieve MDG 5, its maternal death      been achieved in almost all
than 24 of the 46 sub-Saharan          rate having dropped from 880 to        regions, many African countries
countries achieving a reduction of     240 per 100,000 live births.           will be particularly encouraged
more than 40 per cent.                                                        by this report in their efforts
The report shows that in 2010,         The publication also demonstrates      to reach the MDG target of
while the global maternal mortality    how, beginning in 1990, the decline    reducing maternal deaths by 75
ratio was 210 maternal deaths per      in maternal mortality numbers          per cent by 2015.
100,000 live births, sub-Saharan       became more rapid in five year


                                               CARMMA Report 2013
                                                                                                                   9
Trends in maternal mortality
     The target of Millennium Development Goal 5A (MDG 5A) is to reduce maternal mortality by three quarters
     (75 per cent) by 2015. This graphic shows each country’s percentage of progress made. (source: trends in
     maternal mortality, 1990-2010, Who, UNICEF, UNFPA and the World Bank, 2012.)



                                +33% Congo
                                                                      Zimbabwe +25%

                            +21% South Africa
                                                                      Lesotho +19%

                               +15% Somalia                           Chad +15%
                                                                      Botswana +14%
                               +7% Swaziland
                                                                      Cameroon +3%
                                +2% Namibia
                                                                      Central African Republic -4%

                                   -9% Kenya

                                                                      Gabon -15%



                                -26% Burundi
                                                                      Guinea-Bissau -29%
                             -30% Sierra Leone


                                                                      Zambia -37%
                                 -40% Ghana
                                                                      Nigéria -41%
                                  -42% DRC
                                                                      Côte d’Ivoire -43%
                                -45% Sénégal
                                                                      Mozambique -46%
                    -47% Tanzania and Uganda
                                                                      Guinea and Gambia -50%
                          -51% Mali and Togo
                                                                      Niger -53%
                      -54% São Tomé & Príncipe
                                                                      Benin -55%
                            -57% Burkina faso
                                                                      Malawi -59%
                             -61% Cape Verde
                                                                      Angola and Madagascar -62%
                                -63%Rwanda
                                                                      Ethiopia -64%

                                 -73% Eritrea



                                                   MDG 5:
                                                   reduce maternal     Equatorial Guinea -81%
                                                   mortality by
                                                       75%

10                                               CARMMA Report 2013
Steps are the most popular strategies
 What towards achieving results
                    CARMMA is a conducive platform to implement different strategies and actions. The
      24            graphic below shows the most popular ones among African countries.

                    Benin, Burundi, Chad, Central African Republic, Democratic Republic of Congo, Djibouti,
  Budget            Gambia, Ghana, Guinea, Guinea-Bissau, Lesotho, Liberia, Madagascar, Mauritania, Niger, Nigeria,
                    Rwanda, Sao Tome et Principe, Senegal, South Sudan, Sudan, Tanzania, Zambia, Zimbabwe




      22
    Family          Benin, Burundi, Cameroon, Chad, Central African republic, Congo, Democratic Republic of Congo,
   planning/
 contraceptives     Djibouti, Gambia, Ghana, Guinea-bissau, Lesotho, Madagascar, Mauritania, Mozambique,
                    Niger, Sao Tome et Principe, Senegal, South Sudan, Tanzania, Uganda, Zambia


      21
   Health           Cameroon, Chad, Central African Republic, Congo, Democratic Republic of Congo,
  facilities        Djibouti, Guinea, Guinea-Bissau, Kenya, Liberia, Madagascar, Malawi, Mauritania,
                    Mozambique, Niger, Rwanda, Senegal, South Sudan, Sudan, Tanzania, Uganda


      20
   Human            Burkina Faso, Burundi, Cameroon, Chad, Congo, Djibouti, Ethiopia, Guinea, Guinea-Bissau,
  resources         Kenya, Liberia, Malawi, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Sudan,
                    Tanzania


      19
     Free           Benin, Burkina Faso, Cameroon, Chad, Comoros, Congo, Ghana, Guinea, Lesotho,
   services         Liberia, Malawi, Mali, Niger, Nigeria, Sierra Leone, South Sudan, Sudan, Tanzania, Zimbabwe



      16            Burundi, Chad, Central African Republic, Congo, Democratic Republic of Congo,
Birth assisted by   Djibouti, Ethiopia, Gambia, Guinea-Bissau, Madagascar, Mauritania, Mozambique, Niger,
skilled personnel


      16            Cameroon, Central African Republic, Democratic Republic of Congo, Djibouti,
  Vaccination       Ethiopia, Gambia, Ghana, Lesotho, Liberia, Madagascar, Mauritania, Mozambique, South
                    Sudan, Sudan, Tanzania, Togo, Uganda

      16            Benin, Burundi, Cameroon, Chad, Central African Republic, Congo, Djibouti, Gambia,
   PMTCT
                    Uganda

       11           Benin, Botswana, Cameroon, Chad, Central African Republic, Democratic Republic of Congo,
HIV treatment       Djibouti, Ethiopia, Mozambique, South Africa, Uganda

       8
    Schools         Burkina Faso, Burundi, Cameroon, Chad, Mauritania, Niger, South Sudan, Tanzania

       7            Benin, Chad, Central African Republic, Democratic Republic of Congo, Lesotho, Niger,
    Policies        South Sudan

       4            Benin, Burkina Faso, Comoros, Niger
     Laws
                                              CARMMA Report 2013
                                                                                                                      11
                                                                                                                      13
country highlighTs
      Botswana       Cameroon                           Government health
                                                            expenditure as a
                                                                                                                                  Government health
     Neonatal Mortality Rate         Maternal
                                Mortality Ratio   17%             percentage
                                                        of total government
                                                                 expenditure   Neonatal Mortality Ratio         Maternal
                                                                                                           Mortality Ratio   9%
                                                                                                                                      expenditure as a
                                                                                                                                            percentage
                                                                                                                                  of total government
                                                                                                                                           expenditure




                     11            160
                                                                                               33
                               100,000                                                                        690
                                                                                                          100,000
       Following the launch of CARMMA in 2011, the                                 Following the launch of CARMMA by the
       Ministry of Health, working through the Safe                                First Lady, Mrs. Chantal Biya, on May 8,
       Motherhood Initiative Programme and its Public                              2010, the government developed the 2011-
       Relations Section, has collaborated actively with                           2013 national strategic plan on CARMMA,
       the media to enhance the public profile of the                              based on the Maputo Plan of Action. To
       campaign. One of Botswana’s most successful                                 support the Ministry of Public Health in
       maternal mortality reduction efforts has been in                            implementating the Plan of Action, UNFPA
       the very active and public work of her CARMMA                               led the development of the H4+ Joint
       champions. Botswana has started special training                            Programme to implement CARMMA in
       programmes that involve doctors, midwives, and                              Cameroon – the first of its kind in Cameroon.
       nurses, in a variety of subjects and skills.                                A first concrete result of CARMMA and its
                                                                                   supporting programme frameworks is the
                                                                                   decision by the Government of Cameroon to
                                                                                   open eight midwifery training schools across
                                                                                   the country – the last midwife in Cameroon
                                                                                   previously having graduated in 1987. The
                                                                                   second wave of 200 students is currently
                                                                                   being trained as midwives. Among other
                                                                                   recent developments is a project in the North
                                                                                   region to make obstetric kits (for deliveries
                                                                                   and caesarians) available to pregnant women
                                                                                   at a fixed price. This increased the number of
                                                                                   monthly deliveries, during a six-month period,
                                                                                   by about 70 per cent in participating health
                                                                                   facilities. UNFPA Cameroon also benefited
                                                                                   from the first debt-for-health Sectoral Wide
                                                                                   approach from the Government of Cameroon,
                                                                                   with debt relief funding from France. The
                                                                                   programme provides for an innovative
                                                                                   and large-scale training scheme for health
                                                                                   personnel on delivery of emergency obstetric
                                                                                   and neo-natal care, including prevention
                                                                                   of mother-to-child transmission of HIV in
                                                                                   Cameroon’s three northern regions.




12                                                      CARMMA Report 2013
Niger
                                                                                                                               Government health
                                                                                                                                   expenditure as a
                                                                           Neonatal Mortality Ratio         Maternal
                                                                                                       Mortality Ratio   11%             percentage
                                                                                                                               of total government
                                                                                                                                        expenditure




                                                                                           32             590
                                                                                                      100,000
                                                                           The launch of CARMMA in Niger took place on
                                                                           December 20, 2011. CARMMA builds on the road

       Ethiopia                                                            map already in place for accelerating the reduction
                                                                           of maternal and neonatal mortality for the period
                                                                           2006-2015.
                                                    Government health
                                                        expenditure as a
                                                                           Since the launch there has also been a mobilization
Neonatal Mortality Rate          Maternal
                            Mortality Ratio   13%             percentage
                                                    of total government
                                                             expenditure
                                                                           of resources with partners such as UNFPA,
                                                                           UNICEF, WHO and a variety of local organizations
                                                                           such as Animas SUTURA; Association Nigerienne
                                                                           pour le Bien Etre Familial (ANBEF); Societé
                                                                           Nigerienne des Produits Petroliers (SONIDEP);
                  31          350                                          Loterie Nationale du Niger (LOLANI); and Rimbo
                                                                           Transport Passengers. Also involved are a lot of
                          100,000                                          associations and groups, including religious, women’s
                                                                           and youth groups. In the area of health systems
    During the launch of CARMMA on 23 February                             strengthening, Niger has undertaken massive
    2010, the Minister of Health, Hon. Tedros Adhanom,                     recruitment and allocation of health care providers,
    pointed out the importance of having facility-based                    including 536 doctors; ordered equipment and
    interventions in addition to community-based ones.                     materials; purchased an ambulance for emergency
    CARMMA has led to special services on maternal                         cases, and enhanced communication within the
    mortality reduction, as an integral part of the                        system using SSB radios. Childbirth and caesarean
    Health Sector Development Programme and the                            section kits have also been provided in health
    Maternal and Newborn Health road map. Among                            facilities. With reference to the development
    the most significant developments is that the month                    of monitoring & evaluation systems, there are
    of December is now recognized and dedicated                            efforts to strengthen supervision, and monitoring
                                                                           of care providers. Currently, clinical audits of
    nationally to advocacy of the reduction of maternal
                                                                           maternal deaths take place at health facility level,
    mortality.                                                             but there is institutionalization of clinical auditing
                                                                           in the new PDS 2011–2015, including training of
                                                                           trainers on clinical audit across the country. In the
                                                                           implementation of the Maputo PoA in the context




        >
                                                                           of the African Health Strategy, Niger has so far seen
                                                                           a reduction of maternal mortality by 14 per cent
                                                                           between 2006 and 2010, and infant mortality by 34
                                                                           per cent.



                                                             CARMMA Report 2013
                                                                                                                                                      13
Ghana                                                                   Nigeria
                                                        Government health
                                                            expenditure as a

                                                  12%
     Neonatal Mortality Rate         Maternal                     percentage                                                       Government health
                                                        of total government                                                            expenditure as a
                                Mortality Ratio
                                                                 expenditure   Neonatal Mortality Rate           Maternal
                                                                                                            Mortality Ratio   4%             percentage
                                                                                                                                   of total government
                                                                                                                                            expenditure




                     29            350
                               100,000                                                         39            630
                                                                                                         100,000
     Under the guidance of the then First Lady, Mrs.
     Ernestina Naadu Mills, CARMMA made tremendous                              Nigeria launched CARMMA in October 2009, with a
     strides in Ghana after the national launch in 2009.                        focus on aligning and integrating CARMMA within its
                                                                                existing programmes, especially the Integrated Maternal,
     She also formed a technical team from among staff
                                                                                Newborn and Child (IMNCH) Strategy. CARMMA in
     in the Ghana Health Service, UNFPA and her office,                         Nigeria focuses on partnerships at the three tiers of
     which was tasked with formulating a concept paper                          Government – Federal, State and Local Government
     that enabled her to take the message to the nation’s                       – in collaboration with development partners. It aims
     10 administrative regions, which include 170 districts                     to improve maternal health with the introduction of
     and 33 sub metros. She ensured that the traditional                        the Midwives Scheme and the rural posting of resident
     authorities were included because they wield a lot                         doctors or medical officers to improve skilled birth
     of power and have a critical role to play in reducing                      attendants, the provision of contraceptives and other
     maternal deaths. At the launches, Municipal and                            life-saving commodities for Maternal, Newborn and
     District Assemblies made a variety of maternal                             Child Health, and increase budgetary support to
     health commitments that include the development                            MNCH.
     of basic infrastructure, transportation, provision                         Nigeria has reduced the Maternal Mortality Ratio
                                                                                (MMR) from 1100 per 100,000 live births in 1990 to the
     of equipment, personnel training, free ambulance
                                                                                current figure of 545 per 100,000, according to Nigeria’s
     services, CHPS compounds and antenatal clinics.                            latest Demographic and Health Survey (DHS 2008).
     Each region and district of Ghana has pledged to                           Since the launch of CARMMA, Nigeria has developed
     make commitments and contributions to reduce                               a National Strategic Health Development Plan and
     maternal mortality by ensuring the provision of                            adopted a National Road Map for CARMMA. It has also
     services and infrastructure (including transport) that                     seen increases in resources for reproductive health. For
     has a direct bearing on reducing maternal deaths                           example, in addition to several investments into MNCH,
     witnin their respective districts and municipalities.                      the Nigerian Government provided about $3 million for
     These commitments are reviewed yearly as part of                           contraceptives in 2012. There is continued engagement
     the MDG Acceleration Framework (MAF) – Ghana                               of all stakeholders, especially policy makers, as well as
     Action Plan.                                                               collaboration among maternal, newborn and child health
                                                                                partners, including civil society organizations. Nigeria
                                                                                reported a pilot study on community-based access to
                                                                                injectable contraceptives; promotion of the use of anti-
                                                                                shock garments, Misoprostol and magnesium sulphate
                                                                                in the management of post-partum haemorrhage
                                                                                and eclampsia; and free distribution of contraceptive
                                                                                commodities at Government health facilities. President
                                                                                Goodluck Ebele Jonathan, as a leading voice for health
                                                                                improvement in Africa and through his work as Co-
                                                                                Chair of the United Nations Commission on Life-Saving
                                                                                Commodities for Women and Children, as well as
                                                                                his Saving One Million Lives Initiative, has reaffirmed
                                                                                his commitment to intensify maternal health and
                                                                                newborn interventions in Nigeria. He is also committed
                                                                                to mobilizing other African Heads of State and
                                                                                Government to provide fresh impetus to CARMMA and
                                                                                its follow-up implementation.




14                                                       CARMMA Report 2013
Rwanda                                            Government health
                                                                               The Gambia                                    Government health
                                                       expenditure as a                                                          expenditure as a
Neonatal Mortality Rate         Maternal
                           Mortality Ratio   20%             percentage
                                                   of total government
                                                            expenditure
                                                                          Neonatal Mortality Rate         Maternal
                                                                                                     Mortality Ratio   11%             percentage
                                                                                                                             of total government
                                                                                                                                      expenditure




                21            340                                                         34            360
                          100,000                                                                   100,000
 Rwanda has made remarkable strides in maternal
                                                                             Development of the National Road Map for the
 mortality reduction. The Maternal Mortality Rate
                                                                             Implementation of CARMMA in The Gambia
 in 2010 was 487 per 100,000 live births, which is
                                                                             is being undertaken by the National Assembly
 high, but only five years earlier, it stood at 750 per
                                                                             Select Committee on Health. The launch of the
 100,000. Similarly, in 2007/2008, the Infant Mortality
                                                                             campaign on 24 July 2010 by Her Excellency, Dr.
 Ratio in Rwanda was 62 per1000 while in 2010 it
                                                                             Isatou Njie Saidy, the Vice-President, has been
 was 50 per 1000. CARMMA in Rwanda is coupled
                                                                             followed in four regions with social mobilization,
 with the White Ribbon Alliance (WRA) Initiative,
                                                                             behaviour change communication/Information
 which was launched in 2009 with the objective of
                                                                             Education Counselling, publicity, awareness-
 completing national efforts to reduce maternal
                                                                             raising and community sensitization activities.
 mortality and morbidity.
                                                                             These activities have involved the regional
 The WRA strategic plan (2010-2015) is being
                                                                             governors as well as women’s groups and staff
 implemented and it has a key role in uniting the
                                                                             of the Ministry of Health. Some of the activities
 multiple programmes in support of safe motherhood
                                                                             in the regions involved resource mobilization
 around one framework of action. The role and
                                                                             and partnership with the private sector, civil
 commitment of the First Lady, H.E Mrs. Jeannette
                                                                             society and other agencies, cofunded by UNFPA
 Kagame, who launched CARMMA in 2010
                                                                             and regional authorities. The government has
 and brought together many stakeholders, is
                                                                             pledged to continue to support activities on
 significant in the overall drive to reduce maternal and
                                                                             maternal mortality, and there is funding from
 newborn deaths in the country. With Mrs. Kagame
                                                                             The Global Fund to strengthen the health
 as patron, WRA’s board of high level decision makers
                                                                             systems through capacity building. Since 2010,
 and representatives from diverse areas can influence
                                                                             hospitals have been carrying out maternal death
 policies and laws in support of safe motherhood
                                                                             audits, funded by UNFPA, and this has been
 as a human right. As part of the national efforts,
                                                                             expanded to all the regional hospitals and the
 on 11 November 2011, WRA organized a one-day
                                                                             main referral hospital. With the support of
 workshop to increase media awareness of safe
                                                                             UNFPA, WHO and the Global Fund, efforts are
 motherhood and equip journalists on the subjects of
                                                                             underway to improve the capacity of health
 maternal health and family planning.
                                                                             care workers, particularly midwives and those
                                                                             rendering emergency obstetric services. Among
                                                                             the notable local efforts, some communities have
                                                                             developed a funding mechanism through which
                                                                             women preparing for hospital deliveries may
                                                                             obtain interest-free loans for transportation.




                                                      CARMMA Report 2013
                                                                                                                                                    15
Malawi
                                                                               Republic
                                                        Government health
                                                            expenditure as a
     Neonatal Mortality Rate         Maternal
                                Mortality Ratio   14%             percentage
                                                        of total government
                                                                 expenditure




                     27            460
                                                                               of Benin                                           Government health
                                                                                                                                      expenditure as a

                               100,000
                                                                               Neonatal Mortality Rate         Maternal
                                                                                                          Mortality Ratio   10%             percentage
                                                                                                                                  of total government
                                                                                                                                           expenditure



         Malawi was one of the first countries to launch
         CARMMA, on 7 August 2009. It was launched by
         President Joyce Banda (then Vice President). A
         number of CARMMA campaign activities, with
                                                                                               31            350
         Maternal and Newborn Health messages, are being                                                 100,000
         disseminated by radio and television. UNFPA,                           CARMMA was launched in Benin on 27 October
         in collaboration with implementing partners,                           2010, and a National Road Map was developed
         has set up a Media Network on Population and                           and implemented for the duration of the campaign
         Development (MENPOD), which continuously                               in that year. During CARMMA week in 2011,
         advocates and increases awareness on CARMMA-                           that roadmap was revised. Different strategies
         related issues. Malawi has a revised Road Map                          have been adopted in the social mobilization
         on accelerating the reduction of maternal and                          campaign, including free offer of contraceptives
         neonatal morbidity and mortality in the country,                       and voluntary testing for HIV; interaction with
         and the Reproductive Health strategy also has a                        young people; spotlight on reducing maternal
         component on reduction of maternal mortality                           mortality; dissemination of messages through
         through improved maternal health. CARMMA is                            community radio stations; use of billboards across
         making a significant impact in the country because                     the country to display messages; and development
         it is bringing services closer to the community,                       of a short film on the fight against maternal
         and promoting access to Sexual and Reproductive                        mortality. Most of these activities were extended
         Health services. The training of more midwives                         during the CARMMA week in 2011. CARMMA
         is improving skilled attendance at birth, despite                      has had a very positive impact in the country,
         transfers and the movements of medical workers,                        enjoying the support of many activities by partners,
         thereby leading to lobbying for more donor support                     government institutions, traditional leaders, religious
         for Maternal and Neonatal Health interventions.                        organizations, civil society and communities. In
                                                                                the area of resources, while preparing to launch
                                                                                the campaign in 2010, resources were mobilized
                                                                                from technical and financial partners (UNFPA,
                                                                                WHO, UNAIDS, European Union, USAID, Care
                                                                                International, and Population Services International
                                                                                (PSI). Similarly, with the support of UNFPA and
                                                                                other partners, a national strategy to integrate HIV/
                                                                                RH was developed and validated by the Ministry of
                                                                                Health.




16                                                              CARMMA Report 2013
Swaziland                                       Government health
                                                                             Togo
                                                       expenditure as a
Neonatal Mortality Rate         Maternal
                           Mortality Ratio   10%             percentage
                                                   of total government
                                                                                                                             Government health
                                                                                                                                 expenditure as a
                                                            expenditure   Neonatal Mortality Rate         Maternal
                                                                                                     Mortality Ratio   15%             percentage
                                                                                                                             of total government
                                                                                                                                      expenditure




                35            320
                          100,000                                                         36            300
                                                                                                    100,000
 In 2009, Swaziland made history by becoming
 one of Africa’s first nations to launch CARMMA.                             Following the launch of CARMMA by the
 An implementation framework is now in place,                                Republic of Togo on 14 September 2010,
 and CARMMA activities have been incorporated                                a framework for accelerating Millenium
 into the National Sexual and Reproductive Health                            Development Goals 4 and 5 was developed.
 (SRH) programme Annual Work Plan. A dialogue                                The nation then embarked on developing a
 for Members of Parliament on the implementation                             new Health Development Plan as the central
 of the Maputo Plan of Action resulted in Parliament                         axis of maternal health. The national launch of
 pressurizing the Ministry of Health to develop a                            CARMMA was followed by the establishment
 national SRH Policy, which is now at the finalization                       of “committees of men to support the health of
 stage. Since 2011, several regional dialogues in                            mothers and children.” Togo is also developing
 support of CARMMA have been undertaken by the                               a new coordination mechanism for financing
 Reproductive Health programme of the Ministry of                            the health sector, through its membership of
 Health. Political commitment in support of maternal                         the International Health Partnership (IHP) and
 health has been initiated by the Ministry of Health.                        is currently receiving funding from the French
 Among others, it hosted a national symposium on                             Government, through the G-8 MUSKOKA
 sustainable financing for reproductive, maternal,                           Initiative on Maternal, Newborn and Child
 newborn and child health in the country, procured                           Health, to support maternal health. The
 for the six hospitals that provide maternity services.                      campaign has had a very positive impact in Togo,
 Prevention of Mother-To-Child Transmission                                  with many activities receiving the support of
 equipment and testing reagents for CD4 cell machine                         partners, Government institutions, traditional
 were also procured. Swaziland has also developed a                          and religious leaders and communities.
 quarterly review system, followed by an annual review.                      CARMMA has become a gateway to many
 A triennial report (2008-2010) was published in 2011.                       stakeholders in the field of promoting women’s
                                                                             rights.




                                                       CARMMA Report 2013
                                                                                                                                              17
Zimbabwe                                          Government health
                                                                                                                                expenditure as a
                                                                          Neonatal Mortality Rate         Maternal
                                                                                                     Mortality Ratio   9%             percentage
                                                                                                                            of total government




       Zambia
                                                                                                                                     expenditure




                                                   Government health

Neonatal Mortality Rate         Maternal
                           Mortality Ratio   16%
                                                       expenditure as a
                                                             percentage
                                                   of total government
                                                                                          30            570
                                                            expenditure
                                                                                                    100,000
                                                                             CARMMA is being implemented within the nation’s
                                                                             Maternal and Neonatal Road map (2007- 2015).
                27            440                                            The national task force, charged with advocating
                          100,000                                            and monitoring the implementation of the campaign,
                                                                             has mobilized resources for Maternal and Neonatal
       When President Rupiah Bwezani of Zambia                               Health (MNH). It is also advocating for increased
       launched CARMMA on 12 June 2010, he made                              funding for health on the basis of the Abuja target of
       history by being the first African Head of State                      15 per cent. The Ministry of Health and Child Welfare
       to be personally and directly involved in such a                      has also set up a Health Transition Fund (HTF). Some
       launch. CARMMA has contributed to increased                           of the major areas of support by the HTF involve
       government commitment for Maternal Neonatal                           health systems strengthening, as well as the removal
       and Child Health (MNCH) and increased                                 or subsidizing of user fees for maternal health, which
       resources from the Government and donors.                             has been one of the barriers to accessing maternal
       There have been increased referrals for Sexual                        health. The Ministry of Health, with support from
       and Reproductive Health (SRH) and delivery,                           development partners, has scaled up support to 18
       and local chiefs are now champions for Maternal                       active midwifery schools through the procurement
       Health. Most multilateral and bilateral donors                        of midwifery teaching models and textbooks. More
       that pledged support before the launch have                           than 200 nurses have been trained in Emergency
       increased resources for MNCH. Among                                   Obstetric and Neonatal Care (EmONC) by the
       them, USAID procures contraceptives; DfID                             Ministry of Health since the launch of CARMMA.
       has initiated a Maternal Health programme,                            Some strategies have been vital for CARMMA in
       Mobilizing Access to Maternal Health Services                         Zimbabwe. They include the integration of CARMMA
       in Zambia (MAMAZ); UN H4+, in partnership                             into existing MNH strategies, which is critical for
       and collaboration with the Ministry of Health,                        the sustainability and visibility of the campaign, by
       has secured funding from the Canadian                                 ensuring Government ownership of the campaign.
       International Development Agency (CIDA)                               Another important factor is the development and
       for Maternal Health; and the Ministry has                             implementation of an integrated plan towards MNH,
       increased the contraceptive procurement                               Nutrition, Family Planning, HIV and Malaria to ensure
       budget line. The Ministry of Health has also                          meaningful utilization of limited resources. Despite
       introduced mentorships for MNCH in order to                           these, CARMMA has had a positive impact, especially
       strengthen the skills of providers. With support                      the increased commitment of the Government
       from UNFPA and the EU, the Ministry of                                towards maternal and neonatal health issues, evidence
       Health is promoting integrated HIV/ AIDS and                          of which may be seen in the implementation of the
       Reproductive and Family Services, through the                         UN strategy on Women’s and Children’s health, which
       implementation of a programme to strengthen                           is aligned to CARMMA.
       SRH/HIV linkages.




18                                                             CARMMA Report 2013
Uganda
Neonatal Mortality Rate          Maternal
                            Mortality Ratio   12%   Government health
                                                        expenditure as a
                                                              percentage
                                                    of total government
                                                             expenditure




                28            310
                          100,000
    CARMMA is having a positive impact on the
    visibility of maternal and neonatal health issues in
    Uganda. It enjoys parliamentary support. Religious
    and cultural institutions have been mobilized, and
    there are signed commitments with 12 of the 15
    cultural institutions in the country. The UNFPA
    Country Office has developed and implemented
                                                                             Kenya                                           Government health
                                                                                                                                 expenditure as a
    a resource mobilization plan that has yielded                          Neonatal Mortality Rate         Maternal
                                                                                                      Mortality Ratio   7%             percentage
                                                                                                                             of total government
                                                                                                                                      expenditure
    over USD 15 million for Sexual and Reproductive
    Health in the last 2 years. The Ministry of Health
    also created an alternative distribution channel
    for Reproductive Health Commodities, including
    contraceptives, through a public-private partnership                                   27            360
    with the Uganda Health Marketing Group, a social                                                 100,000
    marketing organization. Towards the provision of
                                                                             The launch of CARMMA in Kenya, in
    sustainable funding, Uganda is in the process of
                                                                             November 2010, led to increased publicity and
    establishing a National Health Insurance Scheme
                                                                             donor engagement on Maternal and Newborn
    as a health financing mechanism. The Government
                                                                             Health. Prior to the launch of CARMMA in
    acquired a World Bank Loan of USD 130 million for
                                                                             the country, in August 2010, the Government
    health. Towards strengthening the health system,
                                                                             launched a Maternal and Newborn Health
    a bursary scheme for the training of midwives has
                                                                             (MNH) Road Map, the objective of which is the
    been introduced with support from development
                                                                             achievement of the Millenium Development
    partners, including the Danish International
                                                                             Goals. At the primary and referral levels,
    Development Agency and UNFPA, as a strategy to
                                                                             hospital reforms are continuing. Monitoring
    improve staffing and retention of staff in hard-to-
                                                                             and evaluation systems have also been
    reach and underserved districts. A community-
                                                                             strengthened. An annual national maternal
    based Health Information Management System
                                                                             mortality audit has not been carried out yet,
    has been put in place. The Government has also
                                                                             but Maternal Death Surveillance and Response
    made maternal death a notifiable condition, and
                                                                             is being implemented. Reorientation of some
    Maternal and Peri-natal Death Reviews have been
                                                                             health facility staff was undertaken during the
    institutionalized with notification to the Ministry of
                                                                             first half of 2012 to ensure that regular reviews
    Health required within 24 hours.
                                                                             are conducted and reports submitted.



                                                      CARMMA Report 2013
                                                                                                                                            19
Sierra Leone                                       Government health
                                                                                                                                       expenditure as a
                                                                                 Neonatal Mortality Rate         Maternal
                                                                                                            Mortality Ratio   6%             percentage
                                                                                                                                   of total government
                                                                                                                                            expenditure




      Eritrea                                            Government health
                                                                                                 49            890
                                                                                                           100,000
                                                             expenditure as a
                                                                                The launching of CARMMA in March 2010 was
     Neonatal Mortality Rate           Maternal
                                  Mortality Ratio   4%             percentage
                                                         of total government
                                                                  expenditure   strongly supported by President Ernest Bai
                                                                                Koroma, who, the following month, launched a
                                                                                CARMMA-related free health service of health
                                                                                care facilities for pregnant and breastfeeding
                     21            240                                          women, and for children under five years old. The
                               100,000                                          Government, for the first time, made a pledge to
                                                                                provide contraceptives costing $165,000 per year.
     At the launch of CARMMA in Eritrea, in September                           Strengthening of health systems was identified in
     2010, the Hon. Minister of Health, Ms.                                     the National Health Sector Strategic Plan 2010-
     Amina Nurhussien, pledged the commitment of her                            2015 as an important objective, and assessment of
     Ministry to the accelerated reduction of maternal                          health systems is now being done and strategies
     and perinatal mortality in Eritrea. The focus of the                       are being put in place to address areas that
     Ministry of Health is on such effective strategies                         need to be strengthened. In the area of capacity
     as awareness of clients, families and communities                          building of health workers, a growing partnership
     to make preparations for delivery by skilled birth                         consisting of the government, UN agencies and
     attendants in health facilities; expanding maternity                       NGOs is coordinating capacity building of health
     waiting homes; improving access to fully functional                        workers. Among other initiatives, the Canadian
     basic and comprehensive emergency obstetric care                           International Development Agency initiative is
     facilities; ensuring availability of equipment, supplies,                  sponsoring 100 student midwives per annum for
     drugs and human resources; introducing life-saving                         three consecutive years. The Maternal Health
     drugs such as Magnesium sulphate and Misoprostol;                          Thematic Fund and the Global Programme to
     expanding postpartum home visits within 24 hours                           Enhance Reproductive Health Commodity Security
     and three days of delivery; and strengthening the                          have also been supporting the training of midwives
     programme on fistula prevention, treatment and                             and strengthening of the Midwifery Association. In
     reintegration. The programme is strengthening the                          February 2012, 55 State-registered
     health system by empowering young doctors to                               Nurses graduated from the National Midwifery
     provide Emergency Obstetric and Neonatal Care,                             School Freetown campus, while 75 State-enrolled
     including caesarean deliveries. Also, strategic health                     Community Nurses graduated from the Makeni
     centres are being upgraded to community hospitals                          Midwifery school campus in April 2012.
     to enable them to perform Comprehensive
     Emergency Obstetric and Neonatal Care
     (CEmONC) functions. In terms of capacity building,
     in-service training is being given to midwives and
     other health care providers, as well as to young
     doctors, in the provision of CEmONC services.




20                                                           CARMMA Report 2013
Tanzania
Neonatal Mortality Rate          Maternal
                            Mortality Ratio   14%
                                                    Government health
                                                        expenditure as a
                                                              percentage
                                                    of total government
                                                             expenditure
                                                                           Namibia
                                                                                                                                       Government health
                                                                           Neonatal Mortality Rate          Maternal
                                                                                                       Mortality Ratio   12%   expenditure as a percentage
                                                                                                                                      of total government
                                                                                                                                               expenditure


           25                 460
         1000             100,000
                                                                                      18                 200
        The introduction of CARMMA in Tanzania
        strengthened the nation’s efforts and
                                                                                    1000             100,000
        provided an opportunity for reflection                             Namibia was one of the first countries to launch
        on achievements made towards achieving                             CARMMA, in December 2009. Since the launch,
        MDG 5. CARMMA has provided visibility                              the political commitment of the First Lady
        for national planning and priority setting on                      Mrs. Penehupifo Pohamba, evident through her
        issues related to maternal health. The Health                      involvement as Patron of the maternal health
        Sector Strategic Plan is designed to focus on                      agenda, has proved to be one of the most important
        maternal health as a means of measuring the                        strategies of the campaign. More partners have
        health sector performance. The Government                          become aware of the need to address maternal
        under Sector Wide Approach (SWAp) is                               health issues. There has also been inter-sectoral
        currently formulating the national health                          collaboration at the national level, marked by the
        sector financial strategy. In collaboration                        involvement of various ministries and civil society
        with UNFPA, the Ministry of Health and                             in the national coordination mechanism, as well
        Social Welfare undertook an assessment of                          as the institutionalization of maternal, perinatal
        the midwifery situation in Tanzania. That                          and neonatal death review. Maternal death review
        report is guiding different interventions in                       tools have been launched and the review has been
        the country, including development of the                          institutionalized in all district hospitals. Resources
        midwifery programme. The Maputo Plan of                            have been made available to fund vacancies for
        Action has been domesticated in different                          nurses and midwives, but unavailability of manpower
        national plans, including the National Road Map                    has hindered the process. The Government is
        for Accelerating reduction of Newborn and                          negotiating with other countries to get nurses and
        Maternal Deaths.                                                   doctors into the country to fill vacant positions.
                                                                           CARMMA in Namibia is facing a number of
                                                                           challenges, including inadequate financial resources
                                                                           and health system strengthening at the primary level
                                                                           to deliver Basic Emergency Obstetric Care services.




                                                               CARMMA Report 2013
                                                                                                                                                      21
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013
CARMMA second publication 2013

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CARMMA second publication 2013

  • 1. www.carmma.org Campaign on Accelerated Reduction of Maternal Mortality in Africa No woman should die giving life. It’s within our reach. It’s in our hands. Stirring Continental success in Conscience VE IMPRO maternal into Action L T H MATERNAL HEA death reduction Africa is winning African Union Commission United Nations Population Fund
  • 2. FULL NAME Vision/Mission Connections/Linkages Campaign on Accelerated CARMMA : Our vision > UN Secretary General’s Global Strategy Reduction of Maternal Mortality Continental should die giving Stirring No Woman on Women’s and Children’s Health in Africa Conscience and Action life > Commission on Information and Accountability for Women’s and Our mission is to Children’s Health DATE OF BIRTH SuCCeSSreduce maternal, newborn on MAteRnAl accelerate action across Africa to 2009 deAth ReduCtion : > The UN Commission on Life-Saving and child mortality. Commodities for Women and Africa is winning Children Initiators Our strategic actions > Family Planning Summit on repositioning family planning African Union in collaboration with UNFPA and others 1. Build on existing efforts to > The Global and Regional Partnerships improve maternal, newborn on Reproductive, Maternal, Newborn and child health across Africa and Child Health countries of Launches – particularly by sharing best practice. > The Thematic Think Piece for Health in the post 2015 UN Development Agenda 2012 South Africa 2. Generate and share data on maternal, newborn and child > The Save the Mother and Save the health. Child Initiative of the Prevention Botswana, Liberia, Democratic Republic and Elimination of Mother-to-Child of Congo, Gabon, Tanzania, Equatorial Transmission of HIV 2011 Guinea, Burundi, Burkina Faso, Tunisia and Niger. 3. Advocate for increased > Safe Motherhood Initiative political commitment, and mobilize domestic resources in > White Ribbon Alliance Initiative support of maternal, newborn Ethiopia, Sierra Leone, Central and child health. > The Continental Policy Framework African Republic, Uganda, Cameroon, for Sexual and Reproductive Health 2010 Mauritania, Lesotho, Zambia, and Rights Zimbabwe, Guinea Bissau, Senegal, Gambia, Eritrea, Angola, Togo, Benin, 4. Communicate with the > The Maputo Plan of Action Congo Brazzaville and Kenya. wider African public and inspire > The African Health Strategy action. > The Abuja Declaration on HIV/AIDS, Mozambique, Malawi, Rwanda, Nigeria, tuberculosis and other related 2009 Swaziland, Ghana, Namibia and Chad. infectious diseases 2 CARMMA Report 2013
  • 3. CONTENTS Page 5 : CARMMA in numbers Pages 6-7 : CARMMA stirs continental conscience into action Page 9 : Success in maternal death reduction: report shows Africa is on a winning track Page 10 : Trends in maternal mortality in Africa Page 11 : Steps towards achieving results Pages 12-30 : Country highlights Page 31 : CARMMA - main challenges Page 32-33 : Intersecting views: UNFPA African and Union Pages 34 : Youth for carmma This document was produced by Akinyele Eric Dairo, Olive Bonga, Adebayo Fayoyin, Lindsay Barnes. CARMMA Report 2013 3
  • 4. Her Excellency, Dr. Nkosazana Dlamini-Zuma, AUC Chairperson Women constitute more than 50 per cent of the continent’s population and their engagement in all spheres of human endeavour is imperative. Africa has unacceptably high maternal and infant mortality rates. What women in other countries – especially in the developed world – take for granted as a normal physiological function of giving birth and ensuring the continuation of the human race, on our continent means putting your life at risk. The death of a mother is not just the death of an individual. It means the survival of the young children that she may be leaving behind is not guaranteed, and if they survive, they may not reach their full potential in life. And of course, the loss of a mother is a loss to the family and the community. Africa has many accomplishments in which to take pride and confidence, including a 41 per cent reduction in maternal mortality. Progress on many fronts is dramatic with a new sense of optimism found right across the continent. But if the continent is to make the most of its rich potential, there are many challenges still to overcome. And none is bigger than further improving Africa’s still unacceptably high record on maternal health. While Africa has only 14 per cent of the world’s population, it accounts for well over half of all maternal deaths worldwide – deaths that are overwhelmingly avoidable. For it is not untreatable diseases but the lack of access to family planning, basic care around childbirth, skilled attendance, health checks and advice in pregnancy that are the main reasons for this loss of human life. It is a mark of the new determination across Africa, to remove obstacles to progress, that we are seeing a major drive to end this unnecessary death toll. The Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) was launched three years ago by the African Union, with the support of UNFPA, the United Nations Population Fund, which I am privileged to head. CARMMA has enjoyed tremendous support at the highest levels. We see success stories right across the continent, with strengthened health systems, increased funding and new partnerships between the public, private and voluntary Dr. Babatunde sectors. However, despite some remarkable results, over 450 women and girls continue to die in Africa every day from complications in Osotimehin, pregnancy or childbirth. If the continent is to continue the remarkable economic and social progress achieved over the last decade, then Executive Director, reducing child and maternal deaths must be a top priority. It is within United Nations our reach that no woman should die giving life. The realization of this commitment is also in our hands. Population Fund (UNFPA) 4 CARMMA Report 2013
  • 5. CARMMA in numbers 37 countries have 92% launched the campaign so far of countries have carried out activities that have fostered 50% political commitment of member states have strengthened their health systems, developed a monitoring and evaluation system or 41% reduction in maternal deaths in integrated HIV, reproductive health and family planning services Africa from 1990 to 2010 17% of member states have allocated or increased funding for maternal, newborn and child health (MNCH) and sexual and reproductive health and rights (SRHR) 57.5% of maternal deaths worldwide occur among women on the African continent 452 women are dying every day from pregnancy-related causes in Africa CARMMA Report 2013 5
  • 6. CARMMA Stirs Continental Conscience into Action The aim of CARMMA is to use the vehicles of policy dialogue, advocacy and community social mobilization to Maps; provision of sustainable become an integral part of the enlist political funding; the strengthening of health sector landscape and the commitment health systems; development maternal and neonatal health of monitoring and evaluation road map in Africa. throughout the mechanisms; promotion of Such integration of CARMMA into continent, increase integrated HIV and AIDS, and existing Maternal and Newborn strengthening of reproductive resources and boost and family planning services. Health (MNH) strategies is Maternal Health critical because of the need to Continentally, the campaign has A ensure government ownership of success continental launch, t the made tremendous progress the campaign, so as to boost its in 2009, countries since those early days, with sustainability and visibility. were urged to launch several countries adopting Countries such as Zimbabwe, the campaign and to develop National Road Maps and Namibia and Sierra Leone mechanisms for implementation developing Strategic Health now have extensive MNH and monitoring progress. Development Plans. CARMMA programmes. In Namibia, inter- has also become the platform Since the first national launch, by sectoral collaboration at the for mobilizing commitments and Mozambique on 3 August 2009, national level is marked by the support for the UN Secretary 37 countries have now launched involvement of various ministries General’s Global Strategy on the campaign: eight in 2009; 18 in and civil society in the national Women’s and Children’s Health 2010; 10 in 2011, and one in 2012. coordination mechanism. and the implementation of With launching comes the In Sierra Leone, access to care at the recommendations for the implementation of commitments, health facilities increased with free Commission on Information and policies and activities that include health care services for pregnant Accountability (COIA) of the community mobilization; the and lactating women and under- Global Strategy. CARMMA has development of National Road five children. The involvement 6 CARMMA Report 2013
  • 7. of civil society organizations in kits, and resuscitation equipment also becoming institutionalized monitoring RH commodities has for the adult and child. in many countries. In Namibia, also improved accountability and Cameroon has also begun a pilot maternal death review tools transparency. project in which obstetric kits are have been launched, and reviews In most countries that have being made available to pregnant are being put in operation in all launched the campaign, there women at a fixed price. It is district hospitals. Swaziland holds is broad engagement of all notable that as a result of this, quarterly review meetings as well stakeholders, and growing the number of monthly deliveries as an annual one; while in Gambia, collaboration among maternal, increased by about 70 per cent since 2010, hospitals have been newborn and child health in participating health facilities carrying out maternal death audits partners. within six months. with the assistance of UNFPA. Through CARMMA, Malawi In Uganda, the government has The strengthening of health is also aiming to bring MNH made maternal death a notifiable systems, including the training services closer to the community condition, and Maternal and Peri- of health workers, is being and promote access to Sexual natal Death Review (MPDR) emphasized in many countries, and Reproductive Health (SRH) has been institutionalized, with including Uganda, Botswana, services, including the provision notification to the Ministry of Gambia and Eritrea. With the of Depo-Provera to clients by Health required within 24 hours. support of partners, including UNFPA, With launching comes the “One of our priorities is Uganda operates Millennium Development a bursary scheme implementation of commitments, Goal 5 – improving for the training of policies and activities that include maternal health,” said midwives, while mobilization; the development of Mr. Bunmi Makinwa, Botswana has broad Director of UNFPA’s training programmes National Road Maps; provision East and Southern Africa for doctors, of sustainable funding; the Regional Office. The midwives, and nurses. UNFPA, WHO and strengthening of health systems; “2012 Status Newborn on Maternal, Report the Global Fund are development of monitoring and Child Health” supporting similar and evaluation mechanisms; points to unacceptably processes in Gambia. high maternal and child Eritrea is providing promotion of integrated HIV mortality and morbidity, in-service training and AIDS, and strengthening of despite some progress to midwives and reproductive and family planning in improving the health other health care of women and children: providers, as well as services. “Despite the progress to young doctors, in recorded, Africa is still health surveillance assistants; the provision of Comprehensive confronted with formidable while Nigeria is using anti- Emergency Obstetric and challenges as it strives towards shock garments, Misoprostol Neonatal Care (CEmONC) the attainment of the MDGs, and magnesium sulphate in the services, with Intrauterine Device especially MDGs 4 and 5 by management of post-partum (IUD) and Norplant insertions 2015,” says the report. haemorrhage and eclampsia. introduced following the launch Continentally, Africa has woken of CARMMA in the country. One of the most important up to the wise words of Former Many countries, including dimensions of the work that Zambian president Rupiah Swaziland, Ghana and Malawi, are is going on throughout Africa Bwezani Banda: “Maternal going ahead with the provision on maternal mortality is the mortality is not only an injustice, of facilities and equipment aimed remarkable use of partnership and it is also a tragedy.” at providing the best care for collaboration. Rwanda decided to pregnant women and newborns. merge CARMMA with the White On account of the commitment Swaziland has equipped a Ribbon Alliance (WRA) Initiative of African leaders and their regional hospital with basic in national efforts to reduce development partners, “No MNH equipment such as a digital maternal mortality and morbidity. Woman Should Die Giving Life”. Doppler, scanner, and delivery Maternal mortality review is CARMMA Report 2013 7
  • 8. CARMMA Timeline 2013 Carmma special event on “Reinforcing the Campaign 2011 At the 5th session of the on Accelerated Reduction in Maternal Mortality Pan African Parliament in Africa” at the 2006 twentieth in Johannesburg, it was stressed that maternal, 2012 Ordinary Session Africa, through the Maputo Plan of Action, 2010 The African Union newborn and infant health is critical to overall human and social Launch of the CARMMA of the Assembly of the African Union, organized by the Department of Summit in Uganda development in Africa, website (www. Social Affairs of declared the and governments were carmma.org) by equivalent was convened urged to devote greater the Department of the African Union of a state of under the theme: financing towards the Social Affairs of Commission, in emergency on “Maternal, Infant health of women and the African Union collaboration maternal and and Child Health children. Commission. with UNFPA child health. and Development in and the African Africa.” Development Bank. 2009 2013 Launch of 2011 The African Union 2012 UNFPA, Expected outcomes: Carmma Conference of Ministers of Health expanded the World Health Organization (WHO) and - Reinforcing commitment to Maternal Health - Increase in financial CARMMA to include the United Nations newborn and child Children’s Fund (UNICEF) resources for Maternal health, asthmandated held a regional workshop Health by the 15 Ordinary on maternal death review - Intensified actions on Session of the AU with representatives Maternal and Neonatal Assembly. from 26 sub-Saharan Health. African countries, in Burkina Faso and Tanzania. Countries that are preparing to launch CARMMA Côte d’ivoire Comoros Mauritius South sudan Mali Sudan 8 CARMMA Report 2013
  • 9. Success in maternal death reduction Report Shows Africa is on a Winning Track Among the more prominent success stories for Africa, the report shows that Equatorial Guinea has achieved MDG5, one of 10 countries worldwide that did so during the period. Its maternal death rate dropped by 81 per cent, from 1200 to 240 per 100,000 live births, between 1990 and 2010. W ith the majority of African countries having implemented CARMMA, 2012 Africa had the highest maternal mortality ratio at 500 maternal deaths per 100,000 live births. In increments, with the biggest drop recorded between 2005 and 2010 - from 630 to 500 deaths per bore good news in the form of an Africa, a woman still faces a one- 100,000 live births (see Trends in impressive 41 per cent decline in in-39 lifetime risk of dying due to Maternal Mortality: 1990 to 2010, maternal mortality in Africa from pregnancy or childbirth-related Page 56). 1990 to 2010, according to the complications; that risk is one in Five countries in sub-Saharan report Trends in Maternal Mortality: 3,800 in developed countries. Africa - Botswana, Lesotho, 1990 to 2010 by the World Among the more prominent Namibia, South Africa and Health Organization (WHO), success stories for Africa, the Swaziland - showed an increase United Nations Children’s Fund report shows that Equatorial in maternal deaths from 2000 (UNICEF) and the United Nations Guinea has achieved MDG 5, one to 2005 on account of HIV, Population Fund (UNFPA). of 10 countries worldwide that but their maternal mortality While there were 850 deaths per did so by 2010. Its maternal death rates are currently dropping 100,000 live births in 1990, that rate dropped by 81 per cent, from as antiretroviral treatment has rate had declined to a regional 1200 to 240 per 100,000 live births. become more available. average of 500 deaths per 100,000 Eritrea is considered on track to While substantial progress has live births by 2010, with no fewer achieve MDG 5, its maternal death been achieved in almost all than 24 of the 46 sub-Saharan rate having dropped from 880 to regions, many African countries countries achieving a reduction of 240 per 100,000 live births. will be particularly encouraged more than 40 per cent. by this report in their efforts The report shows that in 2010, The publication also demonstrates to reach the MDG target of while the global maternal mortality how, beginning in 1990, the decline reducing maternal deaths by 75 ratio was 210 maternal deaths per in maternal mortality numbers per cent by 2015. 100,000 live births, sub-Saharan became more rapid in five year CARMMA Report 2013 9
  • 10. Trends in maternal mortality The target of Millennium Development Goal 5A (MDG 5A) is to reduce maternal mortality by three quarters (75 per cent) by 2015. This graphic shows each country’s percentage of progress made. (source: trends in maternal mortality, 1990-2010, Who, UNICEF, UNFPA and the World Bank, 2012.) +33% Congo Zimbabwe +25% +21% South Africa Lesotho +19% +15% Somalia Chad +15% Botswana +14% +7% Swaziland Cameroon +3% +2% Namibia Central African Republic -4% -9% Kenya Gabon -15% -26% Burundi Guinea-Bissau -29% -30% Sierra Leone Zambia -37% -40% Ghana Nigéria -41% -42% DRC Côte d’Ivoire -43% -45% Sénégal Mozambique -46% -47% Tanzania and Uganda Guinea and Gambia -50% -51% Mali and Togo Niger -53% -54% São Tomé & Príncipe Benin -55% -57% Burkina faso Malawi -59% -61% Cape Verde Angola and Madagascar -62% -63%Rwanda Ethiopia -64% -73% Eritrea MDG 5: reduce maternal Equatorial Guinea -81% mortality by 75% 10 CARMMA Report 2013
  • 11. Steps are the most popular strategies What towards achieving results CARMMA is a conducive platform to implement different strategies and actions. The 24 graphic below shows the most popular ones among African countries. Benin, Burundi, Chad, Central African Republic, Democratic Republic of Congo, Djibouti, Budget Gambia, Ghana, Guinea, Guinea-Bissau, Lesotho, Liberia, Madagascar, Mauritania, Niger, Nigeria, Rwanda, Sao Tome et Principe, Senegal, South Sudan, Sudan, Tanzania, Zambia, Zimbabwe 22 Family Benin, Burundi, Cameroon, Chad, Central African republic, Congo, Democratic Republic of Congo, planning/ contraceptives Djibouti, Gambia, Ghana, Guinea-bissau, Lesotho, Madagascar, Mauritania, Mozambique, Niger, Sao Tome et Principe, Senegal, South Sudan, Tanzania, Uganda, Zambia 21 Health Cameroon, Chad, Central African Republic, Congo, Democratic Republic of Congo, facilities Djibouti, Guinea, Guinea-Bissau, Kenya, Liberia, Madagascar, Malawi, Mauritania, Mozambique, Niger, Rwanda, Senegal, South Sudan, Sudan, Tanzania, Uganda 20 Human Burkina Faso, Burundi, Cameroon, Chad, Congo, Djibouti, Ethiopia, Guinea, Guinea-Bissau, resources Kenya, Liberia, Malawi, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Sudan, Tanzania 19 Free Benin, Burkina Faso, Cameroon, Chad, Comoros, Congo, Ghana, Guinea, Lesotho, services Liberia, Malawi, Mali, Niger, Nigeria, Sierra Leone, South Sudan, Sudan, Tanzania, Zimbabwe 16 Burundi, Chad, Central African Republic, Congo, Democratic Republic of Congo, Birth assisted by Djibouti, Ethiopia, Gambia, Guinea-Bissau, Madagascar, Mauritania, Mozambique, Niger, skilled personnel 16 Cameroon, Central African Republic, Democratic Republic of Congo, Djibouti, Vaccination Ethiopia, Gambia, Ghana, Lesotho, Liberia, Madagascar, Mauritania, Mozambique, South Sudan, Sudan, Tanzania, Togo, Uganda 16 Benin, Burundi, Cameroon, Chad, Central African Republic, Congo, Djibouti, Gambia, PMTCT Uganda 11 Benin, Botswana, Cameroon, Chad, Central African Republic, Democratic Republic of Congo, HIV treatment Djibouti, Ethiopia, Mozambique, South Africa, Uganda 8 Schools Burkina Faso, Burundi, Cameroon, Chad, Mauritania, Niger, South Sudan, Tanzania 7 Benin, Chad, Central African Republic, Democratic Republic of Congo, Lesotho, Niger, Policies South Sudan 4 Benin, Burkina Faso, Comoros, Niger Laws CARMMA Report 2013 11 13
  • 12. country highlighTs Botswana Cameroon Government health expenditure as a Government health Neonatal Mortality Rate Maternal Mortality Ratio 17% percentage of total government expenditure Neonatal Mortality Ratio Maternal Mortality Ratio 9% expenditure as a percentage of total government expenditure 11 160 33 100,000 690 100,000 Following the launch of CARMMA in 2011, the Following the launch of CARMMA by the Ministry of Health, working through the Safe First Lady, Mrs. Chantal Biya, on May 8, Motherhood Initiative Programme and its Public 2010, the government developed the 2011- Relations Section, has collaborated actively with 2013 national strategic plan on CARMMA, the media to enhance the public profile of the based on the Maputo Plan of Action. To campaign. One of Botswana’s most successful support the Ministry of Public Health in maternal mortality reduction efforts has been in implementating the Plan of Action, UNFPA the very active and public work of her CARMMA led the development of the H4+ Joint champions. Botswana has started special training Programme to implement CARMMA in programmes that involve doctors, midwives, and Cameroon – the first of its kind in Cameroon. nurses, in a variety of subjects and skills. A first concrete result of CARMMA and its supporting programme frameworks is the decision by the Government of Cameroon to open eight midwifery training schools across the country – the last midwife in Cameroon previously having graduated in 1987. The second wave of 200 students is currently being trained as midwives. Among other recent developments is a project in the North region to make obstetric kits (for deliveries and caesarians) available to pregnant women at a fixed price. This increased the number of monthly deliveries, during a six-month period, by about 70 per cent in participating health facilities. UNFPA Cameroon also benefited from the first debt-for-health Sectoral Wide approach from the Government of Cameroon, with debt relief funding from France. The programme provides for an innovative and large-scale training scheme for health personnel on delivery of emergency obstetric and neo-natal care, including prevention of mother-to-child transmission of HIV in Cameroon’s three northern regions. 12 CARMMA Report 2013
  • 13. Niger Government health expenditure as a Neonatal Mortality Ratio Maternal Mortality Ratio 11% percentage of total government expenditure 32 590 100,000 The launch of CARMMA in Niger took place on December 20, 2011. CARMMA builds on the road Ethiopia map already in place for accelerating the reduction of maternal and neonatal mortality for the period 2006-2015. Government health expenditure as a Since the launch there has also been a mobilization Neonatal Mortality Rate Maternal Mortality Ratio 13% percentage of total government expenditure of resources with partners such as UNFPA, UNICEF, WHO and a variety of local organizations such as Animas SUTURA; Association Nigerienne pour le Bien Etre Familial (ANBEF); Societé Nigerienne des Produits Petroliers (SONIDEP); 31 350 Loterie Nationale du Niger (LOLANI); and Rimbo Transport Passengers. Also involved are a lot of 100,000 associations and groups, including religious, women’s and youth groups. In the area of health systems During the launch of CARMMA on 23 February strengthening, Niger has undertaken massive 2010, the Minister of Health, Hon. Tedros Adhanom, recruitment and allocation of health care providers, pointed out the importance of having facility-based including 536 doctors; ordered equipment and interventions in addition to community-based ones. materials; purchased an ambulance for emergency CARMMA has led to special services on maternal cases, and enhanced communication within the mortality reduction, as an integral part of the system using SSB radios. Childbirth and caesarean Health Sector Development Programme and the section kits have also been provided in health Maternal and Newborn Health road map. Among facilities. With reference to the development the most significant developments is that the month of monitoring & evaluation systems, there are of December is now recognized and dedicated efforts to strengthen supervision, and monitoring of care providers. Currently, clinical audits of nationally to advocacy of the reduction of maternal maternal deaths take place at health facility level, mortality. but there is institutionalization of clinical auditing in the new PDS 2011–2015, including training of trainers on clinical audit across the country. In the implementation of the Maputo PoA in the context > of the African Health Strategy, Niger has so far seen a reduction of maternal mortality by 14 per cent between 2006 and 2010, and infant mortality by 34 per cent. CARMMA Report 2013 13
  • 14. Ghana Nigeria Government health expenditure as a 12% Neonatal Mortality Rate Maternal percentage Government health of total government expenditure as a Mortality Ratio expenditure Neonatal Mortality Rate Maternal Mortality Ratio 4% percentage of total government expenditure 29 350 100,000 39 630 100,000 Under the guidance of the then First Lady, Mrs. Ernestina Naadu Mills, CARMMA made tremendous Nigeria launched CARMMA in October 2009, with a strides in Ghana after the national launch in 2009. focus on aligning and integrating CARMMA within its existing programmes, especially the Integrated Maternal, She also formed a technical team from among staff Newborn and Child (IMNCH) Strategy. CARMMA in in the Ghana Health Service, UNFPA and her office, Nigeria focuses on partnerships at the three tiers of which was tasked with formulating a concept paper Government – Federal, State and Local Government that enabled her to take the message to the nation’s – in collaboration with development partners. It aims 10 administrative regions, which include 170 districts to improve maternal health with the introduction of and 33 sub metros. She ensured that the traditional the Midwives Scheme and the rural posting of resident authorities were included because they wield a lot doctors or medical officers to improve skilled birth of power and have a critical role to play in reducing attendants, the provision of contraceptives and other maternal deaths. At the launches, Municipal and life-saving commodities for Maternal, Newborn and District Assemblies made a variety of maternal Child Health, and increase budgetary support to health commitments that include the development MNCH. of basic infrastructure, transportation, provision Nigeria has reduced the Maternal Mortality Ratio (MMR) from 1100 per 100,000 live births in 1990 to the of equipment, personnel training, free ambulance current figure of 545 per 100,000, according to Nigeria’s services, CHPS compounds and antenatal clinics. latest Demographic and Health Survey (DHS 2008). Each region and district of Ghana has pledged to Since the launch of CARMMA, Nigeria has developed make commitments and contributions to reduce a National Strategic Health Development Plan and maternal mortality by ensuring the provision of adopted a National Road Map for CARMMA. It has also services and infrastructure (including transport) that seen increases in resources for reproductive health. For has a direct bearing on reducing maternal deaths example, in addition to several investments into MNCH, witnin their respective districts and municipalities. the Nigerian Government provided about $3 million for These commitments are reviewed yearly as part of contraceptives in 2012. There is continued engagement the MDG Acceleration Framework (MAF) – Ghana of all stakeholders, especially policy makers, as well as Action Plan. collaboration among maternal, newborn and child health partners, including civil society organizations. Nigeria reported a pilot study on community-based access to injectable contraceptives; promotion of the use of anti- shock garments, Misoprostol and magnesium sulphate in the management of post-partum haemorrhage and eclampsia; and free distribution of contraceptive commodities at Government health facilities. President Goodluck Ebele Jonathan, as a leading voice for health improvement in Africa and through his work as Co- Chair of the United Nations Commission on Life-Saving Commodities for Women and Children, as well as his Saving One Million Lives Initiative, has reaffirmed his commitment to intensify maternal health and newborn interventions in Nigeria. He is also committed to mobilizing other African Heads of State and Government to provide fresh impetus to CARMMA and its follow-up implementation. 14 CARMMA Report 2013
  • 15. Rwanda Government health The Gambia Government health expenditure as a expenditure as a Neonatal Mortality Rate Maternal Mortality Ratio 20% percentage of total government expenditure Neonatal Mortality Rate Maternal Mortality Ratio 11% percentage of total government expenditure 21 340 34 360 100,000 100,000 Rwanda has made remarkable strides in maternal Development of the National Road Map for the mortality reduction. The Maternal Mortality Rate Implementation of CARMMA in The Gambia in 2010 was 487 per 100,000 live births, which is is being undertaken by the National Assembly high, but only five years earlier, it stood at 750 per Select Committee on Health. The launch of the 100,000. Similarly, in 2007/2008, the Infant Mortality campaign on 24 July 2010 by Her Excellency, Dr. Ratio in Rwanda was 62 per1000 while in 2010 it Isatou Njie Saidy, the Vice-President, has been was 50 per 1000. CARMMA in Rwanda is coupled followed in four regions with social mobilization, with the White Ribbon Alliance (WRA) Initiative, behaviour change communication/Information which was launched in 2009 with the objective of Education Counselling, publicity, awareness- completing national efforts to reduce maternal raising and community sensitization activities. mortality and morbidity. These activities have involved the regional The WRA strategic plan (2010-2015) is being governors as well as women’s groups and staff implemented and it has a key role in uniting the of the Ministry of Health. Some of the activities multiple programmes in support of safe motherhood in the regions involved resource mobilization around one framework of action. The role and and partnership with the private sector, civil commitment of the First Lady, H.E Mrs. Jeannette society and other agencies, cofunded by UNFPA Kagame, who launched CARMMA in 2010 and regional authorities. The government has and brought together many stakeholders, is pledged to continue to support activities on significant in the overall drive to reduce maternal and maternal mortality, and there is funding from newborn deaths in the country. With Mrs. Kagame The Global Fund to strengthen the health as patron, WRA’s board of high level decision makers systems through capacity building. Since 2010, and representatives from diverse areas can influence hospitals have been carrying out maternal death policies and laws in support of safe motherhood audits, funded by UNFPA, and this has been as a human right. As part of the national efforts, expanded to all the regional hospitals and the on 11 November 2011, WRA organized a one-day main referral hospital. With the support of workshop to increase media awareness of safe UNFPA, WHO and the Global Fund, efforts are motherhood and equip journalists on the subjects of underway to improve the capacity of health maternal health and family planning. care workers, particularly midwives and those rendering emergency obstetric services. Among the notable local efforts, some communities have developed a funding mechanism through which women preparing for hospital deliveries may obtain interest-free loans for transportation. CARMMA Report 2013 15
  • 16. Malawi Republic Government health expenditure as a Neonatal Mortality Rate Maternal Mortality Ratio 14% percentage of total government expenditure 27 460 of Benin Government health expenditure as a 100,000 Neonatal Mortality Rate Maternal Mortality Ratio 10% percentage of total government expenditure Malawi was one of the first countries to launch CARMMA, on 7 August 2009. It was launched by President Joyce Banda (then Vice President). A number of CARMMA campaign activities, with 31 350 Maternal and Newborn Health messages, are being 100,000 disseminated by radio and television. UNFPA, CARMMA was launched in Benin on 27 October in collaboration with implementing partners, 2010, and a National Road Map was developed has set up a Media Network on Population and and implemented for the duration of the campaign Development (MENPOD), which continuously in that year. During CARMMA week in 2011, advocates and increases awareness on CARMMA- that roadmap was revised. Different strategies related issues. Malawi has a revised Road Map have been adopted in the social mobilization on accelerating the reduction of maternal and campaign, including free offer of contraceptives neonatal morbidity and mortality in the country, and voluntary testing for HIV; interaction with and the Reproductive Health strategy also has a young people; spotlight on reducing maternal component on reduction of maternal mortality mortality; dissemination of messages through through improved maternal health. CARMMA is community radio stations; use of billboards across making a significant impact in the country because the country to display messages; and development it is bringing services closer to the community, of a short film on the fight against maternal and promoting access to Sexual and Reproductive mortality. Most of these activities were extended Health services. The training of more midwives during the CARMMA week in 2011. CARMMA is improving skilled attendance at birth, despite has had a very positive impact in the country, transfers and the movements of medical workers, enjoying the support of many activities by partners, thereby leading to lobbying for more donor support government institutions, traditional leaders, religious for Maternal and Neonatal Health interventions. organizations, civil society and communities. In the area of resources, while preparing to launch the campaign in 2010, resources were mobilized from technical and financial partners (UNFPA, WHO, UNAIDS, European Union, USAID, Care International, and Population Services International (PSI). Similarly, with the support of UNFPA and other partners, a national strategy to integrate HIV/ RH was developed and validated by the Ministry of Health. 16 CARMMA Report 2013
  • 17. Swaziland Government health Togo expenditure as a Neonatal Mortality Rate Maternal Mortality Ratio 10% percentage of total government Government health expenditure as a expenditure Neonatal Mortality Rate Maternal Mortality Ratio 15% percentage of total government expenditure 35 320 100,000 36 300 100,000 In 2009, Swaziland made history by becoming one of Africa’s first nations to launch CARMMA. Following the launch of CARMMA by the An implementation framework is now in place, Republic of Togo on 14 September 2010, and CARMMA activities have been incorporated a framework for accelerating Millenium into the National Sexual and Reproductive Health Development Goals 4 and 5 was developed. (SRH) programme Annual Work Plan. A dialogue The nation then embarked on developing a for Members of Parliament on the implementation new Health Development Plan as the central of the Maputo Plan of Action resulted in Parliament axis of maternal health. The national launch of pressurizing the Ministry of Health to develop a CARMMA was followed by the establishment national SRH Policy, which is now at the finalization of “committees of men to support the health of stage. Since 2011, several regional dialogues in mothers and children.” Togo is also developing support of CARMMA have been undertaken by the a new coordination mechanism for financing Reproductive Health programme of the Ministry of the health sector, through its membership of Health. Political commitment in support of maternal the International Health Partnership (IHP) and health has been initiated by the Ministry of Health. is currently receiving funding from the French Among others, it hosted a national symposium on Government, through the G-8 MUSKOKA sustainable financing for reproductive, maternal, Initiative on Maternal, Newborn and Child newborn and child health in the country, procured Health, to support maternal health. The for the six hospitals that provide maternity services. campaign has had a very positive impact in Togo, Prevention of Mother-To-Child Transmission with many activities receiving the support of equipment and testing reagents for CD4 cell machine partners, Government institutions, traditional were also procured. Swaziland has also developed a and religious leaders and communities. quarterly review system, followed by an annual review. CARMMA has become a gateway to many A triennial report (2008-2010) was published in 2011. stakeholders in the field of promoting women’s rights. CARMMA Report 2013 17
  • 18. Zimbabwe Government health expenditure as a Neonatal Mortality Rate Maternal Mortality Ratio 9% percentage of total government Zambia expenditure Government health Neonatal Mortality Rate Maternal Mortality Ratio 16% expenditure as a percentage of total government 30 570 expenditure 100,000 CARMMA is being implemented within the nation’s Maternal and Neonatal Road map (2007- 2015). 27 440 The national task force, charged with advocating 100,000 and monitoring the implementation of the campaign, has mobilized resources for Maternal and Neonatal When President Rupiah Bwezani of Zambia Health (MNH). It is also advocating for increased launched CARMMA on 12 June 2010, he made funding for health on the basis of the Abuja target of history by being the first African Head of State 15 per cent. The Ministry of Health and Child Welfare to be personally and directly involved in such a has also set up a Health Transition Fund (HTF). Some launch. CARMMA has contributed to increased of the major areas of support by the HTF involve government commitment for Maternal Neonatal health systems strengthening, as well as the removal and Child Health (MNCH) and increased or subsidizing of user fees for maternal health, which resources from the Government and donors. has been one of the barriers to accessing maternal There have been increased referrals for Sexual health. The Ministry of Health, with support from and Reproductive Health (SRH) and delivery, development partners, has scaled up support to 18 and local chiefs are now champions for Maternal active midwifery schools through the procurement Health. Most multilateral and bilateral donors of midwifery teaching models and textbooks. More that pledged support before the launch have than 200 nurses have been trained in Emergency increased resources for MNCH. Among Obstetric and Neonatal Care (EmONC) by the them, USAID procures contraceptives; DfID Ministry of Health since the launch of CARMMA. has initiated a Maternal Health programme, Some strategies have been vital for CARMMA in Mobilizing Access to Maternal Health Services Zimbabwe. They include the integration of CARMMA in Zambia (MAMAZ); UN H4+, in partnership into existing MNH strategies, which is critical for and collaboration with the Ministry of Health, the sustainability and visibility of the campaign, by has secured funding from the Canadian ensuring Government ownership of the campaign. International Development Agency (CIDA) Another important factor is the development and for Maternal Health; and the Ministry has implementation of an integrated plan towards MNH, increased the contraceptive procurement Nutrition, Family Planning, HIV and Malaria to ensure budget line. The Ministry of Health has also meaningful utilization of limited resources. Despite introduced mentorships for MNCH in order to these, CARMMA has had a positive impact, especially strengthen the skills of providers. With support the increased commitment of the Government from UNFPA and the EU, the Ministry of towards maternal and neonatal health issues, evidence Health is promoting integrated HIV/ AIDS and of which may be seen in the implementation of the Reproductive and Family Services, through the UN strategy on Women’s and Children’s health, which implementation of a programme to strengthen is aligned to CARMMA. SRH/HIV linkages. 18 CARMMA Report 2013
  • 19. Uganda Neonatal Mortality Rate Maternal Mortality Ratio 12% Government health expenditure as a percentage of total government expenditure 28 310 100,000 CARMMA is having a positive impact on the visibility of maternal and neonatal health issues in Uganda. It enjoys parliamentary support. Religious and cultural institutions have been mobilized, and there are signed commitments with 12 of the 15 cultural institutions in the country. The UNFPA Country Office has developed and implemented Kenya Government health expenditure as a a resource mobilization plan that has yielded Neonatal Mortality Rate Maternal Mortality Ratio 7% percentage of total government expenditure over USD 15 million for Sexual and Reproductive Health in the last 2 years. The Ministry of Health also created an alternative distribution channel for Reproductive Health Commodities, including contraceptives, through a public-private partnership 27 360 with the Uganda Health Marketing Group, a social 100,000 marketing organization. Towards the provision of The launch of CARMMA in Kenya, in sustainable funding, Uganda is in the process of November 2010, led to increased publicity and establishing a National Health Insurance Scheme donor engagement on Maternal and Newborn as a health financing mechanism. The Government Health. Prior to the launch of CARMMA in acquired a World Bank Loan of USD 130 million for the country, in August 2010, the Government health. Towards strengthening the health system, launched a Maternal and Newborn Health a bursary scheme for the training of midwives has (MNH) Road Map, the objective of which is the been introduced with support from development achievement of the Millenium Development partners, including the Danish International Goals. At the primary and referral levels, Development Agency and UNFPA, as a strategy to hospital reforms are continuing. Monitoring improve staffing and retention of staff in hard-to- and evaluation systems have also been reach and underserved districts. A community- strengthened. An annual national maternal based Health Information Management System mortality audit has not been carried out yet, has been put in place. The Government has also but Maternal Death Surveillance and Response made maternal death a notifiable condition, and is being implemented. Reorientation of some Maternal and Peri-natal Death Reviews have been health facility staff was undertaken during the institutionalized with notification to the Ministry of first half of 2012 to ensure that regular reviews Health required within 24 hours. are conducted and reports submitted. CARMMA Report 2013 19
  • 20. Sierra Leone Government health expenditure as a Neonatal Mortality Rate Maternal Mortality Ratio 6% percentage of total government expenditure Eritrea Government health 49 890 100,000 expenditure as a The launching of CARMMA in March 2010 was Neonatal Mortality Rate Maternal Mortality Ratio 4% percentage of total government expenditure strongly supported by President Ernest Bai Koroma, who, the following month, launched a CARMMA-related free health service of health care facilities for pregnant and breastfeeding 21 240 women, and for children under five years old. The 100,000 Government, for the first time, made a pledge to provide contraceptives costing $165,000 per year. At the launch of CARMMA in Eritrea, in September Strengthening of health systems was identified in 2010, the Hon. Minister of Health, Ms. the National Health Sector Strategic Plan 2010- Amina Nurhussien, pledged the commitment of her 2015 as an important objective, and assessment of Ministry to the accelerated reduction of maternal health systems is now being done and strategies and perinatal mortality in Eritrea. The focus of the are being put in place to address areas that Ministry of Health is on such effective strategies need to be strengthened. In the area of capacity as awareness of clients, families and communities building of health workers, a growing partnership to make preparations for delivery by skilled birth consisting of the government, UN agencies and attendants in health facilities; expanding maternity NGOs is coordinating capacity building of health waiting homes; improving access to fully functional workers. Among other initiatives, the Canadian basic and comprehensive emergency obstetric care International Development Agency initiative is facilities; ensuring availability of equipment, supplies, sponsoring 100 student midwives per annum for drugs and human resources; introducing life-saving three consecutive years. The Maternal Health drugs such as Magnesium sulphate and Misoprostol; Thematic Fund and the Global Programme to expanding postpartum home visits within 24 hours Enhance Reproductive Health Commodity Security and three days of delivery; and strengthening the have also been supporting the training of midwives programme on fistula prevention, treatment and and strengthening of the Midwifery Association. In reintegration. The programme is strengthening the February 2012, 55 State-registered health system by empowering young doctors to Nurses graduated from the National Midwifery provide Emergency Obstetric and Neonatal Care, School Freetown campus, while 75 State-enrolled including caesarean deliveries. Also, strategic health Community Nurses graduated from the Makeni centres are being upgraded to community hospitals Midwifery school campus in April 2012. to enable them to perform Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) functions. In terms of capacity building, in-service training is being given to midwives and other health care providers, as well as to young doctors, in the provision of CEmONC services. 20 CARMMA Report 2013
  • 21. Tanzania Neonatal Mortality Rate Maternal Mortality Ratio 14% Government health expenditure as a percentage of total government expenditure Namibia Government health Neonatal Mortality Rate Maternal Mortality Ratio 12% expenditure as a percentage of total government expenditure 25 460 1000 100,000 18 200 The introduction of CARMMA in Tanzania strengthened the nation’s efforts and 1000 100,000 provided an opportunity for reflection Namibia was one of the first countries to launch on achievements made towards achieving CARMMA, in December 2009. Since the launch, MDG 5. CARMMA has provided visibility the political commitment of the First Lady for national planning and priority setting on Mrs. Penehupifo Pohamba, evident through her issues related to maternal health. The Health involvement as Patron of the maternal health Sector Strategic Plan is designed to focus on agenda, has proved to be one of the most important maternal health as a means of measuring the strategies of the campaign. More partners have health sector performance. The Government become aware of the need to address maternal under Sector Wide Approach (SWAp) is health issues. There has also been inter-sectoral currently formulating the national health collaboration at the national level, marked by the sector financial strategy. In collaboration involvement of various ministries and civil society with UNFPA, the Ministry of Health and in the national coordination mechanism, as well Social Welfare undertook an assessment of as the institutionalization of maternal, perinatal the midwifery situation in Tanzania. That and neonatal death review. Maternal death review report is guiding different interventions in tools have been launched and the review has been the country, including development of the institutionalized in all district hospitals. Resources midwifery programme. The Maputo Plan of have been made available to fund vacancies for Action has been domesticated in different nurses and midwives, but unavailability of manpower national plans, including the National Road Map has hindered the process. The Government is for Accelerating reduction of Newborn and negotiating with other countries to get nurses and Maternal Deaths. doctors into the country to fill vacant positions. CARMMA in Namibia is facing a number of challenges, including inadequate financial resources and health system strengthening at the primary level to deliver Basic Emergency Obstetric Care services. CARMMA Report 2013 21