Presentation in Governance and Poverty seminar class. Explanation of MDG 5 and update on progress status in 2013. Overview of 3 High-Impact Intervention areas and a MOMS (Midwives and Others with Midwifery Skills) with Misoprostol program which addresses #2 and #3 to prevent maternal mortality.

1. MDG 5 INTERVENTIONS:MDG 5 INTERVENTIONS:
Improve Maternal HealthImprove Maternal Health
Solveij Rosa Praxis

2. Maternal Mortality:
The death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the duration and
site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not
from accidental or incidental causes. [14]

3. Maternal Health Targets:
TARGET 5A: Reduce maternal mortality ratio by
three quarters by 2015
Indicators:
• Maternal mortality ratio
• Percentage of births attended by skilled health personnel

4. Maternal Health Targets:
TARGET 5B: Achieve, by 2015, universal access to
reproductive health, including family planning
Indicators:
• Total fertility rate (TFR)
• Contraceptive prevalence rate (CPR: refers to use of
modern contraceptive methods among married women of
reproductive age)
• Adolescent birth rate
• Antenatal care coverage
• Unmet need for family planning

5. Impacts.
Maternal Mortality: 350,000-500,000 girls and women die
each year from pregnancy and childbirth complications. (UNFPA)
Maternal Morbidity: 15 and 20 million girls and women
suffer from maternal morbidities every year. (UNFPA)
Productivity Loss: $15 billion (UNFPA)

6. Progress. 5A
Maternal mortality ratio, 1990 and 2010 (Maternal deaths per 100,000 live births, women aged 15-
49).
Source: The Millennium Development Goals Report 2013
Maternal mortality has declined by
nearly half since 1990, but falls far short
of the MDG target. • Maternal mortality ratio:
240 per 100,000 births in
LDCs (versus 16 per 100
000 in developed countries)
• Percentage of births
attended by skilled health
personnel: 55% to 66 % in
LDCs from 1990-2011 [Urban:
75-->84%; Rural: 44-->53%]

7. Progress. 5B

8. Progress Lag. Why?
• I. Lack of Attention and Funding: “children are the most
vulnerable of the vulnerable.” As a result, it can be easier to
secure the resources needed to meet their basic needs. “But
women have often remained invisible.”
• II. Complex Interventions: good maternal health “requires
skilled personnel and a health system that delivers” – as
opposed to routine immunization and many other child-
health interventions that can be carried out with relatively
basic resources at the community level.

9. Intersectional Issues.
ECONOMIC
Poverty/Inequality: Women most affected have the worst status and least resources.
Health Disparities: Ninety nine percent (99 per cent), of maternal and newborn mortality occurs in the developing
world(UNICEF)
SOCIAL/CULTURAL
Gender inequality: Lack of education; Economic dependency on men
Sexism: gender discrimination, violence, reproductive biases (high fertility rates, early marriage)
“Men often decide whether their pregnant wives live or die. A woman recovers from a caesarean that saved her and her child—
which her husband only reluctantly agreed to when her condition became critical. [...] Taboos prohibit women from being
treated by male doctors further limit access to vital care.” (UNICEF)
INSTITUTIONAL/POLITICAL
War/conflict/violence: restricts access to basic health care
History of Imperialism: health development partnerships with developed world can lack trust

10. Reproductive health and
Development
Family planning is the foundation for human
development, and its interdependency with other
development goals means that, with progress, it can
provide the “demographic dividend”.
Poverty and Hunger—birth spacing reduces incidence of low birth weight and poor maternal nutrition, more economic security and less
hunger
Education—reduces need for girls to drop out of school because of unintended pregnancy or care for younger siblings
Gender Equality—empowers women, enabling them to achieve desired family size
Maternal and Child Health—reduces maternal death due to unintended pregnancy(abortion, complications), increases child survival
HIV/AIDS—preventing unwanted pregnancies among HIV+ women key in preventing mother-to-child HIV transmission
Environment—family with fewer children needs less land, food, and water and puts less pressure on country’s forests and tillable land

11. Responsive strategy
I.Local/community-based
II.Empowerment/community
ownership/collaboration
III.Efficiency/business model (incentives): *goal is
to make intervention adoption as easy as possible*

12. Interventions Framework.
EFFECTIVE INTERVENTIONS(5 levels): clinical interventions; protective interventions; enabling
environment; and socioeconomic interventions. [1] (UNFPA)
HEALTH SYSTEMS to Deliver Interventions: Multi-tiered maternal health programs are complicated and
multi-faceted, involving education, the spread of information, health provider training, client transport, use of
proper equipment, and the establishment of quality health facilities.
Community-level
First-level health facilities
Referral facilities
COMPREHENSIVE POLICIES and STRATEGIES: underlying frameworks that set out how the resources
needed to deliver results will be mobilized and deployed. [2]; there must be a “comprehensive national health
policy & strategy” to ensure this health infrastructure is supported, sustainable and effective. [2] (WHO)

13. Intervention Areas.
3 Intervention Areas:
1. Access to family planning—counseling, services, supplies
2. Access to quality care for pregnancy and childbirth
• antenatal care
• skilled attendance at birth, including emergency obstetric and neonatal care
• immediate postnatal care for mothers and newborns
3. Access to safe abortion services, when legal (as per paragraph 8.25 of the Programme of Action for ICPD)
3 High-Impact Interventions:
1. Access to contraceptive services for all women, to prevent unwanted pregnancies (and complications associated
with pregnancies)
2. Access to care by a skilled attendant for pregnancy and childbirth
3. Access to emergency obstetric care for all women and newborns with complications.

14. http://kihefoblog.wordpress.com/2013/07/10/meet-sister-beatrice-the-mother-of-family-planning-at-kihefo/

15. Intervening at CAUSAL PATHWAY for
Safe Motherhood.
GOAL: Access to quality obstetric care with trained providers for Safe Motherhood.
CAUSAL PATHWAY... for intensive care, near-misses, and maternal death.
Postpartum hemorrhage (PPH), Severe Aenemia
Obstructed labor
Unsafe Abortion
Infection/Sepsis
Pre-eclampsia, Eclampsia (hypertensive disorders)

16. GOAL: Access to quality obstetric care with trained providers for Safe Motherhood.
CAUSAL PATHWAY... for intensive care, near-misses, and maternal death.
Postpartum hemorrhage (PPH), Severe Aenemia
Obstructed labor
Unsafe Abortion
Infection/Sepsis
Pre-eclampsia, Eclampsia (hypertensive disorders)
Intervening at CAUSAL PATHWAY for
Safe Motherhood.

17. 2. Access to care by a skilled attendant for
pregnancy and childbirth
Intervention:
MOMS with Misoprostol
Address PPH

18. 3. Access to emergency obstetric care for
all women and newborns with
complications
Intervention:
MOMS with Misoprostol
Address PPH

19. Intervention: MOMS with
Misoprostol Address PPH
Challenges for resource-poor, socioeconomically disadvantaged
settings.
1. Inadequate number of health care facilities staffed with trained providers in
emergency obstetric care (EmOC).

20. Challenges for resource-poor, socioeconomically disadvantaged
settings.
1. Inadequate number of health care facilities staffed with trained providers in
emergency obstetric care (EmOC).
2. Financial barriers to care, with high costs
for maternal health care services, including
unofficial payments to access care, and the
cost of drugs, supplies and transportation.
3. Lack of effective technology to manage
complications in home births, where most
of the deliveries occur in poor settings.
Intervention: MOMS with
Misoprostol Address PPH

21. Response...
COMMUNITY-BASED
MOMS (Midwives and Others with Midwifery Skills)
trained as skilled health workers
for short-term goal of *protecting births in the HOME.*
Intervention: MOMS with
Misoprostol Address PPH

22. Midwives and Others with Midwifery Skills (MOMS)
“midwives are usually women working with and for women, and as such have not
caught the attention of politicians and policy-makers” (UNFPA)
MOMS perform 3 essential functions:
• supervise and preferably provide hands-on quality care that is acceptable to women and their families, at
the point where women need it most–close to where they live and frequently give birth, and within reach
of emergency care whenever necessary
• teach and supervise other health workers who need some midwifery skills, but are not required to be
experts
• work with, educate and help empower communities to recognize the need and increase demand for
skilled midwifery services
Intervention: MOMS with
Misoprostol Address PPH

23. https://vietnam.unfpa.org/public/pid/6629 http://tanzania.unfpa.org/
http://www.unfpa.org/sowmy/resources/docs/photos/1_TorfinnS_Sudan.jpg http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862013001100804&lng=en&nrm=iso

24. Midwives and Others with Midwifery Skills (MOMS)
Challenges to scaling up midwifery capacity:
1. Lack of numbers of midwives and in most cases poor quality of midwifery training. Lack
of investment meant clinical and theory training were not updated.
2. Lack of funding for pre-service, in-service and continuing training, and for employment of
midwives.
3. Competition and conflicts between physicians and nurses, physicians and midwives, nurses
and midwives – with midwives trying to establish professional space.
4. Lack of incentives and lack of polices and plans to develop human resources for health. There is
also need for support for the basics such as housing, light, water, topping up of salaries.
5. Need for close relationships between women and midwives. Where midwives worked with women
and women’s groups the midwifery profession was usually stronger.
Intervention: MOMS with
Misoprostol Address PPH

25. Midwives and Others with Midwifery Skills (MOMS)
Investing in MOMS:
•Numbers
• raising the profile of midwives
• financial, human or technical support
•Quality
• strong regulation
• development of strong and credible professional associations and education institutions
• supportive supervision of both public and private midwives
Intervention: MOMS with
Misoprostol Address PPH

26. IMPACTS DISCUSSION
“No country has managed to reduce their
maternal mortality figures without investing in
the capacities of midwives working at the
community level undertaking home births.” (UNFPA)
http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862013001100804&lng=en&nrm=iso
Intervention: MOMS with
Misoprostol Address PPH

27. Postpartum Hemorrhage (PPH) and Misoprostol
• PPH is the leading cause of maternal death worldwide.
correct diagnosis and management of PPH in a timely manner determines level of maternal deaths in
poor settings
method used in “developed” countries, oxytocin, requires injection and refrigeration
rural, resource-poor areas lack the necessary drugs and skilled attendance at delivery
• Misoprostol is a uterotonic increasingly used in obstetrical and gynecological
practice including the control of PPH.
inexpensive tablet, it is easy to store, stable in field conditions, and
has an excellent safety profile with multiple routes of administration
useful in these rural, resource-poor settings and home births with
a skilled attendant or health worker trained in PPH prevention use
Intervention: MOMS with
Misoprostol Address PPH

28. MOMS...Postpartum Hemorrhage (PPH) and Misoprostol
• Study (2005-7): Intervention trial in Tigray region of Ethiopia, 966 participants.
Focusing on the safety of misoprostol for prophylaxis of PPH at home births attended
by TBAs. (Traditional Birth Attendants...term now updated to MOMS.)
http://www.berkeley.edu/news/media/releases/2006/03/28_misoprostol.shtml
TBAs (MOMS) trained...
✓ to administer misoprostol for PPH
✓ in visual perception of approximate 500ml
and 1000ml of blood loss
✓ to know when to safely refer women to
clinics for additional treatment
Intervention: MOMS with
Misoprostol Address PPH

29. MOMS...Postpartum Hemorrhage (PPH) and Misoprostol
• Study: Intervention trial in Tigray region of Ethiopia, focusing on the safety of
misoprostol for prophylaxis of PPH at home births attended by TBAs.
http://www.berkeley.edu/news/media/releases/2006/03/28_misoprostol.shtml
Results...
✓ “prophylactic use of misoprostol in home births is a safe and feasible
intervention” “women in intervention areas were significantly less likely
to be referred for additional treatment related to excessive bleeding
(8.9%) compared to women in non-intervention areas (18.9%)”
✓ over half of referrals were being addressed by interventions at home,
which lowers the risk for maternal death by PPH and “relieves the
overtaxed health care system”
Intervention: MOMS with
Misoprostol Address PPH

30. MOMS...Postpartum Hemorrhage (PPH) and Misoprostol
Implications and Impacts:
✓ “[w]here women deliver far from a health facility, they must be empowered with an
effective means of preventing the leading cause of maternal death. […] at the
lowest level of the health care system – community health care workers, such as
TBAs, and even the mother herself – can and should use misoprostol in home births
to prevent PPH.” [19]
✓ Misoprostol can be very useful in settings of home births
with traditional, or unskilled, birth attendants trained in
PPH prevention. In 2006, Nigeria became the first country
in the world to approve the distribution of misoprostol for
PPH, followed later that year by India, and by Tanzania
in 2007.
http://bixby.berkeley.edu/research/maternal-health/miso/nigeria/
Intervention: MOMS with
Misoprostol Address PPH

31. MOMS...Postpartum Hemorrhage (PPH) and Misoprostol
Study: Intervention trial in Tigray region of Ethiopia, focusing on the safety of
misoprostol for prophylaxis of PPH at home births attended by TBAs. (Traditional Birth Attendants...term
now updated to MOMS.
✓ Barriers: Abortion stigma-fear that women would use misoprostol to induce
abortion
✓ fear of misuse at the home level
✓ concerns that home use would discourage facility deliveries
✓ registration of misoprostol for obstetric indications is time consuming
✓ some countries do not have a drug distribution network that can reach poor women
in the remote areas at affordable prices[16]
Intervention: MOMS with
Misoprostol Address PPH

32. Follow-Up
Program-Specific Funding
✓Bixby Center for Population Health and Sustainability, UC Berkeley
✓Venture Strategies Innovations
✓Continued funding—realistic affordable and sustainable financing strategies, for
governments working with their own finance ministries as well as with donors
Family Planning and Maternal and Newborn Care Funding: In 2010, global investment was
at about $11.8 billion annually. “Doubling the modest, current global investment in family
planning and maternal and newborn care—to just over $24 billion combined annually—
would reduce maternal mortality by at least 70%, halve the number of newborn deaths and
do so at a lower total cost than investing in maternal and newborn care alone.”(Guttmacher) [17] In
September 2010, United Nations Secretary-General Ban Ki-moon and Heads of State and
Government launched the “Global Strategy for Women’s and Children’s Health” with
stakeholders pledging over $40 billion in resources for women’s and children’s health.
Intervention: MOMS with
Misoprostol Address PPH

33. Follow-Up
GENERAL Take-Aways for Maternal Health Interventions [16]
‣ Political commitment beyond the health sector
‣ Notable champion(s) and partner collaboration
‣ Community provision of services and scale-up vision
‣ Community engagement, innovative human resource strategies
‣ Establishment of effective strategies and systems
Intervention: MOMS with
Misoprostol Address PPH

34. Follow-Up: SPECIFIC Lessons Responding to Major Challenges of Poor, Rural Maternal
Health in Developing World:
1.QUALITY SERVICES: Training community-based health providers is a central strategy in
overcoming the under-supported, underfunded health care facilities and inadequate number of
professional health care providers, at least in the short term.
2.COMMUNITY-BASED ACCESS: MOMS or TBAs are central in overcoming financial barriers
to care associated with facilities and can reach women where they are at--in the home.
3.APPROPRIATE TECHNOLOGICAL INNOVATION: Appropriate, effective technology, like
misoprostol, can manage complications in home births, where most of the deliveries occur in poor
settings. [15]
Intervention: MOMS with
Misoprostol Address PPH

35. thank youthank you
http://bixby.berkeley.edu/wp-content/uploads/2009/03/cropped-mama-+-baby+TBA-bang.jpg

36. UNDP http://www.undp.org/content/undp/en/home/mdgoverview/mdg_goals/mdg5/
UNICEF—Maternal Health http://www.unicef.org/maternalhealth/index_587.htm
http://www.unicef.org/health/index_maternalhealth.html
UNFPA http://www.unfpa.org/webdav/site/global/shared/documents/publications/2009/Focus-on-5.pdf
Skilled Birth Attendant http://www.unfpa.org/public/home/mothers/pid/4383
Life and Death: http://www.unfpa.org/webdav/site/global/shared/factsheets/srh/EN-SRH%20fact%20sheet-LifeandDeath.pdf
MOMS: http://www.unfpa.org/webdav/site/global/shared/documents/publications/2006/midwives_mm.pdf
Costs and Benefits FP http://unfpa.org/webdav/site/global/shared/documents/Reproductive%20Health/Fact%20Sheets/AIU_2012_Estimates
%20Factsheet_ENGLISH.pdf
Fact Sheets http://www.unfpa.org/public/mothers/pid/4390/index.htm
Maternal Death Fact Sheet http://www.unfpa.org/webdav/site/global/shared/factsheets/srh/EN-SRH%20fact%20sheet-LifeandDeath.pdf
Guttmacher Institute (Induced Abortion Worldwide): http://www.guttmacher.org/pubs/fb_IAW.html
Family Planning and Maternal Health Costs and Benefits: https://www.guttmacher.org/presentations/Adding-It-Up.pdf
[17] http://www.guttmacher.org/pubs/gpr/13/2/gpr130212.html
WHO Maternal and Infant Health Strategy http://www.who.int/pmnch/activities/advocacy/global_strategy_resources/en/
Cost-Effectiveness http://www.who.int/choice/en/
Intervention Packages: World Health Organization, UNICEF, UNFPA, The World Bank and different members of The Partnership for Maternal, Newborn and
Child Health (PMNCH) http://www.who.int/pmnch/activities/jointactionplan/srhp_packages.pdf?ua=1
[12] http://www.who.int/pmnch/media/press/2010/20100603_countdownpressrelease/en/
Bixby Center
http://bixby.berkeley.edu/wp-content/uploads/2010/05/Avoidable-maternal-deaths-three-ways-to-help-now-09.pdf
http://bixby.berkeley.edu/research/maternal-health/miso/nigeria/
[13] http://bixby.berkeley.edu/wp-content/uploads/2011/01/2010-Prata-et-al-MM-in-Dping-Cs-in-Womens-Health.pdf
[14] http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf?ua=1
[15] http://bixby.berkeley.edu/wp-content/uploads/2010/05/Avoidable-maternal-deaths-three-ways-to-help-now-09.pdf
FHI 360 Family Planning http://www.fhi360.org/sites/default/files/media/documents/FHI360-FP_brochure_v5_WEB.pdf
[16] Intervention Strategies for Contraceptive Prevalence Rate (Sub-Saharan Africa successes) http://www.fhi360.org/sites/default/files/media/documents/africa-
bureau-case-study-report.pdf
Statistics:
IndexMundi http://www.indexmundi.com/map/?t=0&v=2223&r=af&l=en
World Bank http://data.worldbank.org/indicator/SH.XPD.PCAP/countries
Citations