HNP -Accelerating Progress towards Achieving the MDG to Improve Maternal Health

Publication date: 2005

H N P D I S C U S S I O N P A P E R About this series. This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank’s Human Development Network. The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual authors whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Managing Editor Joy de Beyer (jdebeyer@worldbank.org) or HNP Advisory Service (healthpop@worldbank.org, tel 202 473-2256, fax 202 522-3234). For more information, see also www.worldbank.org/ hnppublications. THE WORLD BANK 1818 H Street, NW Washington, DC USA 20433 Telephone: 202 473 1000 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: feedback@worldbank.org Accelerating Progress towards Achieving the MDG to Improve Maternal Health: A Collection of Promising Approaches Geeta Nanda, Kimberly Switlick and Elizabeth Lule April 2005 ACCELERATING PROGRESS TOWARDS ACHIEVING THE MDG TO IMPROVE MATERNAL HEALTH: A Collection of Promising Approaches Geeta Nanda, Kimberly Switlick and Elizabeth Lule April, 2005 ii Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network. The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual author(s) whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Managing Editor. Submissions should have been previously reviewed and cleared by the sponsoring department, which will bear the cost of publication. No additional reviews will be undertaken after submission. 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For information regarding this and other World Bank publications, please contact the HNP Advisory Services at healthpop@worldbank.org (email), 202-473-2256 (telephone), or 202-522-3234 (fax). © 2005 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. iii Health, Nutrition and Population (HNP) Discussion Paper Accelerating Progress towards Achieving the MDG to Improve Maternal Health: A Collection of Promising Approaches Geeta Nandaa, Kimberly Switlickb and Elizabeth Lulec a Consultant, Health, Nutrition, and Population, Human Development Network, World Bank, Washington DC, USA b Junior Professional Associate, Health, Nutrition, and Population, Human Development Network, World Bank, Washington DC, USA c Adviser for Population and Reproductive Health, Health, Nutrition, and Population, Human Development Network, World Bank, Washington DC, USA Paper prepared with funding from the Bank Netherlands Partnership Program (BNPP) Abstract: One of the Millennium Development Goals (MDG) is to improve maternal health, with the target of reducing maternal mortality by three-quarters between 1990 and 2015. In an effort to accelerate progress towards achieving this MDG, this paper brings together high-quality information on a wide range of promising approaches that aim to improve maternal health outcomes. These global promising approaches, based on field research and practice by experienced organizations working in this arena, can serve as a useful starting point in the process to improve current maternal health programming. This paper will be useful for World Bank staff when assisting client countries in developing their National Poverty Reduction Strategy Papers (PRSPs) and costing health sector plans. Moreover, the paper provides Bank staff with substantive evidence to share with governments on how best to prioritize and implement maternal health programs, and scale up efforts to achieve progress. Although primarily intended for use by Bank staff, we hope this guide will also be useful to governments, other international donor agencies, and nongovernmental organizations (NGOs), who are interested in improving maternal health, and minimizing the disparities that currently exist between industrialized and developing countries. Keywords: maternal health, maternal mortality, developing countries, MDGs Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Geeta Nanda, World Bank, Mail Stop G7-701, 1818 H Street N.W., Washington, DC 20433, USA, Tel: 202.458.7910, Email: gnanda@worldbank.org or geeta_nanda@yahoo.com; Elizabeth Lule, World Bank, Mail Stop G7-701, 1818 H Street N.W., Washington, DC 20433, USA, Tel: 202.473.3787, Email: elule@worldbank.org, Fax: 202.522.3489. This report is available on the following website: http://www.worldbank.org/hnppublications. iv v Table of Contents PREFACE. VII ACKNOWLEDGEMENTS . IX ABBREVIATIONS AND ACRONYMS. X 1. OVERVIEW. 1 1.1 BACKGROUND . 1 1.2 OBJECTIVES. 2 2. INTRODUCTION. 4 2.1 MAGNITUDE OF THE PROBLEM . 4 2.2 RATIONALE FOR INVESTING IN MATERNAL HEALTH . 5 2.3 KEY TECHNICAL INTERVENTIONS TO IMPROVE MATERNAL HEALTH . 6 2.3.1 Emergency Obstetric Care . 7 2.3.2 Skilled Attendance at Birth. 9 2.3.3 Management of Unsafe Abortion. 11 2.3.4 Focused Antenatal Care . 12 2.3.5 Family Planning Services. 13 2.4 CONCEPTUAL FRAMEWORK FOR UNDERSTANDING MATERNAL HEALTH OUTCOMES . 15 3. BUILDING ON EXPERIENCE: AN OVERVIEW OF PROMISING APPROACHES TO IMPROVE MATERNAL HEALTH. 18 3.1 GOVERNMENT POLICIES AND ACTIONS . 18 3.2 HEALTH SYSTEMS AND HEALTH FINANCING. 19 3.2.1 Decentralization . 21 3.2.2 Public-Private Partnerships. 23 3.2.3 Integration of Health Services. 25 3.2.4 Costing of Maternal Health Services . 26 3.2.5 Alternative Health Financing Schemes . 28 3.3 ACCESS TO HEALTH SERVICES . 30 3.3.1 Increasing the Availability of Health Services . 31 3.3.2 Strengthening the Referral System . 33 3.3.3 Reaching Hard to Reach and Marginalized Groups. 36 3.4 BUILDING CAPACITY . 41 3.5 QUALITY OF CARE. 43 3.6 COMMUNITY INVOLVEMENT. 48 3.7 MONITORING AND ADVANCING PROGRESS. 50 3.7.1 Measurement Issues. 50 3.7.2 Research Efforts . 54 3.8 PARTNERSHIPS AND COLLABORATIONS . 56 4. CONCLUDING REMARKS . 59 vi REFERENCES. 61 ANNEXES . 74 List of Boxes Box 1: Definition of Reproductive Health. 2 Box 2: Definition of ‘Skilled Attendant’ . 9 Box 3: The Role of Antenatal Care . 12 Box 4: Supply Chain: A Vital Component of Health Systems. 20 Box 5: Five Goals of Health Sector Reform. 21 Box 6: Lessons Learned from a Decentralization Experience in the Philippines. 22 Box 7: Contracting of Reproductive Health Services. 23 Box 8: Mother-Baby Package. 27 Box 9: Marginal Budgeting for Bottlenecks. 28 Box 10: Averting Maternal Death and Disability Program . 32 Box 11: The Household to Hospital Continuum of Care (HHCC) for Maternal and Newborn Care . 35 Box 12: Elements of Good Quality Maternal Health Services. 44 Box 13: Improving the Quality of Obstetric Care through Criterion-Based Clinical Audit (CBCA): A Collaborative Field Trial in Ghana and Jamaica. 47 Box 14: Reproductive Age Mortality Study (RAMOS) . 50 Box 15: The Initiative for Maternal Mortality Program Assessment (IMMPACT). 55 Box 16: Better Births Initiative – Improving Health through Evidence-Based Obstetrics . 56 List of Figures Figure 1: Maternal Deaths Averted with Full Use of Existing Interventions. 7 Figure 2: The Enabling Environment . 9 Figure 3: Proportion of Births Attended by Skilled Health Personnel in 2004 . 10 Figure 4: Malaria during Pregnancy . 13 Figure 5: Percent of Married Women Aged 15 – 19 Who Would Prefer to Avoid a Pregnancy. 14 Figure 6: Pathways to Improve Maternal Health Outcomes. 15 Figure 7: Poorest Women Have the Least Access to a Skilled Attendant at Delivery . 37 List of Tables Table 1: The Millennium Development Goal to Improve Maternal Health . 1 Table 2: Signal Functions of Basic and Comprehensive EmOC . 8 Table 3: Decentralization – Types and Definitions . 21 Table 4: The Six UN Process Indicators. 52 Table 5: Approaches for Generating Information on Maternal Health . 54 vii PREFACE For almost two decades, the World Bank has been dedicated to the objective of improving maternal health outcomes, which is fundamental to improving human welfare, reducing poverty, and promoting economic growth, which are the overarching goals of the World Bank. The Bank has made maternal health an important corporate priority and is committed to assisting countries in accelerating progress towards achieving the Millennium Development Goals, which all 191 United Nations Member States have pledged to meet by 2015. Included in the health-related Millennium Development Goals is the goal to improve maternal health, calling on developing countries to reduce their maternal mortality ratios by three-quarters from 1990 to 2015. The Bank is a co-founder of the Safe Motherhood Initiative, which was launched in 1987, and also supported the Program of Action of the 1994 International Conference on Population and Development. This paper builds on ongoing work to enhance the Bank’s leadership in efforts to improve the lives of women, and particularly, to support the objectives of the Bank’s Health, Nutrition, and Population Sector. The document is part of the activities aimed at increasing the effectiveness of the Bank’s efforts in maternal health and poverty reduction, and will be useful in dialogue with client countries to scale up efforts, and strengthen action and progress towards achieving the Millennium Development Goal to improve maternal health. In particular, when assisting client countries in the development of their National Poverty Reduction Strategy Papers, we hope this document can be used as a tool to inform the process, and provide an opportunity to mobilize policymakers to prioritize the goal of investing in maternal health. By bringing together a collection of promising approaches, this paper provides substantive evidence and useful program experiences for Bank operations staff to advise governments on how to scale up efforts to achieve the Millennium Development goal of improving maternal health. This guide is intended for the use of World Bank staff, governments, other international donor agencies, and nongovernmental organizations, who are interested in improving maternal health outcomes and minimizing the disparities that currently exist between industrialized and developing countries. We look forward to hearing about any initiatives that emerge as a result of this discussion paper. viii ix ACKNOWLEDGEMENTS We would like to express our sincere appreciation to the following organizations for their support and important contributions to this Discussion Paper: Abt Associates, Academy for Educational Development, American College of Nurse-Midwives, Averting Maternal Death and Disability (AMDD) Program, CARE, CEDPA, EngenderHealth, Family Care International, Initiative for Maternal Mortality Program Assessment (IMMPACT) Program, IntraHealth International, Ipas, JHPIEGO Maternal and Neonatal Health Program, John Snow Inc., Johns Hopkins University Center for Communication Programs, Marie Stopes, Options Consultancy Services, Partnership for Safe Motherhood and Newborn Health, Regional Prevention of Maternal Mortality (RPMM) Network, Reproductive Health Response in Conflict (RHRC) Consortium, Save the Children, University Research Co. LLC, UNICEF, UNFPA, USAID, White Ribbon Alliance, Women’s Commission for Refugee Women and Children, and the World Bank. At the World Bank, we would like to thank: Isabella Danel, Qiu Fang, Ramesh Govindaraj, Rama Lakshminarayanan, Margaret Maier, Puti Marzoeki, John May, Khama Rogo, Fadia Saadah and Hope Phillips Volker. We would also like to convey our gratitude to the following peer reviewers of this paper for their valuable technical input: France Donnay (UNFPA), Mary Ellen Stanton (USAID), and GNV Ramana (World Bank). The Discussion Paper was prepared by Geeta Nanda, with significant contributions from Kimberly Switlick and under the supervision of Elizabeth Lule. Financial support for this paper from the Bank Netherlands Partnership Program (BNPP) is appreciatively acknowledged. The authors are grateful to the World Bank for publishing this report as an HNP Discussion Paper. x ABBREVIATIONS AND ACRONYMS ACNM American College of Nurse-Midwives AED Academy for Educational Development AIDS acquired immunodeficiency syndrome AMDD Averting Maternal Death and Disability Program AMTSL active management of third stage of labor ANC antenatal care BBI Better Births Initiative BCC behavior change and communication BCI behavior change initiative BLP Better Life Options Program BNPP Bank Netherlands Partnership Program C-section Caesarean section CBCA criterion-based clinical audit CCP Center for Communications Programs CEDAW Convention on the Elimination of All Forms of Discrimination Against Women CEDPA Center for Development and Population Activities CFR case fatality rate CmSS community support system CPR contraceptive prevalence rate CTT core training team D & C dilatation and curettage DALY disability-adjusted life year DANIDA Danish International Development Agency DFID Department for International Development (UK) DHMT district health management team DSI Dinajpur Safe Motherhood Initiative EC emergency contraception EmOC emergency obstetric care ESARO UNICEF Regional Office of East and Southern Africa EsOC essential obstetric care FCI Family Care International FEMME Foundations to Enhance Management of Maternal Emergencies FIGO International Federation of Gynecology and Obstetrics FP family planning HBLSS home based life saving skills HHCC household to hospital continuum of care HIS health information system HIV human immunodeficiency virus HNP Health, Nutrition, and Population ICM International Council of Midwives ICPD International Conference on Population and Development IDP internally displaced person xi IEC information, education, and communication IMMPACT Initiative for Maternal Mortality Program Assessment IPT intermittent preventive treatment IRC International Rescue Committee ITN insecticide-treated nets IUD intrauterine device JHU Johns Hopkins University JSI John Snow, Inc. KAP knowledge, attitudes, and practices LHW lady health worker LSS lifesaving skills M & E monitoring and evaluation MASAF Malawi Social Action Fund MBB marginal budgeting for bottlenecks MCH maternal and child health MDG Millennium Development Goal MH maternal health MHO mutual health organization MIP malaria in pregnancy MM maternal mortality MMR maternal mortality ratio MNH maternal and neonatal health MOH Ministry of Health MSF Médecins Sans Frontières MTCT mother-to-child transmission MTEF Medium Term Expenditure Framework MVA manual vacuum aspiration NGO nongovernmental organization NSMP Nepal Safer Motherhood Project OBGYN obstetrician gynecologist PAC post-abortion care PHC primary health center PHMT provincial health management team PMM Prevention of Maternal Mortality (Network) PMTCT prevention of mother-to-child transmission PNM private nurse-midwife PPH postpartum hemorrhage PPP public-private partnership PQI performance and quality improvement PRSP Poverty Reduction Strategy Paper PVO private voluntary organization QAP Quality Assurance Project QI quality improvement RAMOS reproductive age mortality survey RBM Roll Back Malaria xii RESCUER Rural Extended Services and Care for Ultimate Emergency Relief (Project) RH reproductive health RHRC Reproductive Health Response in Conflict (Consortium) RPMM Regional Prevention of Maternal Mortality SBL social and behavioral change SCI Skilled Care Initiative SIDA Swedish International Development Cooperation Agency SM safe motherhood SMA safe motherhood advocate SMI Safe Motherhood Initiative SMV safe motherhood volunteer SNL Saving Newborn Lives initiative SP sulfadoxine-pyrimethamine SRH sexual and reproductive health STIs sexually transmitted infections SWAp sector-wide approach TBA traditional birth attendant TFR total fertility rate TOT training of trainers TPC targeted performance-based contract UN United Nations UNDP United Nations Development Program UNFPA United Nations Fund for Population Activities UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund UON unmet obstetric need USAID United States Agency for International Development WHO World Health Organization 1 1. OVERVIEW 1.1 BACKGROUND While some developing countries have shown great progress in improving maternal health, progress remains slow and levels of maternal mortality are persistently high in much of the developing world (Pathamanathan et al., 2003; Koblinsky, 2003). The United Nations Millennium Development Goals (MDGs) represent a concerted global pledge to significantly improve the human condition by 2015, with efforts aimed at reducing poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. One of the MDGs aims to improve maternal health, with a target of reducing the maternal mortality ratio by three-quarters between 1990 and 2015 (Table 1). By building on past declarations of United Nations (UN) conferences, this goal reaffirms an international commitment to addressing the problems associated with reproductive health, safe motherhood, and family planning. Furthermore, the MDG initiative provides a unique opportunity to refocus and accelerate program efforts by donors, governments, and civil society, to improve maternal health for individual and societal well-being. Table 1: The Millennium Development Goal to Improve Maternal Health Goal 5 Target Indicators Improve maternal health Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Maternal mortality ratio Proportion of births attended by skilled health personnel Source: United Nations Millennium Declaration, 2000. Of particular importance in influencing the women’s health field was the UN International Conference on Population and Development (ICPD) held in Cairo in 1994, which led to a “paradigm shift” in addressing maternal health, from within a demographically-driven framework to a reproductive health framework that incorporates reproductive rights (Box 1). The ICPD Program of Action clearly frames maternal health within the context of reproductive health. However, the framing of the MDG to improve maternal health presents at least two conceptual challenges for providing guidance on scaling up efforts to achieve progress (Freedman et al., 2003). First, the goal is improved maternal health, yet the target is stated in terms of reduction in maternal death. Although health and death are related, in practice, efforts can improve maternal health without directly reducing maternal death, and vice-versa. For example, most aspects of routine care during pregnancy will have little impact on the likelihood of a woman developing a life-threatening obstetric complication (Freedman et al., 2003). At the same time, reducing maternal deaths will not reduce the burden of pregnancy-related complications and subsequent poor maternal health (Graham and Hussein, 2004). Second, the goal is stated in terms of maternal health, without explicitly indicating that maternal health is inextricably linked to reproductive health, of which maternal health is one facet (Lule et al., 2003). Thus, it should be clarified that while we use the phrase maternal health 2 throughout this document, we recognize that maternal health is, of course, intrinsically linked to the broader concept of reproductive health. Furthermore, in the context of this paper, we are focusing on maternal health as specified in the MDG to improve maternal health (including the reduction of maternal mortality), and not focusing on the entire gamut of women’s reproductive health issues, which would entail a much broader and more comprehensive focus. Box 1: Definition of Reproductive Health Reproductive Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. Source: ICPD Program of Action (Paragraph 7.2), 1994. 1.2 OBJECTIVES We have the knowledge to improve maternal health outcomes and in general, we know what interventions and strategies are needed to achieve this goal. In order to scale up efforts and accelerate progress towards achieving the Millennium Development Goal to improve maternal health, however, we must also be able to implement effective maternal health programs given a country’s particular setting, policies, and resource constraints. The objective of this discussion paper is to share up-to-date high quality information on a wide range of promising approaches1 that aim to improve maternal health outcomes. By bringing together a set of global promising approaches, based on field research and practice by experienced organizations working in this arena, this document is a resource for program planners and managers involved in designing and implementing maternal health programs in developing countries. Specifically, the practical examples described here, including the successes achieved, challenges addressed, and lessons learned, can serve as a useful starting point in the process to improve current maternal health programming. By learning from the experiences of others, these promising approaches can be further improved and adapted to different field situations in order to scale up efforts to ensure improved maternal health outcomes. For the most part, the promising approaches presented in this paper are supported by evidence-based knowledge and strategies that have proven to be effective in improving maternal health outcomes. 1 Promising approaches may include overall programs, specific practices, research efforts, complex or discrete interventions, innovations, or other strategies to improve maternal health outcomes. 3 However, some of the promising approaches described in this report are more recent or innovative, and may not yet have been evaluated rigorously to show impact in changing maternal health outcomes. Thus, without such measurable results, we have used the term ‘promising approaches’ rather than ‘best practices’ to describe this collection. These approaches are being documented and disseminated to share knowledge, and to illustrate current efforts from the field, although this collection of promising approaches is not exhaustive. Discussion papers such as this one are disseminated to a large audience, including World Bank staff members, bilateral and multilateral agencies, country policymakers, and other stakeholders and donors. In particular, this paper will be useful for World Bank staff when assisting client countries in developing their National Poverty Reduction Strategy Papers (PRSPs) and costing health sector plans. Moreover, the paper provides Bank staff with substantive evidence to share with governments on how best to prioritize and implement maternal health programs, and scale up efforts to achieve progress. Although primarily intended for use by Bank staff, we hope this guide will also be useful to governments, other international donor agencies, and nongovernmental organizations (NGOs), who are interested in improving maternal health, and minimizing the disparities that currently exist between industrialized and developing countries. 4 2. INTRODUCTION 2.1 MAGNITUDE OF THE PROBLEM Maternal mortality, the most severe maternal health outcome, has been described as “one of the shameful failures of development” (Freedman et al., 2003: 6). Although some developing countries have shown great progress in reducing maternal mortality (for example, Sri Lanka and Malaysia), progress remains slow and levels of maternal mortality are persistently high in much of the developing world (Pathmanathan et al., 2003). It is estimated that each year, some 8 million women suffer pregnancy-related complications and over 500,000 women die, with 99 percent of these maternal deaths taking place in developing nations, mainly in sub-Saharan Africa and South Asia (WHO, 2004a; AbouZahr and Wardlaw, 2003a). Thus, most maternal deaths result not from ‘disease’ per se, but from pregnancy-related complications, which are now widely recognized as a leading cause of death and disability among women of reproductive age in developing countries. The five direct obstetric complications that cause the majority of maternal deaths throughout the developing world are hemorrhage, sepsis, unsafe induced abortion, hypertensive disorders of pregnancy, and obstructed labor (WHO, 1996). What is especially tragic is the fact that most of these maternal deaths could be averted with very cost-effective interventions, even where resources are limited (Koblinsky, 1995; WHO, 2004a). Maternal mortality is often characterized as the ‘tip of the iceberg’ since for every maternal death an estimated 20 women suffer injury, infection, or disease – about 10 million women each year. In some cases, long-term disabilities (such as prolapse, infertility, obstetric fistula, incontinence) can result (Fortney and Smith, 1999). More than 40 percent of pregnant women in developing countries may experience complications, illnesses, or permanent disability (WHO, 1996). Among commonly used human development indicators, maternal mortality shows one of the starkest disparities between developed and developing countries, and between the rich and poor within countries. For example, in developing countries, one woman in 16 is at risk of dying of pregnancy-related complications, whereas in developed countries, the risk is one woman in 2800 (WHO, 2004a). Moreover, the poorest countries are progressing the slowest towards reducing maternal mortality: low-income countries have been reducing maternal mortality by 2.4 percent a year, compared to lower middle- income countries (4.9 percent) and upper middle-income countries (2.5 percent) (Wagstaff and Claeson, 2004). At 18 percent, maternal causes of death and disability comprise the biggest contribution to disability-adjusted life years (DALYs) lost among reproductive age women in low-income countries (World Bank, 1993; WHO, 1999). 5 2.2 RATIONALE FOR INVESTING IN MATERNAL HEALTH The death or illness of a woman of reproductive age has clear implications for a country’s productive capacity, labor supply, and economic well-being, and also translates into substantial economic loss and social hardship for her family. Pregnancy-related disease burden associated with frequent or too-early pregnancies, poor maternal health and pregnancy complications, drains women’s productive energy, jeopardizes their income- earning capacity, and contributes to their poverty. Especially important is that women’s wage earnings are critical to the family unit, community, and overall poverty reduction, and in fact, benefit family welfare more than men’s wage earnings. Experience in Bangladesh has shown that when women have an income, they invest their money toward the well-being of their families, particularly their children’s health and education (World Bank, 1998). For example, a study from Bangladesh found a positive impact of women’s participation in credit programs on their decision to seek formal health care, whereas there was no such impact of men’s participation in credit programs on their demand for formal health care (Nanda, 1999). In addition, children whose mothers die or are disabled in childbearing have vastly diminished prospects of leading a productive life (World Bank, 1999). Thus, poor maternal health exacts costs and incurs losses not only at the household level, but at the community and national levels as well. In addition to the economic justification for investing in maternal health, it is now recognized that the well-being of women is an end in itself, because women are intrinsically valuable (Thaddeus and Maine, 1994). There are also compelling human rights and social justice dimensions to reducing death and illness associated with pregnancy and childbirth. During the last decade, a human rights lens has been increasingly applied to view and monitor maternal health, and these issues have been codified in a number of international covenants including the Convention on the Elimination of all forms of Discrimination (CEDAW) and the international policy agenda that emerged from the Cairo ICPD. Poor maternal health and health care (for example, lack of skilled care) not only affects women’s survival but has serious implications for the survival of their newborns as well (Lawn et al., 2005). Pregnant women’s poor nutrition contributes to low birth weight in 20 million babies each year. In one study that reported on child outcomes for mothers who died in labor, all the newborn babies died within one year of birth (Greenwood et al., 1987; cited in Lawn et al., 2005). The risk of death for children under 5 years is doubled if their mothers die in childbirth, and at least 20 percent of the burden of disease among children under the age of 5 is attributable to conditions directly associated with poor maternal and reproductive health, nutrition, and the quality of obstetric and newborn care (World Bank, 1999). It is also recognized that motherless children, especially girls, are less likely to have access to education and health care resources as they grow up (Strong, 1992; Panos London, 2001). 6 2.3 KEY TECHNICAL INTERVENTIONS TO IMPROVE MATERNAL HEALTH In developing countries, historically, approaches to reducing maternal mortality tended to focus on training traditional birth attendants (TBAs) and prenatal screening to identify women at ‘high risk’ of developing obstetric complications. However, we now know that all pregnant women are at risk of developing obstetric complications and some 15 percent of them will develop a life-threatening obstetric complication that requires treatment at a health facility (WHO, 1996). Thus, over the last decade, the effectiveness of these earlier strategies has been questioned. It is now recognized that the success of TBA training programs in reducing maternal mortality is limited (Bergström and Goodburn, 2001). Traditional birth attendants can, however, provide essential social support to women during childbirth, and where they are more formally linked to the health care system, trained TBAs can play a role in birth preparedness and strengthening community-based referral practices (Lule et al., 2003). Furthermore, it has become increasingly understood that prenatal screening programs that focus on identifying ‘high risk’ women are not effective in reducing maternal mortality. The risk approach fails to identify the majority of women who will develop obstetric complications since a greater number of complications and deaths occur among ‘low risk’ women (Rosenfield and Maine, 1985; Maine et al., 1997). Moreover, risk screening can create a false sense of security among those in low risk groups, and may leave them unprepared for an obstetric emergency (Yuster, 1995). Nevertheless, antenatal care remains important to improving maternal health and in the management of certain conditions, and can serve as an initial point of contact between women and the health care system (Carroli, Rooney and Villar, 2001). Given that the majority of maternal deaths occur around the time of labor and delivery, it has been necessary to shift the focus of maternal health programs from an emphasis on these earlier strategies, to strategies that prioritize skilled delivery care and the management of complications to save women’s lives (UNICEF, 2003). It is estimated that 391,000 maternal deaths worldwide might be averted if coverage rates of key maternal mortality interventions were increased from current levels to 99 percent (Wagstaff and Claeson, 2004) (Figure 1). Notably, access to essential obstetric care accounts for more than half the maternal deaths averted. The WHO’s Mother-Baby Package (MBP), which incorporates a set of key maternal health problems and interventions, would cost approximately $2 per capita to deliver the maternal component alone in low-income countries (WHO, 1996; Jowett, 2000). Essential obstetric services, costing approximately 24 percent of the Mother-Baby Package, could reduce maternal mortality by about 74 percent (Jowett, 2000). The following sections provide an overview of major technical interventions to improve maternal health outcomes, including emergency obstetric care, skilled attendance, management of unsafe abortion, focused antenatal care, and family planning services. It must be emphasized that these interventions should not be implemented as stand-alone vertical interventions or programs, but rather, they should be part of an overall package of essential services to improve maternal health. They are described here separately for clarity in identifying and understanding some of the key technical interventions that are required to improve maternal health outcomes. 7 Figure 1: Maternal Deaths Averted with Full Use of Existing Interventions 0% 10% 20% 30% 40% Antibiotics for preterm rupture of membranes Antibiotics for treating bacterial vaginosis Calcium supplements during pregnancy Magnesium sulphate for pre-eclampsia Active management in third stage of labor Drugs for preventing malaria Treatment for iron deficiency Tetanus toxoid immunization Improved access to comprehensive essential obstetric care Improved access to safe abortion services Percentage of maternal deaths averted Hemorrhage Puerperal infection Eclampsia Obstructed labor Abortion complications Malaria Anemia Tetanus Source: Wagstaff and Claeson, 2004. 2.3.1 Emergency Obstetric Care There is strong supporting evidence that emergency obstetric care should be an essential component of programs aimed at reducing maternal mortality (Paxton et al., 2005). The majority of obstetric complications cannot be predicted, but almost always can be treated successfully with good, timely medical care (Maine, 1993). Health facilities that provide certain medical services including antibiotics, blood transfusions, and Caesarean sections, can save nearly all women with obstetric complications (Maine and Chavkin, 2002). Since most women in developing countries deliver outside of health facilities, and since most maternal deaths occur during labor, delivery, and the immediate postpartum period, it is essential that all women with obstetric complications who need treatment have timely access to health facilities providing good quality emergency obstetric care. Thus, unlike many other public health problems, reducing maternal death and disability depends on effective medical treatment rather than primary prevention (Ganatra et al., 1996). Emergency obstetric care (EmOC) refers to a set of signal functions performed at health facilities that can prevent the death of a woman experiencing an obstetric complication. (UNICEF/WHO/UNFPA, 1997). For Basic EmOC, usually provided at health centers 8 and small maternity homes, these signal functions include administering certain drugs and performing lifesaving procedures as described in Table 2. For Comprehensive EmOC, usually provided at sub-district or district hospitals, this means being able to provide Caesarean sections and blood transfusions, in addition to Basic EmOC signal functions. According to current UN recommendations, for every 500,000 population, there should be at least 1 Comprehensive and 4 Basic EmOC facilities (Table 2). Table 2: Signal Functions of Basic and Comprehensive EmOC Basic EmOC Comprehensive EmOC 1. Administer parenteral antibiotics 2. Administer parenteral oxytocic drugs 3. Administer parenteral anticonvulsants for pre- eclampsia and eclampsia 4. Perform manual removal of placenta 5. Perform removal of retained products 6. Perform assisted vaginal delivery Includes all the signal functions in Basic EmOC as well as: 7. Perform surgery (caesarean section) 8. Perform blood transfusion A Basic EmOC facility is one that is performing all of functions 1 to 6. A Comprehensive EmOC facility is one that is performing all of functions 1 to 8. Source: UNICEF/WHO/UNFPA, 1997. Increasing the provision of EmOC does not necessarily require the construction of new health facilities. Much can be accomplished by upgrading existing infrastructure, staff skills, and service provision guidelines. Moreover, efforts to strengthen maternal health services also benefit the entire health care system, for example, by providing services that are important for treating other health problems such as road traffic accidents, which comprise a large proportion of the disease burden in many low-income countries (Jowett, 2000). An increasing number of maternal health programs now recognize that EmOC is critical to reducing maternal death and disability. When programming for maternal health, bottlenecks in accessing EmOC services are generally assessed using the “Three Delays” Model, which addresses the delays involved between the onset of an obstetric complication and its outcome: 1) delay in the decision to seek care; 2) delay in arrival at a health facility; and 3) delay in the provision of adequate care at the health facility (Thaddeus and Maine, 1990; 1994). 9 2.3.2 Skilled Attendance at Birth Box 2: Definition of ‘Skilled Attendant’ According to a statement by WHO, ICM, and FIGO, the term ‘skilled attendant’ refers to “an accredited health professional – such as midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management or referral of complications in women and newborns”. Traditional birth attendants, either trained or not, are excluded from this category of skilled health workers. Source: WHO, 2004b. A skilled attendant who is present during childbirth and the immediate postpartum period is a key player in saving women’s lives (WHO, 1996). Appropriate management by skilled attendants at labor, delivery, and the immediate postpartum period, can avert complications such as retained placenta, even without modern obstetric techniques that require surgery and blood transfusion (MacDonald and Starrs, 2002). In order to be effective, however, a skilled attendant requires an enabling environment that includes access to a referral system, communication and transport, drugs and supplies, and equipment. Furthermore, the enabling environment – a well functioning health system – requires adequate human resources and management systems, which ensure that there are: sufficient skilled attendants with all the necessary skills deployed where they are needed; satisfactory pay scales and career advancement opportunities; continuing education opportunities to maintain and upgrade skills; supportive supervision mechanisms; and possibilities for skilled attendants to refer women and newborns directly to higher-level care if necessary (WHO, 2004b). Hence, the term skilled attendance refers to both the skilled attendant and the enabling environment (Figure 2). Figure 2: The Enabling Environment Source: Family Care International and the Safe Motherhood Inter-Agency Group, 2001. 10 The “proportion of births attended by skilled health personnel” is one of two indicators to measure the Millennium Development Goal to improve maternal health. In developed countries, the use of a skilled attendant at delivery is nearly universal. However, only 58 percent of pregnant women in developing countries deliver with the assistance of skilled health personnel (WHO, 2004c). In Africa, for example, just 44 percent of births are attended by skilled health personnel compared to about 99 percent in Europe and North America (Figure 3). Some developing regions have shown improvement in the use of skilled attendants. For example, Sri Lanka and Malaysia have reduced maternal deaths considerably, and providing professional midwives to assist deliveries is likely to have played a major contributing role (Pathmanathan et al., 2003). In Tunisia too, increasing skilled attendance at birth was a key factor in reducing maternal deaths by 80 percent in only 23 years (Panos London, 2001). Nevertheless, progress in increasing the proportion of births attended by skilled personnel has been slow, particularly in resource-constrained settings in Africa and Asia (WHO, 1999). Given the chronic shortages of skilled personnel and weak health systems, many women still deliver without the presence of an attendant who can provide lifesaving care. Figure 3: Proportion of Births Attended by Skilled Health Personnel in 2004 Source: WHO, 2004c. One of the core functions of a skilled birth attendant is the active management of the third stage of labor (AMTSL), which is a proven, simple, preventive measure for reducing postpartum hemorrhage (PPH). Postpartum hemorrhage, or severe bleeding, is a leading cause of maternal mortality worldwide with at least 25 percent of maternal deaths being attributed to PPH (AbouZahr, 1998). The majority of women with PPH have no identifiable risk factors and PPH is often unpredictable, occurs suddenly, and can rapidly become life-threatening. The majority of cases of PPH occur during the third stage of labor. The most common cause of severe PPH that occurs within 24 hours of delivery is uterine atony, or the failure of the uterus to properly contract after delivery (Ripley, 1999). Other factors that contribute to PPH are retained placenta, vaginal or cervical lacerations, and uterine rupture or inversion. 11 Skilled attendants, who manage the third stage of labor actively, carry out interventions to avert uterine atony, and thus prevent PPH (Prendiville, Elbourne, and McDonald, 2004). One component of AMTSL is the injection of a uterotonic drug immediately after delivery of the newborn. Oxytocin is the most commonly used uterotonic drug, and has proven to be very effective in reducing the incidence of PPH and prolonged third-stage labor (Ripley, 1999). Another drug that can help reduce postpartum bleeding is misoprostol, which has a wide range of potential benefits over other available uterotonic drugs including its ease of administration (oral or rectal), low cost, and stability at room temperature (Ripley, 1999; Tsu, Langer and Aldrich, 2004). Several recent and ongoing studies have been evaluating misoprostol’s effectiveness in reducing PPH as compared to other uterotonic drugs. In places where women do not receive any uterotonic drugs, the use of misoprostol may be a feasible option (Darney, 2001). 2.3.3 Management of Unsafe Abortion Unsafe abortion is defined as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both (Panos London, 2001). Although accurate data are difficult to obtain, the World Health Organization estimates that there are 46 million pregnancies each year that end in an induced abortion; nearly 20 million of these are estimated to be unsafe (WHO, 2003a). Approximately 13 percent of pregnancy-related deaths have been attributed to complications of unsafe abortion, amounting to roughly 67,000 deaths annually. There are also long-term health problems that result from unsafe abortion, including chronic pelvic pain, pelvic inflammatory disease, tubal blockage, and infertility (Family Care International and the Safe Motherhood Inter-Agency Group, 1998a). In addition, complications of unsafe abortion exact a toll on health care systems in terms of hospital space, providers’ time, antibiotics, blood, and supplies (Dayaratna et al., 2000). Almost all the deaths and complications from unsafe abortion are preventable. In many developing countries, women who lack access to safe and acceptable contraceptive services may be faced with an unwanted or unplanned pregnancy, which too often results in unsafe abortion. Moreover, even where family planning services are accessible, pregnancy may still occur as a result of contraceptive failure or as a result of incest or rape (Thonneau, 2001). Women who have abortions (either spontaneous or induced) need access to comprehensive post-abortion care (PAC) services since they are susceptible to a variety of complications. For incomplete abortion, follow up with evacuation of the uterus may be needed to stop bleeding and prevent infection. Three important features of PAC services include: emergency treatment of complications of abortion; family planning counseling and services; and linkages to other reproductive health services (JHPIEGO, 2004). Skilled providers are critical to ensure the success of PAC services, and services should be available at all levels of the health care system. 12 2.3.4 Focused Antenatal Care It is now understood that antenatal care (ANC) interventions, in and of themselves, cannot be expected to reduce maternal mortality significantly (Bergsjø, 2001). Although antenatal care is not an effective means of identifying women who will develop life- threatening obstetric complications during pregnancy and childbirth, antenatal care can play a role in improving maternal health and improving the health and survival of infants (AbouZahr and Wardlaw, 2003b). Current recommendations for routine antenatal care in developing countries are described below (Box 3). Box 3: The Role of Antenatal Care ƒ 4 antenatal visits with a skilled provider to detect problems ƒ Birth preparedness and complication readiness planning with family ƒ Detection and management of co-existing conditions and complications ƒ Voluntary counseling and testing for HIV (especially in areas with high HIV prevalence) ƒ Counseling for breast feeding, family planning, HIV/STIs, nutrition, and danger signs of pregnancy and delivery complications ƒ In select populations: address iodine deficiency; treatment for malaria; and helminth presumptive treatment ƒ Treatment of diagnosed infections (i.e., syphilis, gonorrhea, or tuberculosis) ƒ Tetanus toxoid immunization (2 doses) ƒ Where iron deficiency and anemia are high, supplying iron and folate supplements ƒ Where vitamin A deficiency is prevalent, supplying low-dose supplements of vitamin A ƒ Screening women for domestic violence and providing appropriate counseling and referral Sources: White Ribbon Alliance for Safe Motherhood/India, 2002; Ransom and Yinger, 2002. Detection and management of anemia Anemia during pregnancy is a significant problem for many women in developing countries. In India, for example, the prevalence of anemia among pregnant women is estimated at almost 50 percent (Shali, Singh, and Goindi, 2004). An important component of antenatal care is for the detection and management of severe anemia among pregnant women, which is a significant underlying cause of maternal mortality and low birth weight outcomes. Iron-deficiency anemia also causes deficits in work productivity, care-giving capacity, and child development (Stoltzfus, 2001; Elder, 2000). The use of iron and folate supplementation to treat iron-deficiency anemia has been shown to reduce the prevalence of anemia. Prevention and treatment of malaria Forty percent of the world’s pregnant women are at risk of malaria infection (Shulman and Dorman, 2003). Pregnant women are particularly vulnerable to malaria since pregnancy reduces immunity, making women more susceptible to malaria infection, and increasing the risk of illness, severe anemia, and death. HIV infection may further compromise a pregnant woman’s immunity to malaria (Steketee et al., 1996). Malaria in pregnancy is also a major cause of miscarriage, premature delivery, low birth weight, and newborn death. Pregnant women in non-endemic areas are more likely to die than non- 13 pregnant women if they develop malaria, and their health is more likely to deteriorate faster (Panos London, 2001) (Figure 4). Figure 4: Malaria during Pregnancy In areas of low or In areas of high or moderate epidemic transmission (stable) transmission Acquired clinical immunity – low or none Acquired clinical immunity – high Clinical illness Asymptomatic infection Severe disease Maternal anemia Placental infection Risk to mother Risk to fetus Maternal morbidity Low birth weight Death from severe malaria Spontaneous abortion Higher infant mortality Premature delivery Impaired child development Stillbirth Source: WHO/UNICEF, 2003. The World Health Organization recommends a three-pronged approach using low-cost interventions to address malaria in pregnancy: insecticide-treated nets (ITNs); intermittent preventive treatment (IPT); and effective case management of malarial illness during pregnancy (WHO/UNICEF, 2003). Antenatal care provides a major opportunity for applying this three-pronged approach since the majority of women in developing countries attend antenatal care at least once during pregnancy (WHO/UNICEF, 2003). Despite the high toll malaria exacts on pregnant women and their infants, malaria control during pregnancy had not received adequate attention or program support until relatively recently. In the Abuja Declaration from the African Summit on Rollback Malaria in 2000, the following goals for the prevention and control of malaria were agreed upon: 1) at least 60 percent of pregnant women will have access to and use effective preventive measures; and 2) at least 60 percent of children under five will have access to prompt and effective treatment (WHO, 2003b). 2.3.5 Family Planning Services Undesired fertility contributes directly to maternal death. According to a Global Health Council report analyzing the impact of unintended pregnancies on maternal deaths in developing countries, more than 300 million unintended pregnancies and the resulting deaths of nearly 700,000 women occurred between 1995 and 2000 (Daulaire et al., 2002). Providing access to voluntary, safe, affordable, and appropriate family planning (FP) knowledge and information services can have a significant impact on averting maternal mortality by reducing the number of pregnancies, and thus, reducing women’s exposure 14 to the risk of developing an obstetric complication that will possibly lead to maternal death (Freedman et al., 2003; Maine, 1997). Moreover, family planning services can be used to prevent unwanted pregnancies and abortions, and promote optimal birth spacing. Although family planning is cost-effective at US$0.90/ per capita, unmet need for contraception remains a significant problem (World Bank, 2002). It has been estimated that if unmet need was met and women had only the number of pregnancies at the interval they desired, maternal mortality would drop by 20–35% (Freedman et al., 2003). Furthermore, it is estimated that 122.7 million women in developing countries have an unmet need for contraception; women aged 15-24 account for one-third of unmet need (Ross and Winfrey, 2002). In many settings, unmet need is especially a problem for sexually active adolescent girls and young women who want to avoid pregnancy for limiting or spacing births, but are not using contraception for various reasons. Figure 5 shows the proportion of young people using family planning and their levels of unmet need in selected countries. Data also suggest that the unmet spacing needs of young people are 2.3 times higher than those of the adult population as a whole (UNFPA, 2003). Family planning also contributes to slower population growth, a reduction in poverty, and preservation of the environment. A variety of means have been tried for providing contraceptives, including clinics, private providers, community-based distribution systems, pharmacies, and social marketing (Dayaratna et al., 2000). Figure 5: Percent of Married Women Aged 15 – 19 Who Would Prefer to Avoid a Pregnancy Source: Ashford, 2003. 4 15 23 28 54 56 64 10 28 35 40 15 11 10 Chad Cote d'Ivoire Uganda Haiti Bangladesh Egypt Turkey Using contraception Not using contraception (unmet need) 15 2.4 CONCEPTUAL FRAMEWORK FOR UNDERSTANDING MATERNAL HEALTH OUTCOMES Maternal health outcomes are influenced by a range of multisectoral factors, including household and community behaviors along with cultural norms, health systems and other sectors, and government policies and actions. All of these factors have the potential to impede or enhance maternal health. One way of contextualizing how these multisectoral factors affect maternal health outcomes is through the Pathways to Improved Maternal Health Outcomes framework (Figure 6), which was adapted from the World Bank’s Health, Nutrition and Population Chapter in the Poverty Reduction Strategy Paper Sourcebook (Claeson et al., 2001). The Pathways framework is used in the Poverty Reduction Strategy process because it responds to the results-based approach. The framework allows one to conceptualize the interconnectedness of variables that affect health outcomes and helps to identify risk factors and interventions at different levels of the system, all of which affect maternal health outcomes. It can also help us understand disparities in health status between the rich and the poor. As illustrated in the framework, the solid lines link the predominant pathways through which factors influence maternal health outcomes. The dashed lines represent some of the “secondary linkages” that also need to be considered. Figure 6: Pathways to Improve Maternal Health Outcomes Maternal health outcomes Households/ Communities Health system and other sectors Government policies and actions Source: Claeson, et al, 2001. As shown in the framework, maternal health outcomes are directly and indirectly affected by factors at different levels. Under government policies and actions, for example, health reforms and actions in other sectors (e.g. transport or infrastructure sectors) directly affect the health service supply and other parts of the health system, heavily influencing factors at the household and community level, which are immediate determinants of maternal health outcomes. Traditionally, efforts to improve maternal health have tended to focus on issues within the health system. However, as indicated by the framework, improving maternal health outcomes requires strategic efforts that address forces inside Household behaviors and risk factors Household resources Community Factors Health service supply Supply in related sectors Health financing Actions in other sectors Health sector reforms Maternal health outcomes 16 and outside the health system. For appropriate interventions to comprehensively address maternal health, investments are needed at all levels of the Pathways framework. The Pathways framework makes clear the steps between policy action and improved maternal health outcomes. The framework can help in identifying the desired outcomes, the actions needed to achieve the outcomes, the inputs required to produce the actions, and a strategy for linking it all together to attain good maternal health. Further, the process requires achieving consensus on: key problems and how to address them; risks that need to be managed to achieve the outcomes; and indicators that should be measured to monitor and evaluate performance. All of these are imperative to obtaining good health outcomes (Claeson, et al, 2001). According to the framework, household and individual behaviors can be major determinants of maternal health outcomes. These behaviors include: use of household resources, nutrition behaviors, health-care demand (demand for contraception, antenatal care, etc.), and early marriage and pregnancy. To promote healthy behaviors adequately requires knowledge about how to promote health, and also requires the ability to use and act on this information. Household resources, such as access to food, clean water and sanitation, as well as financial resources to meet basic needs, can influence behavior and therefore affect health outcomes. Risks during pregnancy and early life are exacerbated by behaviors and by limited household resources. Furthermore, poor maternal health outcomes can affect household resources. Research and interventions have tended to regard all members of a household as a single unit: whatever benefits one member of the household was assumed to benefit all members equally. Evidence now suggests that this is not, in fact, the case. For example, food distribution in a family and utilization/access to health services are often not equal. It is commonly acknowledged that intra-household differences affect how decisions are made. Recognizing the importance of individuals and households in generating good or poor reproductive health outcomes should lead policy makers to focus on the constraints faced by vulnerable households and vulnerable members within households (Merrick, 2004). Community factors, such as gender norms and practices, fatalistic attitudes, social cohesion, access to community services and cultural practices can also have a direct impact on maternal health outcomes. These factors can affect the way a household member behaves or uses household resources, which, as discussed above, can greatly affect maternal health outcomes. For example, in Ghana, pregnant women were forbidden to eat food rich in protein, including meat, fish, and fresh milk, in order to prevent the fetus from becoming overweight, thereby prolonging labor. This traditional practice could potentially have detrimental effects on the health of the expecting mother and fetus (Mills and Bertrand, 2005). Because the community factors that determine maternal health outcomes are often not within the health sector, it is essential that initiatives that aim to achieve improved maternal health outcomes encompass multisectoral issues. The health sector and other sectors are also important areas for achieving improved maternal health. For example, an ample supply blood and other medical supplies that are required for treating an emergency are also vital to ensuring safe delivery. An often- 17 overlooked area is the management of reproductive health commodities. Without a sustainable and ample supply of commodities, good maternal health will not be achieved. Sectors outside of health are also crucial, such as the education sector, water and sanitation, and transportation sectors. For example, in rural Tanzania, 84 percent of women who gave birth at home intended to deliver at a health facility but did not due to distance and lack of transportation (Bicego et al., 1997). Other examples include human resources, a referral system, and health education and outreach services. Finally, government policies and actions impact health services and therefore health outcomes. These include health reforms, health financing mechanisms, factors that improve health sector performance, and public-private partnerships. Also, policies from other sectors can greatly affect maternal health outcomes. Education policies, for example, that aim to improve girls’ access to education will have long–lasting effects on maternal health outcomes. If all the arrows from the pathway boxes pointed directly to health outcomes, achieving improved maternal health would be significantly easier than it has proven to be. However, different factors within the Pathways framework affect one another, both positively and negatively, and influence the final desired outcome. It is therefore of paramount importance that we recognize the synergies of the different factors inside and outside the health sector, and how they are linked to the desired outcome of improved maternal health. 18 3. BUILDING ON EXPERIENCE: AN OVERVIEW OF PROMISING APPROACHES TO IMPROVE MATERNAL HEALTH In light of the Millennium Development Goal to improve maternal health, this global compendium includes selected current approaches to improve maternal health outcomes that appear good or promising, or that demonstrate an innovative approach to addressing maternal health. In collecting these approaches, we contacted expert external organizations working in the area of maternal health and sought their participation in sharing their experiences. In addition, although this document is not a comprehensive review of the World Bank portfolio of maternal health-related projects, we have also shared a handful of examples from within the Bank. We have also included relevant program examples from available literature on maternal health. It should be reiterated that the approaches described are at varying stages of implementation. Although many examples have evaluation findings available, others do not yet have measurable results from evaluations to show that they work. Nonetheless, this chapter illustrates the wide range of approaches that are necessary to accelerate progress towards achieving the MDG to improve maternal health. Based on the promising approaches included in this collection and using the Pathways framework as a guide, we were able to distill a number of salient themes that emerged, and that provided a means for organizing the promising approaches. The themes describe various aspects related to improving maternal health outcomes, including government policies and actions; health systems and health financing; access to health services; building capacity; quality of care; community involvement; monitoring and advancing progress; and partnerships and collaborations. For ease of understanding, the promising approaches have been organized according to these salient themes where applicable. However, this organization is not rigid, and in practice, there is overlap of promising approaches across the different themes, with many promising approaches addressing more than one theme. The sections below provide a short narrative that describes each theme, followed by a brief overview of relevant examples. For promising approaches contributed by external organizations or from the World Bank, annexes provide more detailed information. For examples of promising approaches from the literature, we have indicated the source that was used; the full citation may be found in the References section. 3.1 GOVERNMENT POLICIES AND ACTIONS A major challenge in achieving the Millennium Development Goal to improve maternal health is mobilizing political commitment and creating an enabling and supportive policy environment to implement evidence-based interventions and strategies effectively. Investing in social and economic development – for example, female education, poverty 19 reduction, and improving and women’s status – is critical to improving maternal health (Koblinsky, 2003). National-level policies that improve the functioning of health systems as a whole and that foster multisectoral linkages among the ministries of health, education, social protection, and transport are necessary for improved maternal health outcomes (Lule et al., 2003). Developing countries that have successfully improved maternal health outcomes generally had strong political commitment and enabling policies that supported women’s education, voting and employment; and had health programs that specifically target maternal mortality reduction. Importantly, countries that have policies that explicitly target maternal mortality reduction can be successful in reducing levels of maternal mortality. Further, evidence-based advocacy using available data can enhance political commitment and is important for fostering an enabling policy environment that promotes maternal health. Honduras In 1990, a surveillance study found that maternal mortality was much higher than expected at an estimated 182 maternal deaths per 100,000 live births. This finding prompted the MOH to target mortality reduction explicitly and implement policies to increase the availability of maternal health services. Regions in the country with the highest MMRs were targeted, and the government, with donor assistance, built seven new rural area hospitals and, with community input, five new maternity waiting homes attached to rural hospitals, as well as eight new birthing centers. Efforts to train health personnel, especially auxiliary nurses, accompanied the rise in facilities. By 1997, the MMR was measured at 108 deaths per 100,000 live births. [Source: Koblinsky, 2003.] Africa, Asia In order to stimulate policy dialogue and strategic planning on maternal health and safe motherhood, the Academy for Educational Development (AED) developed REDUCE, an advocacy tool. The REDUCE process uses computer models to estimate the human and economic consequences of poor maternal health and maternal mortality. During a two-week workshop, a team of local experts projects the survival, health, and economic impact of maintaining the status quo versus implementing known interventions that result in reductions in mortality and morbidity. The data provide sound arguments for giving higher priority to maternal health in policy formulation, strategy development, and resource allocation. The computer models have been used in nine countries: Ethiopia, Ghana, Mali, Mauritania, Mozambique, Nigeria, Senegal, Uganda and Viet Nam. [Annex 2] 3.2 HEALTH SYSTEMS AND HEALTH FINANCING According to the World Health Organization, a health system may be defined as including all the activities whose primary purpose is to promote, restore or maintain health (WHO, 2000). The specific vital functions of a health system relate to service provision; providing financial protection against the cost of illness by raising, pooling and allocating financial resources for services; responding to people’s expectations of how health is delivered by making available skilled providers, equipment, drugs and supplies; and providing overall stewardship or oversight through regulation, other policies, and the collection and dissemination of information (WHO, 2000). 20 Box 4: Supply Chain: A Vital Component of Health Systems Supply chain management is crucial to the success of any health system and public health program. Without an adequate supply of essential health commodities – from medicines and HIV test kits, contraceptives, to routine and emergency health supplies – the maternal health MDG will not be achieved. Simply put, if there is no product, there will be no program. In order to deliver the products to the end-users requires logistics support. Improving logistics systems and ensuring product availability requires focusing on the customer – regardless of where on the supply-chain you are working. Further, when public health logistics systems use accurate, current information, they run more efficiently and save countries money. Finally, it is important to secure policymaker support and ensure a sustained funding stream specifically for supplies and logistics. For example, the Chilean Ministry of Health is developing software with its own funding to track inventory movements and consumption. Another example is in Bangladesh, where they redesigned its in-country distribution system, installed a logistics management information system, improved forecasting procedures, and trained more than 10,000 staff in the family planning community. Today, fewer than 5 percent of facilities under its control run out of supplies. Sources: John Snow, Inc. 2005; Global Health Council, 2002. Strong functioning health systems are the necessary platform from which good quality maternal health services can be provided. Strengthening maternal health services benefits the entire health system – ensuring that a health facility can provide essential obstetric care (for example, anesthesia, blood transfusion, surgery) also means that it can provide care for trauma, accidents, and other medical emergencies (Family Care International and Safe Motherhood Inter-Agency Group, 1998b). Countries need to engage their national health systems at all levels in order to develop a culture of quality and professional accountability (Van Lererghe and De Brouwere, 2001). Unfortunately, enormous gaps remain between the potential of health systems and their actual performance, with much variation among countries that appear to have the same resources and possibilities. Health systems have failed to narrow the gap in health status disparities between rich and poor countries over the last century, and in fact the gap is widening (WHO, 2000). In search of more accountable and efficient health systems, and to address fundamental deficiencies, many health ministries throughout the developing world are engaged in health sector reform (Box 5). These intensive long-term efforts are aimed at strengthening and improving health systems by addressing system-wide problems that hinder the adequate delivery of health services. In the end, health sector reforms should ensure equitable access to efficient, sustainable, and good quality health services. Components of health sector reform may include a variety of strategies, policies, and interventions that focus on organizational changes (decentralization, public-private partnerships, integration of service delivery); expanding health financing (alternative financing approaches); and policy changes (providing oversight, changing laws and regulations) (Dmytraczenko, Rao, and Ashford, 2003). 21 Box 5: Five Goals of Health Sector Reform ƒ Efficiency. Health improvements should be achieved at the lowest possible cost. ƒ Quality. Appropriate and safe clinical services, adequate amenities, skilled staff, and essential drugs, supplies, and equipment should be available. ƒ Equity. Health resources should be distributed fairly so no one is denied access to essential care. ƒ Client responsiveness. The system should meet people’s expectations and protect their rights, including their rights to individual dignity, privacy, autonomy in decision-making, and choice of health provider. ƒ Sustainability. The health system can continue to achieve its goals using available resources. Source: WHO, 2000; cited in Dmytraczenko, Rao, and Ashford, 2003. 3.2.1 Decentralization A common organizational change under health sector reform is decentralization – the transfer of decision-making authority and management from higher levels of government (typically from central agencies) to agencies at the regional, provincial or local levels (Brinkerhoff and Leighton, 2002). These transfers may include a number of responsibilities, including planning, finance, human resources, service delivery, operations, maintenance, and information management. Decentralization is based on the notion that local organizations are in the best position to respond to the needs of health service users (Dmytraczenko, Rao and Ashford, 2003). Decentralization involves one or more of the following: delegation, privatization, devolution and deconcentration (Table 3). Table 3: Decentralization – Types and Definitions Delegation Privatization Devolution Deconcentration Transfer of managerial authority to organizations outside of the government structure, such as parastatals or NGOs Transfer of government functions to voluntary organizations or to for- profit/non-profit organizations with varying regulation from the government Authority transfer that creates or strengthens sub-national units of government with clear legal and geographic boundaries Transfer of administrative authority from a central agency located in the country’s capital to the central agency’s field offices Source: Brinkerhoff and Leighton, 2002. As decentralized systems become better established, the hope is that they will improve accountability and transparency, and ensure that maternal health services reach vulnerable populations at the community level. Decentralization of services means that facilities are available as close to people’s homes as possible; there are adequate supplies, equipment, and trained staff (particularly in rural and remote areas); and written policies and protocols to guide service provision and allow certain functions to be delegated to appropriately trained personnel at lower levels (World Bank, 1993). Decentralization brings both advantages and disadvantages to the achievement of improved maternal health. One main advantage is the possibility of developing the District Health Systems approach, which encourages community participation as well as integration between primary care services and the district hospital (Aitken, 1998). It also allows ownership at 22 the district level and flexibility in the integration of different reproductive health services in a manner that best responds to local needs and available resources. However, it should be noted that if not carried out properly, decentralization and other structural changes could lead to a loss of focus and deterioration of services – for example, local entities may lack the technical and managerial skills to address maternal health issues (Lakshminarayanan, 2003) (see Box 6). To help avoid such shortfalls, health specialists and other stakeholders need to be part of the reform process, and engaged in discussions about the financing, management, and structure of the health system (Dmytraczenko, Rao, and Ashford, 2003). Box 6: Lessons Learned from a Decentralization Experience in the Philippines The decentralization experience in the Philippines offers many lessons to suggest that decentralization alone does not always ensure positive results, efficiency, and equity. Decentralization in the Philippines affected service delivery by disrupting the links between rural health units at the municipal level and referral facilities at the district and provincial levels. It also weakened local commitment to reproductive health problems, aggravating disparities between women and men and between the poor and non-poor. The Church had greater jurisdiction and control over some local health posts, which influenced the nature of reproductive health services that were provided. Health personnel were also affected, receiving fewer benefits and incentives for working in the decentralized system. Five years after the decentralization process was implemented, MCH outcomes remained unimpressive. The Philippines decentralization demonstrates important lessons: ƒ Non-health factors, such as gender and the church, can affect health outcomes ƒ Health sector reforms should not be initiated without clear objectives and action plans ƒ Health sector reform is affected by and affects other elements of health sector performance and any reform needs other factors to be in place to achieve efficiency and effectiveness ƒ Not all processes and functions should be decentralized ƒ Monitoring and evaluation is crucial during implementation to balance authority, ensure efficiency, equity, and effectiveness ƒ Stakeholder involvement is critical to ensure needs are met, and fosters ownership of the process ƒ Decentralization, and health reform in general, is a means to an end ƒ Reproductive health can be acutely affected by health sector reforms ƒ Decentralization should be introduced gradually, focusing on institutional capacity at all levels With a centralized health system, initiatives were generally driven from the center. With decentralization, however, such efforts must be regionally driven and regionally owned. Thus reproductive health must have advocates and proponents at the regional levels to ensure availability and access to services. Source: Lakshminarayanan, 2003. India The World Bank-assisted Family Welfare Urban Slums Project in India aimed to improve access and demand for family planning services in urban slums. It also aimed to improve maternal and child health by decreasing maternal and infant mortality rates among slum residents. The key strategy was to decentralize program management to municipalities and empower slum communities through a network of women mobilizers. The results indicated a significant decline in fertility among slum dwellers and improved maternal and child health outcomes, evidenced by a decrease in child mortality and an increase in the use of essential reproductive health services. [Annex 3] 23 3.2.2 Public-Private Partnerships Public-private partnerships (PPP) are another type of organizational change in health sector reform. Governments worldwide have been looking for new techniques of providing and funding services with limited involvement and resources from the government. Engaging the private sector has the potential to improve the quality of services, expand the supply of key health goods and services, complement and supplement public health schemes, and increase utilization of health services. Public- private partnerships contribute to the financing and provision of health services by combining the skills and resources of a wide range of collaborators in innovative ways (Widdus, 2001). The private sector includes all actors outside the government, such as for-profit, nonprofit, formal and non-formal entities, and comprises service providers, non- governmental organizations, pharmacies and pharmaceutical companies, producers and suppliers, shopkeepers, and traditional healers, among others. Examples of instruments available to engage the private sector include: contracting (Box 7), social marketing, regulation and standard setting, information dissemination and training, conversion, and social franchising. Box 7: Contracting of Reproductive Health Services Government contracting of private organizations is increasingly being used to meet the growing demand for quality reproductive health care in developing nations. Although contracting is not a cure-all for ailing health systems, many recognize the potential of contracting as a powerful tool to improve reproductive health care. Many different forms of contracting exist, such as contracting out (outsourcing), contracting in, subsidy, leasing or rental, and privatization. There are many reasons to contract health services, such as: to improve access and quality; to improve access for the poor and for other under-served groups; to minimize the financial burden on the public sector; and to make up for lack of capacity in specific tasks. For example, in Madagascar, non- governmental groups were contracted for maternal and child nutrition programs, as the existing government programs were not reaching the poor and peri-urban areas. Further, contracting of reproductive health services can shield governments from the controversy around services such as family planning: to avoid criticism by religious conservatives, the Colombian government left the provision of family planning services to the private sector. Source: Rosen, 2000. Pakistan A 2003 needs assessment found that women in 6 out of 8 sub-districts in Khairpur did not have 24-hour EmOC and that services were poorly managed and of poor quality. Thus, a partnership between Marie Stopes Society, a public sector NGO, and a government Rural Health Center in Khairpur district, Sindh, Pakistan aims to upgrade the center as a referral facility for EmOC. The project is in the process of making investments in physical infrastructure and equipment, training key staff in surgery and anesthesia, and helping set up community management teams to act as local watchdogs. To increase the sustainability of the intervention, a revolving fund managed by the 24 community will be set up to pay for recurring maintenance expenses. The project is underway and a formal impact assessment has not yet been done. [Annex 3] India The Family Welfare Project, supported by the World Bank, aimed to strengthen and improve the performance of the Government of India’s Family Welfare Program in three states: Assam, Rajasthan, and Karnataka. The goal was to improve maternal health and reduce maternal and child mortality. One component of this project implemented public-private partnerships, particularly to make reproductive and maternal health information and services more available to people in hard to reach areas. NGOs and private voluntary organizations (PVOs) were contracted to conduct information, education, and communication (IEC) campaigns, social marketing of contraceptive supplies, training of auxiliary nurse-midwives, and management of service delivery in remote areas. The partnerships between the Government of India and the NGOs/PVOs were deemed successful and are being scaled up. [Annex 3] Kenya Experienced private nurse-midwives (PNMs) are an ideal cadre for scaling-up primary-level PAC services in Kenya, as they are the major source of antenatal care, family planning and other reproductive health services in many parts of the country. The PRIME Project developed a pilot program in 1998 to train PNMs in key areas of PAC services. Through the PRIME II Project (implemented by IntraHealth International Inc. and partners), the program was scaled-up in the three pilot provinces in 2000 and expanded to a fourth province in 2003. Components of training included values, client- provider interaction and counseling, management of complications, manual vacuum aspiration procedures, infection prevention, pain management, post-abortion family planning counseling and other services, STI/HIV management, record keeping and community outreach. Cost-sharing by providers was an important part of scale-up. The program demonstrated that PNMs can and do deliver comprehensive PAC services and that they are acceptable to women. Results from a 2004 study on sustainability of private providers of PAC services are expected to have implications for future scale-up efforts. [Annex 3] Jordan The MOH Health Insurance Directorate in Jordan is working with the Partners for Health Reformplus (PHRplus) project, Abt Associates Inc., to develop a financing mechanism for contracting with private hospitals that would contain better financial incentives for care as well as improve continuity of care for MOH beneficiaries. The new contracting system would enable expectant women to enroll with a participating private hospital that would be paid a single amount for the entire bundle of necessary services, including prenatal, delivery, and postpartum care. After conducting a comprehensive assessment of private hospitals in Amman, the MOH plans to launch a pilot project to contract with three private hospitals to provide maternity care for 250 MOH beneficiaries, which will be launched in 2005. [Annex 3] Indonesia A Safe Motherhood Project, launched by the Government of Indonesia with support from the World Bank, was designed to meet the needs of the poor and attempted to improve maternal health status and reduce mortality and morbidity. The unique component of this project was the targeted performance-based contracts (TPC) 25 component that used privately trained village midwives (BDD) to provide reproductive health services. To ensure equity amongst poorer women receiving maternal health services and to enhance the TPC BDD’s revenue-earning potential in poor villages, poor women who qualify under a certain set of criteria, received booklets of printed vouchers. The vouchers were used to pay for a basic package of safe motherhood services from the TPC BDD, and the TPC BDD could present the vouchers to the government for payment. The TPC pilot successfully demonstrated that performance-based contracts for private healthcare providers, in combination with demand side intervention strategies such as the vouchers that reach and empower the poor, is a suitable, practical and sound model for continued use by the district health systems. [Annex 3] 3.2.3 Integration of Health Services In the years prior to health sector reform, many programs, such as those for family planning, immunization, and tuberculosis treatment, were usually provided by stand- alone, vertical programs that rarely coordinated their efforts or pooled resources with other services. A key initiative in health sector reform has been to combine separate health services into a single restructured system, which in principle, reduces cost and improves services by using the same infrastructure, supplies, equipment, and personnel for multiple functions. Although integration can potentially improve the overall efficiency of service delivery, if conscious efforts are not made to ensure the integration, it can also lead to the loss of certain services, since providers have to divide their time and resources over a wider array of health services (Dmytrazcenko, Rao, and Ashford, 2003). Zambia In order to improve the care and health outcomes of all pregnant women, regardless of HIV status, the USAID-funded LINKAGES Project, managed by AED, integrated prevention of mother-to-child transmission (PMTCT) services with maternal and child (MCH) services in 48 sites in 9 districts in 3 provinces of Zambia by providing a comprehensive clinical and community care package. The package featured training providers in PMTCT and infant feeding counseling, safe delivery practices, universal HIV counseling as part of routine antenatal services, short-course antiretroviral prophylaxis for HIV-infected women and their infants, and referrals to family planning, child health, and community services. Other program interventions included facility, community, and behavioral assessments; policy advocacy for maternal and infant health and nutrition; and community mobilization. To increase demand for HIV testing and counseling and raise awareness of risk reduction methods, the program developed a behavior change communication strategy. [Annex 3] Ghana A community-based Safe Motherhood Initiative was piloted in Ghana for 17 months by the Center for Development and Population Activities (CEDPA). The initiative integrated safe motherhood activities into existing family planning programs in 3 rural communities in northern Ghana. A main component of the initiative was training safe motherhood volunteers (SMVs) and safe motherhood advocates (SMAs). SMVs were originally community-based distributors and educators in family planning, whose expanded role included providing information to help women and families recognize 26 danger signs. SMAs were community development workers who helped remove barriers that prevented pregnant women from reaching appropriate care promptly. An endline evaluation identified a number of the initiative’s achievements: 86% of pregnant women visited an antenatal clinic within the first trimester of pregnancy (compared to only 5% before); 75% of recently delivered mothers indicated that they ate more food during their recent pregnancy than during their previous pregnancy; 44% of recently delivered mothers indicated that they introduced nutritious foods into their diet during their most recent pregnancy; 7% of pregnant women said they used a local herb with toxic effects to induce labor during their most recent pregnancy, compared to 49% during their previous pregnancy; and 36% of mothers said they breastfed their babies immediately after delivery, compared to only 15% before the SMI. Furthermore, through counseling provided by SMVs, pregnant women and their families were able to: organize a birth plan for normal birth; anticipate and identify obstetric complications and self-refer for care; and organize an emergency plan for unanticipated complications. [Source: Payne and Afenyadu, 2003.] 3.2.4 Costing of Maternal Health Services Achieving the MDGs and the goals set forth in the ICPD Program of Action require significant improvements in maternal and reproductive health. Yet despite extensive sector reforms, health systems in many developing countries still fail to reach large numbers of women with appropriate interventions – especially the poorest and most vulnerable (Knippenberg et al., 2004). There are a number of reasons for estimating the costs, effectiveness, and benefits of safe motherhood programs. Cost analysis is necessary for assessing the affordability of proposed or ongoing programs, considering the need to mobilize resources, and identifying effective interventions to which more resources should be directed. Since ICPD, there has been considerable interest among policy makers, program planners, and managers in the cost of providing maternal and reproductive health (RH) services. In part, there was concern that the delivery of the full package of RH services that was recommended in the ICPD Program of Action would be too costly for countries realistically to afford. It is much easier to identify what is needed to ensure improved maternal health outcomes than it is to identify what those services are going to cost and where the finances are going to come from. Considering the financial costs and constraints to health service provision is a crucial component when motivating policy makers and service providers to invest in maternal health and allocate resources effectively. At the time of ICPD, there was a substantial lack of good data regarding the true costs of running a reproductive health program. However, several studies since then have measured the costs of these services and identified methodologies to do so, for example, the Mother-Baby Package as described in Box 8. Costing information can be used to improve maternal health outcomes through advocacy, planning, implementation and monitoring. 27 Box 8: Mother-Baby Package The Mother-Baby Package Costing Spreadsheet is a tool that estimates the cost of implementing a set of WHO Safe Motherhood Program interventions to reduce maternal and newborn mortality and morbidity at the district level. It provides a detailed list of clinical assumptions that can be modified or adapted to different settings. The tool also has a number of tables with comparative country data for the user to access in case local data are not readily available. Included are estimates of total, per capita and per-birth cost for the district. The estimates are further broken down by input (such as drugs, vaccines, salaries and infrastructure), by intervention (such as management of normal birth, hemorrhage, eclampsia and sepsis), and by service location or level (hospital, health centre and health post). The Mother-Baby Package was used in Uganda, where it was realized that the government was spending about US$0.50 per capita on maternal and newborn health care. To increase expenditures to correspond with the standards and guidelines set forth in the Mother-Baby Package would cost approximately US$1.40 per capita, an incremental cost of US$0.90. The inclusion of capital and overhead costs would raise the cost to approximately US$1.80 per capita, bringing the incremental cost up to US$1.30. This study assisted national authorities, donor governments, and other partners at the national level in considering the substantial recurrent cost implications of providing higher-quality maternal and newborn care, and in doing so it has facilitated an important dialogue on maternal and newborn health care financing and sustainability issues. For more information: http://www.who.int/reproductive-health/economics/intro.html Further, there is another aspect of “costing” that estimates the added resources required to scale up key public health interventions to achieve the MDGs. Both developing country governments and donors ask how much additional resources will be required to accelerate progress towards the health MDGs by 2015. There are a variety of methods used to estimate these figures, which has led to debates over the most appropriate and reliable method that should be used for policy dialogue and decision making at the global and country level. Some of these methods include the MDG Needs Assessments Model developed by the United Nations Millennium Project; elasticity estimates through econometric modeling developed by World Bank staff; and Maquette for MDGs developed by DECVP of the World Bank (Gottret, Fang and Brenzel, 2004). One promising approach is the Marginal Budgeting for Bottlenecks tool developed by UNICEF, the World Bank and WHO (Box 9). 28 Box 9: Marginal Budgeting for Bottlenecks The Marginal Budgeting for Bottlenecks (MBB) was developed by the United Nations Children’s Fund, the World Bank, and the World Health Organization to facilitate countries’ preparation of a medium- term national health expenditure plan that is linked to national health outcomes, such as the PRSP targets and the MDGs. The objective of the MBB tool is to estimate the cost of removing country- specific constraints – or bottlenecks – that are identified as inhibiting the effective delivery and utilization of services. Further, it estimates the marginal costs of overcoming those constraints and facilitates a budgeting process for government health expenditures that improves the efficiency of allocations of the newly available resources, providing a basis for policy dialogue and planning. The MBB helps answer the following questions: What are the major health systems bottlenecks that hamper the delivery of health services and what can be done to address them? How much money is needed to achieve the expected results? And how much can health outcomes be improved by removing the bottlenecks? When using the MBB tool, the first steps are to evaluate the current level of effective coverage with the specific health intervention, set the target coverage level and identify what and where the bottlenecks exist. The next step is to address the issues of how to remove the bottlenecks by: identifying the inputs related to the planned actions to overcome the bottlenecks, assigning the actions values, determining the quantities, and estimating the cost. More simply put, the model flows from defining the desired coverage of a particular service/intervention, identifying the obstacles to achieving the coverage, establishing an action plan for overcoming those obstacles, and estimating the cost of such actions. The MBB has often been used for maternal and child health, as it estimates the impact on under five mortality and maternal mortality reduction. As this paper emphasizes, improving maternal health outcomes requires a multisectoral approach. The MBB model takes multisectoral issues into consideration (such as education of mothers, water and sanitation) and allows one to identify what the determinants and thus bottlenecks are to improving maternal health, identify appropriate interventions, and estimate the cost of implementing the intervention. To date, the tool has been used effectively in the preparation of Medium Term Expenditure Frameworks (MTEF) for Mauritania and Mali, which resulted in a doubling of the health budgets. It has also been used for policy dialogue in Madagascar and India. The process has begun in Benin, Ghana, Sierra Leone, and Ethiopia. Sources: Wagstaff and Claeson, 2004; Knippenberg et al., 2004; Gottret, Fang and Brenzel, 2004; and Yazbeck, 1999. 3.2.5 Alternative Health Financing Schemes An efficient health system should improve health outcomes and ensure financial protection for the poor, especially during catastrophic illness. The shortage of economic resources, high costs of seeking care, and lack of health financing schemes can affect a family’s decision-making process, leading to delays in the use of appropriate medical care. There are numerous ways in which governments, employers, private companies and communities can reduce the amount households have to pay out-of-pocket when using maternal health services. In most cases, some type of health insurance scheme is used to reduce the role of user fees and out-of-pocket payments. Insurance schemes are intended to provide a way of both increasing utilization of health services and reducing the impact 29 of service utilization on household incomes. For example, government-owned social health insurance has been introduced in several countries, including Bolivia, with considerable impact on the overall use of maternal health services (WHO, 2000). Community financing schemes are another approach to increasing access to health care, and are formed on the basis of mutual aid and collective pooling of financial risk associated with health. These initiatives can help increase access and utilization of maternal health services for vulnerable and marginalized populations who otherwise often face exclusion from these services for financial reasons. A review of community financing approaches from Asia and Africa concluded that they can indeed improve access to care and that broad risk-sharing arrangements in health financing have a considerable impact on health (Preker et al., 2002; Jakab and Krishnan, 2004). The use of appropriate medical care is especially critical in the event of an obstetric emergency. There is evidence to suggest that the lack of financial resources has a negative effect on utilization of medical care when women develop obstetric complications (Nanda, 2003). The use of loan funds to improve financial access to health care has been developed and documented in several countries, and is particularly relevant in the context of access to emergency obstetric care. Projects carried out by the Prevention of Maternal Mortality (PMM) Network in Africa included the use of community loan funds to increase access to emergency obstetric care (PMM Network, 1996). No prepayment was required for the provision of these loans, but women were required to repay the loan as soon as possible. Findings from the PMM Network studies showed that repayment rates were often not in full, but the use of loans is likely to have influenced the increases in utilization of services that were evident (Fofana et al., 1997; Chiwuzie et al., 1997; Essien et al., 1997). Bolivia One aim of the government’s Health Sector Reform Project, supported by the World Bank, was to reduce infant and maternal mortality rates in the country. To do this, the project introduced an infant and maternal public insurance scheme, which helped increase coverage of high priority health interventions. The insurance scheme was financed through a public financing scheme (SBS) for high priority health interventions for infants, pregnant women, and women of reproductive age. The development of the public insurance scheme has had a sustained impact on the role municipalities play in the health sector and on public providers. The establishment of an explicit package of services free-of-charge for the population increased public awareness of health issues and their right to access health services. An evaluation showed that the percentage of births attended by trained personnel was 42% in 1998 and increased to 54% in 2002. The percentage of women who had gone through a complete cycle of antenatal care visits increased from 30% to 34% during the same period. Further, the early neonatal hospital mortality decreased slightly from 9 to 7 per 1000 live births. There was substantial growth in the use of prenatal care and inpatient deliveries because of the insurance program. There was also a 39% increase in prenatal visits in public facilities and the private sector saw a decrease in patients during that time. Finally, when the data were disaggregated by socio-economic status, analysis shows that the poorest segment of the population increased use of skilled birth attendants and of institutional deliveries. [Annex 3] 30 Rwanda The Rwandan MOH, with technical support from Abt Associates Inc., piloted prepayment schemes known as Mutual Health Organizations (MHOs). MHO membership covers a basic health care package that includes a variety of services (e.g., deliveries, essential drugs, curative and preventive services, and selected hospital based services). Households can join the district scheme by paying an annual fee (currently $4.25). There is a small co-payment per visit to the health center, but none for covered district hospital services. The existence of MHOs provided a mechanism to target subsidies to the very poor, through purchase of memberships by government and local charities. Following the pilot’s success and subsequent spontaneous community development efforts, there were 214 MHOs across Rwanda by 2003 covering 1.7 million people, about 21% of the total population. [Annex 3] Ghana, Senegal, Mali Abt Associates Inc., through the USAID-funded Partners for Health Reform plus (PHRplus) Project, has been actively involved in the development and promotion of community-based health financing schemes, also known as Mutual Health Organizations (MHOs) in West Africa. Results to date indicate that despite a significant increase in MHOs in Ghana, reproductive health benefits, such as coverage of normal deliveries (covered by 35% of MHOs) and family planning (covered by 5%) could be strengthened, though more than half of the MHOs cover complicated deliveries. In Senegal, approximately one-third of existing MHOs cover family planning, and most cover some reproductive health services. In Mali, while knowledge of maternal health issues is high, actual use of services is low because of perceived lack of need and associated costs. Through PHRplus, 4 new MHOs that cover maternal and reproductive health services are now operational in Mali. Forthcoming results of household surveys in all three countries will shed further light on the impact of MHOs on reproductive health utilization. [Annex 3] 3.3 ACCESS TO HEALTH SERVICES Access to maternal health services means that services are within reach of women who need it: women can get to these services easily and are not deterred from using available services. Unfortunately, great disparities in access to maternal health services persist between developing and developed countries, and between poor and rich women, rural and urban women, and uneducated and educated women (AbouZahr, 1997). In the context of maternal health, access to care varies depending on the type of health service considered since it is generally easier to use services for family planning or antenatal care than for delivery care. However, it is during labor, delivery, and the immediate postpartum period that most obstetric complications arise and thus, care is most urgently needed (Maine 1993; AbouZahr, 1997). In many places, the primary mode of transportation for women in labor is walking (WHO, 1998). Hence, care-seeking may be limited by the unpredictability of the situation, fear of delivering en route, and the physical hardships of traveling in such a state (Rose et al., 2001). This makes it especially important for health services to be available and accessible so that women can readily seek care in the event of an obstetric emergency. Sadly, many pregnant women in 31 developing countries continue to lack access to essential maternal health services, placing these women at risk for maternal death and poor maternal health. Despite the myriad barriers to accessing maternal health services, there is evidence that women and their families do indeed go to great lengths to access care, particularly when obstetric emergencies arise, and under very difficult circumstances; for example, where a woman in labor walks for hours over rugged terrain to try and reach a health facility (McCord and Chowdhury, 2003). Improving access to maternal health care entails a wide variety of measures to address supply and demand side barriers. The sections below focus on increasing the availability of health services, strengthening the referral system, and reaching hardly reached and marginalized groups. 3.3.1 Increasing the Availability of Health Services The concept of access includes physical barriers such as the supply and availability of health services. At a minimum level, maternal health services need to be available in order for women to be able to use them. Poor utilization of maternal health services may arise when services are too far away (Rose et al., 2001). Moreover, even when women reach a health center, they may not be able to receive the services they require. Public facilities, especially those serving poor and geographically remote areas, commonly face limited human resources and a shortage of skilled providers. In Asia and sub-Saharan Africa, only one skilled attendant is available for every 300,000 people, resulting in a ratio of one skilled attendant for every 15,000 births (MacDonald and Starrs, 2002). Mozambique In Mozambique, where there is strong government commitment to improve maternal health, UNFPA, with support from the Averting Maternal Death and Disability (AMDD) Program (Box 10), has implemented a project in the central province of Sofala, in a poor and rural population, to increase utilization of health services by improving availability, accessibility, and quality of EmOC provided at Basic and Comprehensive facilities. The UN Process Indicators2 used to monitor and evaluate the project have shown positive trends since inception: 130% increase of deliveries in EmOC facilities, 150% increase in Met Need for EmOC, 20% increase in Caesarean sections, and 20% decrease in the obstetric case fatality rate. These findings have encouraged the government to upscale and mobilize resources for sustaining the national strategy in the whole country. [Annex 4] Mali, Vietnam A similar AMDD-supported project to increase availability, access, quality and utilization of emergency obstetric care services at rural, district, and provincial hospitals was carried out by Save the Children in Mali and Vietnam. UN Process Indicators (the key monitoring and evaluation tools used) showed improvements 2 The UN Process Indicators for monitoring obstetric services, issued by UNICEF, WHO, and UNFPA in 1997, describe the major pathway to reducing maternal mortality in terms of the availability, use, and (to some extent) quality of emergency obstetric care. (For more information, see Table 4.) 32 between 2001 and 2004 in both countries. In Vietnam: 95% increase in deliveries in improved hospitals, 33% increase in Met Need for EmOC, 38% increase in C-sections. In Mali: 130% increase in deliveries in improved hospitals, increase in Met Need from 6% to 23%, 62.5% increase in C-sections, and 50% decrease in the case fatality rate. In addition, there was impact beyond the borders of the project sites at the national level where changes occurred with the adoption of EmOC standards into existing national reproductive health norms and procedures. [Annex 4] Box 10: Averting Maternal Death and Disability Program The Averting Maternal Death and Disability Program is a 5-year initiative supported by a generous grant from the Bill and Melinda Gates Foundation and based at Columbia University. AMDD seeks to increase the availability, utilization, and quality of emergency obstetric care in developing countries. AMDD works in partnership with United Nations agencies and non-governmental organizations that already have field operations. AMDD-supported projects include 83 projects in 51 countries. For more information: http://www.amdd.hs.columbia.edu Burkina Faso, Kenya, Tanzania Increasing access to skilled care has been a major focus of Family Care International’s efforts in Africa through its Skilled Care Initiative (SCI), which aims to increase the number of women who receive skilled care before, during, and after childbirth. The project works to strengthen the capacity of the skilled attendant, as well as the enabling environment, which includes policy and regulatory frameworks; supplies, equipment, and infrastructure; and systems of communication, transportation, and referral. SCI improves services where the need is greatest–in the health centers and dispensaries closest to women. Since the project is not scheduled to end until August 2005, no formal impact evaluation has yet been done. [Annex 4] Indonesia In Indonesia, where many births are at home without a skilled provider, PPH causes an estimated 45% of maternal deaths. To address this problem, JHPIEGO’s Maternal and Neonatal Health (MNH) Program conducted a safety, acceptability, feasibility, and program effectiveness study on community-based distribution of misoprostol for prevention of PPH. The study revealed that women who used misoprostol were 24% less likely to report excessive bleeding, 31% less likely to need any emergency referral, and 47% less likely to need an emergency referral for PPH. A large proportion of women reported that they would be willing to use misoprostol in their next pregnancies, pay for it themselves, and recommend it to friends. A resolution incorporating prevention of PPH into the national health strategy has been issued, and the government plans to scale up community-based distribution of misoprostol as an effective strategy for reducing the risk of PPH when skilled care during childbirth is not available. [Annex 4] Peru Ipas worked to improve quality and accessibility of PAC services in 14 public sector rural hospitals and health centers in Ayacucho in 2001–2002 by: training and supervision of providers, including university-trained midwives; introduction of manual vacuum aspiration (MVA); provision of post-abortion family planning; and use of practical computer-based recordkeeping and monitoring tools. At the project’s end, PAC- 33 trained providers were more widely available; all 8 hospitals and 78% of health centers in the state had a trained provider. In the 14 core hospitals and health centers, use of MVA and provision of post-abortion contraception increased, while patient waiting times before treatment decreased. The addition of PAC as a routine health service is not an enormous, high-cost challenge, and existing infrastructure can be used for PAC services. [Annex 4] Malawi To help improve maternal health and improve access to contraceptives in Malawi, the Ministry of Health and Population, with funding from the World Bank, implemented the Population and Family Planning project, which aimed to determine the feasibility of a comprehensive, district-wide community-based distribution approach to the provision of family planning services. Given the shortage of skilled health personnel in Malawi, Community-Based Distribution Agents were trained to provide family planning services and referrals to women and men of reproductive age in the communities. The evaluation showed that contraceptive use doubled in all villages covered in the pilot districts and that women were using modern contraceptives at younger ages and with lower parity. [Annex 4] Burkina Faso JHPIEGO’s Maternal and Neonatal Health Program used a variety of strategies to address malaria in pregnancy in Burkina Faso including: interagency collaboration; policy and advocacy; updated skills training in ANC; and community social mobilization educational campaigns. Sixteen months after introducing intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) to 23 health centers in the Koupéla district, follow-up data show that 92% of women attending ANC received at least one dose of SP, 64% received two doses, and 40% received three doses. The rate of first-time ANC users rose from 66% in 2000 to 83% in 2003, and for the first quarter of 2004 the rate was 88%. Several countries are now addressing the problem of rising resistance to chloroquine by conducting pilot programs and/or adopting policies to implement IPT using SP based on the Burkina Faso model project. [Annex 4] 3.3.2 Strengthening the Referral System An essential component of access to health services is a functioning referral system – it is particularly important during pregnancy and delivery for providing access to emergency obstetric care to save women’s lives, and for providing backup support to antenatal and delivery care in first line facilities (Maine, 1999; Jahn and De Brouwere, 2001). A functioning referral system requires adequate information and communication between the birth attendant at the household and up through the level of a health facility (Freedman et al., 2003). Therefore, it also implies a transportation system, the existence of health facilities close enough to where women live, and trained providers who are equipped and supported to provide the services appropriate at each level. The specific requirements of an effective referral system may be summed up to include the following: 1) an adequately resourced referral center; 2) communications and feedback systems; 3) designated transport; 4) agreed setting-specific protocols for the identification of complications; 5) personnel trained in their use; 6) teamwork between referral levels; 7) a unified records system; and 8) mechanisms to ensure that patients do not bypass a level 34 of the referral system (Murray et al., 2001). A functioning referral system is not only important for maternal health, but also for all health emergencies in which such systems can be mobilized to benefit the entire community (Tsu and Shane, 2004). A well-functioning referral system provides linkages and referrals between women and their families in the community, the peripheral health facility, and the hospital. Thus, for women with obstetric complications, the referral system aims to ensure that women are cared for in the right place with lifesaving treatment provided at the minimum cost (Murray et al., 2001). Related to this concept of referral is a new approach that is under development by Save the Children known as the Household to Hospital Continuum of Care (HHCC) for Maternal and Newborn Care. The HHCC approach to improving maternal and newborn outcomes is a more systematic and comprehensive approach to programming that recognizes the need to respond to complications for the mother and newborn as quickly and as close to home as technically feasible. Specifically, the HHCC approach seeks to develop capacity along a continuum of health promotive and lifesaving care that links households, peripheral facilities, and district referral hospitals in order to improve maternal and newborn health outcomes (Box 11). Uganda In 1996, with support from UNFPA, the Ugandan Ministry of Health launched the RESCUER Project – the Rural Extended Services and Care for Ultimate Emergency Relief Project. This pilot project was launched in Iganga district, Eastern Uganda in order to establish a sustainable and effective referral system to handle emergency obstetric cases. The three main components of the project were: 1) equipping health referral facilities to provide good quality obstetric care including provision of minimum equipment and renovation, and training and posting of nurses and midwives; 2) establishing feasible, reliable, and cost-effective communications systems between referral facilities and traditional birth attendants in selected villages in the catchment areas; and 3) devising an efficient means of transporting women to the facilities using three-wheeled motorized vehicles. An evaluation of the project found that there was a dramatic increase in the number of obstetric referrals and Caesarean sections; improved care-seeking behavior on the part of the community; and an appreciation by the community of the usefulness of the referral system. There was also a reduction in the maternal mortality ratio in Iganga district over the project period from 500 maternal deaths per 100,000 live births in 1996 to 271 deaths/100,000 live births in 1999. The project has been expanded to additional districts. [Sources: Starrs, 1998; Musoke, 2002.] 35 Box 11: The Household to Hospital Continuum of Care (HHCC) for Maternal and Newborn Care The HHCC approach to improving maternal and newborn outcomes seeks to develop capacity along a continuum of health promotive and lifesaving care that links: 1) households; 2) peripheral facilities; and 3) district referral hospitals. In the process, the HHCC approach looks critically at what services and interventions could ideally be provided and by whom at each of these 3 levels, to prevent maternal and neonatal mortality and morbidity. In other words, if effective interventions related to pregnancy, delivery, and postpartum care that we know could be implemented at the given level, were in fact successfully implemented in the household, at the peripheral health center and at the hospital level, then a greater proportion of the current maternal and newborn mortality and morbidity could be averted at lower cost to the family and possibly to the system. Strengthening hospitals to provide quality care is critical, but is not sufficient for reducing maternal and newborn mortality. The approach recommends investments to strengthen peripheral facilities and even community health workers to provide at least some elements of quality Basic EmOC and essential newborn care either through skilled birth attendants or trained community-based health workers in the facility or through outreach efforts. These facilities and their staff members are the first point of contact for women and newborns with the formal health system, and are more accessible during the day and even at nighttime when compared to district referral hospitals. Key household practices and behaviors that support healthy pregnancy, newborn care and delivery care are an important component of the approach and should also be strengthened as part of community level continuum of care. Finally, communications, transport and feedback mechanisms need to be established to complete the continuum of care through social mobilization and additional investments. Putting in place the HHCC approach will require social, political and financial commitment to creating the enabling environment inside and between the home, the peripheral facility and the hospital to influence survival outcomes, and advocacy at all the 3 levels. Below is a simplified diagram of the HHCC Approach for Maternal and Newborn Care: Household Peripheral Facility District Referral Facility Mo th er p racticin g h ealth fu l self care fo r h erself an d h er n ewb o rn , su p po rted b y family, co mmu n ity , an d lo cally -av ailab le sk illed atten d an t, an d willin g /able to seek timely an d ap p ro p riate emerg en cy matern al an d n ewb o rn care. Perip h eral h ealth facility with sk illed staff, equ ip men t, an d su p p lies n eed ed to d eliv er an ten atal an d no rmal d eliv ery care, p o stp artu m care an d p rev en t and man ag e so me k ey matern al an d n ewb o rn co mp licatio n s. Referral facility , with sk illed staff, eq u ip men t, an d su pp lies n eed ed to p rev en t an d man ag e o b stetrical & n ewb o rn co mp licatio n s, p rov id in g cu ltu rally ap p ro p riate care, acco u n tab le to th e co mmu n ities it serv es. Communities and civil society mobilized to reduce maternal and newborn mortality/morbidity Enabling environment with supportive maternal and newborn policies that protect survival, standards and protocols promoted, resources deployed and political/f inancial commitment to ensure that allwomen & their newborns have the best chance to survive and thrive The Household to Hospital Continuum of Care For more information, contact: Save the Children; Tel: 202.530.4387 or 203.221.4269; Email: sotchere@dc.savechildren.org / mpowers@savechildren.org 36 3.3.3 Reaching Hard to Reach and Marginalized Groups The hardly reached and marginalized groups refer to women and men who are the most disadvantaged and underserved by existing maternal health programs (PATH, 2002). Achieving equitable access in maternal health services means reaching out with inclusive programs and policies to hardly reached and marginalized groups, including the poor, refugees and internally displaced persons, rural and remote populations, adolescents, and men. Each of these groups is discussed in more detail below. Addressing inequities Recent evidence suggests that a huge disparity exists by economic status in the use of maternal health services, including the use of skilled delivery attendants, antenatal care, modern contraception, and immunization (Gwatkin et al., 2000a). As seen in Figure 7, in all regions, there is a gap between the poorest and richest quintiles in the proportion of births attended by a skilled attendant. In some regions, the gap is huge. In Zambia, for example, 90 percent of women in the richest quintile used a trained medical professional at delivery compared to just 20 percent in the poorest quintile (Kunst and Houweling, 2001). Similar findings are reported from Rajasthan, India where almost 80 percent of deliveries are attended by a medically trained person for women in the richest quintile compared to only 16 percent for women in the poorest quintile (Oomman, Lule and Chhabra, 2003). Moreover, these poor-rich differences in the use of delivery assistance generally exceed disparities in the use of most other maternal and reproductive health services (for example, use of modern contraception, antenatal care, immunization). Addressing inequities in the provision and utilization of services is critical for meeting the needs of the poor and the vulnerable (Wagstaff, 2002). 37 Figure 7: Poorest Women Have the Least Access to a Skilled Attendant at Delivery 30.5 82.7 40.2 12.8 5.3 24.6 31.2 93.4 99.7 94.3 82.2 49.3 82.1 84.0 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Ea st As ia, Pa cif ic (3 co un tri es ) Eu ro pe , C en tra l A sia (4 co un tri es ) La tin A me ric a, Ca rib be an (9 co un tri es ) Mi dd le Ea st, N or th Af ric a ( 3 c ou ntr ies ) So uth A sia (4 co un tri es ) Su b-S ah ara n A fri ca (2 2 c ou ntr ies ) Al l C ou ntr ies (4 5 c ou ntr ies ) A tte nd ed D el iv er y by a M ed ic al ly T ra in ed P er so n Poorest Quintile Richest Quintile Source: Gwatkin et al., 2000b. Mexico The PROGRESA (Programa Nacional de Educación, Salud y Alimentación) program combines a traditional cash transfer program with financial incentives for families to invest in their own health, education and nutrition. Cash transfers are disbursed (up to 25% of household income to the extremely poor) if: every family member accepts preventive health services; children ages 0–5 and lactating mothers attend nutrition monitoring clinics where their growth is measured, they obtain nutrition supplements, and they receive education on nutrition and hygiene; and pregnant women visit clinics to obtain prenatal care, nutritional supplements, and health education. Further, one woman in each locality is selected by the community to act as the PROGRESA outreach worker. They provide information on program requirements and schedules and procedures for receiving different support. A rigorous evaluation showed that the program significantly increased utilization of public health clinics for preventive care including prenatal care, child nutrition monitoring, and adult checkups. Moreover, there was no reduction in utilization of private providers, suggesting that the increase in utilization at public clinics was not substituting public care for private care. The nationwide program serves 20 million people, and almost 60% of the people reached belong to the poorest 20% of the country’s population. [Sources: Skoufias, 2000; Gertler, 2000.] China The World Bank-assisted Comprehensive Maternal and Child Health Project (Health VI) introduced a Poverty Alleviation Fund in Yunnan province, China that provided vouchers to poor women, which they could use instead of cash to pay for a variety of basic maternal health services at government facilities – for example, antenatal care, hospital delivery, EmOC services, and postnatal care. The service-providing 38 facilities then forwarded the vouchers received to the project authorities, which reimbursed the facilities. Preliminary data analysis from an evaluation suggests that the Fund has made noteworthy progress toward reaching the poorest 5% of the population. [Source: Kelin, Kaining, and Songuan, 2003.] Rural and remote populations An effective strategy to mitigate distance and other problems of accessibility is to take services directly to hard to reach populations, for example, those in rural or remote areas. Services that have used mobile clinics and community health workers to provide antenatal and family planning services have been successful in reaching these populations. For example, in both Sri Lanka and Malaysia, a national network of health centers with government-employed midwives facilitated community outreach in each country (Pathmanathan et al., 2003). In Mexico, a US$310 million World Bank loan supported the expansion of a basic health services program to reach remote villages – this unprecedented collaboration between the federal and local governments enabled hundreds of mobile units to deliver services such as family planning, health and nutrition information, and delivery care (World Bank, 2000). Guatemala To help reach Guatemalan refugees who were repatriated into poor, isolated regions lacking health services, a mobile team from Marie Stopes Mexico worked to provide comprehensive outreach health services in order to improve access to high quality sexual and reproductive health (SRH) services and to raise awareness of SRH issues. The project team provided non-surgical family planning, maternal and child health services; trained traditional midwives and health promoters; and carried out IEC activities in Spanish and Kanjobal, the local indigenous language. Additionally, traditional midwives and health promoters were trained. Evaluation findings show that antenatal and childbirth care by midwives increased from 71% to 89%; knowledge of delivery problems increased from 53% to 67%; and use of modern family planning methods increased from 9% to 30%. [Annex 4] Pakistan The National Program for Family Planning and Primary Health Care created in 1993 established an organization of paid community health workers called Lady Health Workers (LHWs) who were to provide basic primary health care to the community at their doorsteps. The LHWs work predominantly in rural areas in Pakistan and supply some types of family planning and basic curative care, and are trained to identify and refer more serious cases. The extensive network of LHWs allows them to access women who are difficult to reach. An evaluation of the program revealed promising results, which indicated that a substantial impact on the uptake of important preventive health services was due to the LHW program. The population served by the LHWs, particularly those in rural areas, was found to have substantially better health indicators than the control population, including: use of antenatal services (53% versus 38%, respectively); use of family planning (32% versus 23%, respectively); and health knowledge. Further, 51% of women in LHW areas received at least one tetanus toxoid injection during their last pregnancy versus 30% in the control areas. A number of breastfeeding measures were also better. The evaluation found that LHWs play an important and active role in 39 the provision of services, which they either provide themselves or refer clients to other providers. [Source: Oxford Policy Management, 2001.] Refugees and internally displaced persons According to the World Refugee Survey, in the year 2003, there were over 35 million refugees, asylum seekers, and internally displaced persons (IDP) worldwide (USCRI, 2004). Approximately 25 percent of women in this population are of reproductive age and one in five is likely to be pregnant (UNFPA, 2001). An estimated 15 percent of these women will develop life-threatening obstetric complications that require treatment at a health facility. In war-torn southern Sudan, for example, a UNICEF survey found that girls are more likely to die in pregnancy and childbirth than to finish primary school (Save the Children, 2002). Refugee and IDP populations often face precarious living conditions in remote locations where health services are nonexistent or difficult to access, or where aid organizations may opt not to provide comprehensive services. Services may be limited to those provided by traditional birth attendants, and there is a lack of continuum of care that includes management of obstetric complications, provision of safe abortion services where legal, and post-abortion and postpartum care. Furthermore, in some settings, women’s mobility may be restricted, requiring that a male relative or an older female accompany women to seek services (Goodyear, 2002). Regional The Reproductive Health Response in Conflict (RHRC) Consortium works to increase access to and availability of EmOC services to populations affected by conflict, and has implemented 12 pilot projects in several countries. The projects focused on the health facility level to improve their capacity to provide high quality EmOC services. Activities included facility renovation, maintenance, provision of equipment and supplies, facility setup, placement of staff and training. The Consortium’s experiences show that progress can be made, even under extremely difficult circumstances. The use of process indicators has revealed a number of positive trends at many project facilities, including increases in the number of total deliveries, MVA procedures, new family planning acceptors, and EmOC signal functions being provided. [Annex 4] Adolescents Because of physiological and social factors, pregnant adolescent girls are vulnerable to anemia, unsafe abortion and complications (for example, prolonged or obstructed labor which can lead to mortality or long-term injuries such as obstetric fistulae) (Focus on Young Adults, 2001). Complications from pregnancy and childbirth are the leading cause of death and disability in young women aged 15–19 years in developing countries (Save the Children, 2004). It is estimated that 70,000 young mothers die annually because they have children before they are physically ready. Save the Children estimates that one-tenth of all births, approximately 13 million births, are to women below the age of 20; more than 90 percent of these births are in developing countries. Further, babies born to adolescents are 50 percent more likely to die than children born to women in their twenties (Save the Children, 2004). The utilization of health care by pregnant adolescents has the potential to reduce maternal death and disability. However, socioeconomic and cultural factors limit girls’ ability to 40 access health services, prevent early marriage, and most importantly, prevent early childbearing. The evidence suggests that adolescents are less likely to seek prenatal care and delivery care from a skilled provider (Govindasamy et al., 1993; cited in YouthNet, 2004). Unmarried pregnant adolescents are even less likely to utilize prenatal care than to their married peers (Okonofua et al., 1992; cited in YouthNet, 2004). Moreover, in some countries, barriers to seeking care may be more pronounced for adolescents who are pregnant for the first time and who may have limited ability to make decisions about their own use of medical care (Chowdhury, 2003). Programs that target adolescents should focus on increasing their use of appropriate health services as well as on efforts that offer adolescents the opportunity to develop life skills, to learn about sexual and reproductive health, and be empowered so that they are enabled to protect their own health and their futures. India The Better Life Options Program (BLP) for adolescents has been implemented in India by the Center for Development and Population Activities (CEDPA) through its partner organizations since 1989. The BLP uses an empowerment model that offers adolescent girls a combination of life skills: literacy and vocational training, support to enter and stay in formal school, family life education, and leadership training. An impact study was carried out to compare BLP alumnae who completed the program between 1996–99 (in the peri-urban slums of Delhi, rural Madhya Pradesh, and rural Gujarat) with a similar control group of women (aged 15–26) who had not been exposed to the program, while controlling for confounding variables including girls’ education and parents’ education/occupation. The study found that BLP alumnae were more likely to marry at age 18 or above and to use contraception. Among those who had experienced a pregnancy, BLP alumnae were more likely than controls to have received antenatal and postnatal care, and to have delivered in a health institution. [Source: CEDPA, 2001.] Reaching Men It is now recognized that improving maternal health outcomes requires men to be active participants in the process. Maternal health programs have become increasingly aware of the role of men as important decision-makers in women’s care-seeking behavior (WHO, 2003c). In order to support women, men need to understand women’s health needs, risks and danger signs of pregnancy, childbirth, and the postpartum period; and where to seek appropriate medical care in the event of an obstetric emergency. Previous research supports the notion that educating male partners and increasing male involvement in women’s maternal health can lead to improved antenatal care attendance as well as discourage home deliveries (Raju and Leonard, 2000; Nuwaha and Amooti-Kaguna, 1999). There is also evidence to suggest that men who understand the risks of pregnancy and childbirth may influence whether emergency obstetric care is sought (Roth and Mbizvo, 2001). Indonesia The Suami Siaga campaign began in 1998 and was implemented by the Ministry for Women's Empowerment, UNFPA, and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP). It was the first ever campaign with the primary goal of involving husbands in safe motherhood. A key intervention was a large-scale media campaign with complementary community-level activities that aimed 41 at positively affecting individual and community behavior surrounding healthy pregnancy and safe delivery as a means of reducing maternal mortality. Results from the impact evaluation found that more than 80% of respondents indicated that the Suami Siaga campaign had taught them something new; over 64% of midwives observed a significant increase in husbands accompanying their wives for check-ups and delivery; and that respondents who have been exposed to the campaign are almost 15 percentage points more likely to practice behaviors promoted in the campaign in contrast to their past behavior. [Annex 4] Nepal The SUMATA initiative (a Nepali acronym for Care, Share and Prepare) was designed by the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. It aimed to reduce the social barriers affecting maternal mortality by focusing on husbands and mothers-in-law because of their decision-making power in matters relating to all aspects of health care for wives/daughters-in-law. The initiative called on them to care for the wife/daughter in law during her pregnancy, birth and postpartum period. SUMATA used mass media, community-based media and interpersonal communication to disseminate safe motherhood messages in a complementary and reinforcing manner. Among those exposed to SUMATA activities, nearly 95% comprehended the messages; more than 75% of the respondents reported having used the information contained in the SUMATA messages; and nearly 90% acknowledged their intention to do so in the future. Survey results also showed higher levels of awareness of the danger signs during pregnancy, childbirth, and postpartum. [Annex 4] 3.4 BUILDING CAPACITY At the health systems level, one of the biggest challenges to achieving the Millennium Development Goal to improve maternal health is the shortage of human resources and the poor distribution of trained providers. This is particularly an issue in countries implementing health sector reform, which leads to increased requirements for staff capacities in terms of staffing numbers and skills. Human resource shortages are the result of several factors, including the limited training capacity of medical and nursing schools; economic constraints; and migration of health professionals to urban areas, the private sector, and developed countries (Hutton, 2002). Furthermore, in many developing countries, mid-level providers often lack the required knowledge and obstetric skills, and few have received refresher or in-service training in reproductive health or obstetric care, including management of obstetric complications. Thus, ensuring adequate numbers of skilled health care workers remains problematic in many developing countries and will require changes that focus on improving pre-service curricula and in-service training; deployment of personnel to areas where there are poor and vulnerable populations; and support and supervision to ensure good quality care and continuing motivation of health staff. Shortages and poor accessibility of higher-level medical cadres necessitates changes in policy and management that support mandates for health personnel, other than 42 specialists, to expand their roles and provide lifesaving interventions for the management of obstetric complications (Lubben et al., 2002). In some countries, legal restrictions prevent midwives from carrying out even basic obstetric procedures. However, such workers can perform many essential obstetric care procedures effectively, if they have received adequate training and work in an environment that has equipment, supplies and supportive supervision. Basic lifesaving obstetric care can be provided by midwives, or doctors and nurses with midwifery training, and can be delivered at home, and in health centers or hospitals. In several developing countries, programs have been set up to upgrade the skills of general practitioners in rural areas. In some places, programs have also successfully trained paraprofessional health staff members to provide a set of surgical and obstetric interventions and anesthesia (Pereira et al., 1996; Vaz et al., 1999). Tajikistan In 2000, CARE began work in Tajikistan on a project supported by the AMDD Program to strengthen the capacity of health providers to deliver quality EmOC services by creating a core training team (CTT) of specialist doctors and midwives from district hospitals in advanced lifesaving skills. Project evaluation conducted in 2003 revealed that trained staff have increased proficiency in key skills (e.g, AMTSL, management of PPH), respond better to emergencies and complications, and report increased confidence. The CTT has expanded its reach outside of CARE and now serves as a training resource for activities sponsored by the Ministry of Health and other NGOs. [Annex 5] Nepal The Nepal Safer Motherhood Project (NSMP), implemented by Options Consultancy Services, aims to bring about a sustainable increase in utilization of and access to good quality emergency obstetric lifesaving care in order to reduce maternal mortality. An innovative approach was introduced by NSMP in 17 project-supported health facilities to incorporate Basic EmOC skills into nurses’ six week refresher course. Nurse's job descriptions were revised in light of their expanded roles and their clinical competencies were upgraded to the level of Basic EmOC. Further, an enabling environment was created at the health facility and JHPIEGO provided technical assistance to establish a quality Basic EmOC training site. An evaluation found that more than 70% of obstetric complications arising during all institutional deliveries were being managed by nurses only, safely, competently, and with confidence. [Annex 5] Rwanda Vacuum delivery is the most often missing signal function to be performed at Basic and Comprehensive EmOC facilities in Africa. UNICEF – ESARO carried out a study of vacuum deliveries in Nyanza district hospital, a Comprehensive EmOC facility where midwives and nurses in the labor ward routinely conduct vacuum assisted vaginal deliveries independently.3 Based on a review of delivery registers over a four-year period, the study found that under adequate supervision and with immediate Caesarean section back-up, vacuum deliveries conducted by competent mid-level providers are safe. Furthermore, the cost savings of using vacuum delivery (US$5) instead of C-sections (up 3 Few countries in Africa legally allow mid-level providers to perform lifesaving functions during obstetric complications, even though the availability of medical doctors is quite limited. 43 to US$34) are very large, and makes lifesaving services for obstetric complications more accessible and affordable for low-income households and those living in rural areas in Rwanda. [Annex 5] Zambia Postpartum hemorrhage is a leading cause of maternal death in Zambia. Ninety percent of cases of PPH are due to uterine atony, the failure of the uterus to contract after childbirth, which can be addressed by skilled providers who can provide AMTSL. JHPIEGO’s Maternal and Neonatal Health Program in Zambia worked with the General Nursing Council to help standardize AMTSL into national health protocols and standards of practice in pre-service curricula and in-service training. The program used team meetings to gain consensus on the clinical protocols and guidelines for program activities. To identify barriers to the practice of AMTSL, the program collected baseline data in four districts regarding current incidence and management of PPH. A costing study showed that AMTSL resulted in cost savings. As a result of the baseline analysis, all four districts now implement action plans that address barriers to practicing AMTSL. AMTSL is now a standardized protocol for every woman giving birth in Zambia. [Annex 5] Sub-Saharan Africa The Regional Prevention of Maternal Mortality (RPMM) Network is a multidisciplinary network of NGOs and country teams currently operating in 20 countries in Sub-Saharan Africa. RPMM focuses on improving quality of and access to EmOC, and ENC, in district health systems by building the capacity of District Health Management Teams (DHMTs) and local health staff in the design, implementation and evaluation of interventions using UN Process Indicators. At country level, the RPMM national team starts in 1 or 2 districts, and interventions are progressively scaled up nationally on a sustainable basis, as local experience is built and as resources permit. The teams, which act as national catalysts, use intervention results to influence governments to focus on allocation of resources and formulation of policies that address the reduction of maternal and neonatal mortality. [Annex 5] 3.5 QUALITY OF CARE “The question should not be why do women not accept the service that we offer, but why do we not offer a service that women will accept?” Mahmoud F. Fathalla, 1998 The poor quality of maternal health services in many developing countries is often a deterrent to their use, even when services are available. Poor quality of care may result from a variety of factors including insufficient and unqualified staff; clinical mismanagement of patients; insensitive treatment of patients by health staff; chronic lack of essential equipment, supplies, drugs, and blood for transfusion; inadequate management of health facilities; as well as from inadequate functioning of referral systems (Thaddeus and Maine, 1990; 1994). Substandard care contributes adversely to maternal health outcomes. For example, a study in Masavingo, Zimbabwe found that a significant proportion of maternal deaths resulted from a failure to identify women with 44 severe conditions (including post-abortion complications and sepsis), and refer them for treatment at a higher-level health facility (Fawcus et al., 1996). Improving the quality of maternal health services is a cost-effective way to save women’s lives. Quality improvement depends on appropriate standards and tools, a good information system, and expertise in problem identification and solution. To address the gaps between current practices and desired standards, and to support an accountable and systematic review of maternal and reproductive health programs, there is a need for formalized systems that engage health providers, managers and clients in regularly reviewing processes and outcomes. Quality improvement systems may include licensure and certification of service providers, as well as certification of health facilities and teaching programs. Box 12: Elements of Good Quality Maternal Health Services ƒ Promotion and protection of health ƒ Accessibility and availability of services ƒ Acceptability of services ƒ Technical competence of health care providers ƒ Essential supplies and equipment ƒ Quality of client-provider interaction ƒ Information and counseling for the client ƒ Involvement of clients in decision-making ƒ Comprehensiveness of care and linkages to other reproductive health services ƒ Continuity of care and follow-up ƒ Support to health care providers Source: WHO, 1996. Kenya In Kenya, EngenderHealth, in collaboration with the MOH and Ipas, are working to improve the quality of essential obstetric care (EsOC) including PAC services in 4 district hospitals and 1 health center, where services had either not been offered or were of poor quality. The project oriented Provincial Health Management Teams (PHMTs) and District Health Management Teams (DHMTs) on the rationale and benefits of integrated quality EsOC and PAC. Doctors and nurse teams were trained as trainers in EsOC/PAC and quality improvement, who then trained district hospital service providers in these services. An external trainer in EsOC and QI tools worked with each hospital for 5 days in Whole Site Training. All DHMT members reported that the EsOC/PAC intervention helped their facilities, with the most frequent benefit being a reduction in waiting time for clients. Other improvements include: better referral systems; early detection and management of complications; improved staff knowledge; and improved availability and management of emergency supplies. Mid-level providers can offer quality EsOC and comprehensive PAC services safely and effectively. [Annex 6] India and Ghana EngenderHealth and the AMDD Program jointly developed quality improvement (QI) tools for EmOC, which outline a QI process for providers to follow and offer a set of tools for gathering and analyzing information about the quality of 45 EmOC. The primary focus of this QI process is on tackling solvable problems. The materials were field tested in India and Ghana over a 9-month period, and subsequently revised based on feedback from these field tests. In both countries, about 75% of identified problems were solved by facility staff themselves (the remaining 25% were issues requiring outside resources to resolve). Providers spoke of improved attitudes towards colleagues, better communication among different hierarchy levels, and a new sense of empowerment to take initiatives to improve services. Positive changes to service provision include: improved record keeping; improved infection prevention practices; development of protocols and guidelines; greater degree of privacy in the labor room; improved cleanliness of hospital premises; and improved emergency preparedness and response in some areas. [Annex 6] Guatemala Through implementation of the performance and quality improvement (PQI) process in Guatemala, JHPIEGO’s Maternal and Neonatal Health Program helped the MOH, providers and community members to work together to improve the delivery of quality maternal and newborn services. Moving beyond a focus on clinical quality only, the program systematically applied the PQI process to support functions, infection prevention practices, and client preferences as well. A key element of the program is an accreditation component: if the facility achieved a satisfactory percentage of the criteria for quality, it received official MOH accreditation as a quality site for essential maternal and newborn care and recognition through a community event or ceremony. The MNH Program initiated the PQI process in 153 of the 428 health facilities in target health areas in Guatemala. By 2004, the MOH and other donors and cooperating agencies scaled up the PQI process to an additional 222 facilities, covering nearly one-third of all public sector healthcare facilities in the country. [Annex 6] Kazakhstan An innovative Safe Motherhood pilot project focusing on prenatal care and delivery services in Zhezkazgan was carried out with the help of the ZdravPlus project (funded by USAID and implemented by Abt Associates Inc. and John Snow, Inc.). Using a systems perspective, the project worked both in primary health care clinics (FGPs) and hospitals to create improved care and continuity of care across levels of the health system, reached out to women and their partners. The impact of the new approaches on utilization of hospital services was documented. Key evaluation findings after one year of implementation showed that both average length of stay following delivery and number of C-sections performed declined, while the level of new mothers’ satisfaction with their care increased. By the end of the pilot, all FGPs in Zhezkazgan had integrated prenatal care into their services, making care accessible to women close to where they live and work. Given the project’s success, the Government of Kazakhstan has since adopted a perinatal care program based on the approaches piloted in Zhezkazgan. [Annex 6] One innovative approach to improving the quality and efficiency of health care that is now being applied to the area of maternal health is the Breakthrough Series Improvement Collaborative, first developed by the Institute for Healthcare Improvement (IHI) in the mid-1990s. IHI has demonstrated significant results with this method, mostly involving health care organizations in the United States, Europe, and Australia. Improvement collaboratives aim to adapt and spread existing knowledge (for example, best practices; 46 evidence-based guidelines) to multiple settings (Bornstein and Marquez, 2004). According to the Quality Assurance Project, an improvement collaborative comprises 20 – 40 teams from different organizations or geographic regions that are all focused on making rapid incremental improvements in a single technical area and committed to working and learning together intensively for 12 to 18 months (Bornstein and Marquez, 2004). Three important objectives of an Improvement Collaborative are: 1) dramatic improvements in the quality and outcomes of care in a short period of time; 2) sharing of strategies for improving services among teams participating in the Collaborative; and 3) planning for spread of the new model of care from the Collaborative sites to the entire parent organization. Basic principles include the following: a collaborative is organized around a specific topic; expert knowledge about the topic is assembled and made available to participants in a readily usable form; a collaborative uses the same basic tools as traditional quality improvement approaches, such as flow charts to analyze complex health care processes and run charts to track variables over time; emphasis on rapid testing of changes; an improvement collaborative creates a “community of practice” focused on achieving results in a short period of time; collaboratives seek to create a culture among participants where everyone learns and everyone teaches, with friendly competition and urgency to action; collaboratives use several mechanisms for learning and changing current practices, chiefly mutual learning by peers; and, collaboratives are different from traditional quality improvement approaches by virtue of their focus on achieving specific improvements in a single content area by multiple teams and their emphasis on rapid results, documented over time (Bornstein and Marquez, 2004). 47 Box 13: Improving the Quality of Obstetric Care through Criterion-Based Clinical Audit (CBCA): A Collaborative Field Trial in Ghana and Jamaica The CBCA tool was developed to help health professionals and managers improve the quality of EmOC, at the district hospital level, in order to reduce maternal mortality. CBCA is the “systematic critical analysis of the quality of care, with the aim of improving clinical practice”, and involves data analysis to determine the proportion of patients receiving care. The effectiveness of this form of audit is assessed in terms of changes in the proportion of cases where management met the criteria. The emphasis is not on searching for errors, but on education through reflecting on practice, without generating feelings of blame or guilt. CBCA was adapted from an industrialized country setting for the developing country context. The methodology was designed to be adapted and applied where resources are poor and to incorporate local expert opinion in addition to research evidence. A CBCA project was implemented in 4 district hospitals in Ghana and Jamaica (1998–2000), and concentrated on the management of five major obstetric complications that contribute to over 80% of direct maternal deaths in developing countries – obstetric hemorrhage, eclampsia, severe genital tract sepsis, obstructed labor, and ruptured uterus. The five steps of the audit cycle were: establish criteria for good quality care (e.g., systematic review; expert panels); observe current practice (e.g., case-note review; labor ward and discharge registers; and staff questionnaire); feedback findings and set local standards; take action to change practice; and reevaluate practice. Case definitions and clinical audit criteria deemed realistic in relation to conditions in the field were established and were used to rate the optimal management of the obstetric complications identified. The senior medical officer at each of the 4 hospitals was to introduce the concept of CBCA and be supported by the hospital’s own records staff. It was found that CBCA is acceptable and feasible for ensuring quality of care and appears to have improved clinical practice where it was developed and applied. Significant improvements were seen in the management of three of the five major obstetric complications – obstetric hemorrhage, eclampsia and genital tract sepsis. The other two complications, obstructed labor and uterine rupture, also showed improvements but failed to reach statistical significance. The study suggests that CBCA may have a significant impact in developing countries, where its dual function as a means of monitoring and as an educational tool has a particular value given the context. For more information, contact: Dugald Baird Centre for Research on Women’s Health, University of Aberdeen 44.1224.553429 (tel); immpact@abdn.ac.uk; http://www.abdn.ac.uk/dugaldbairdcentre Ecuador, Honduras, Nicaragua The Quality Assurance Project (QAP) is currently working with partners in Ecuador, Honduras, and Nicaragua to implement an Essential Obstetric Care (EOC) Improvement Collaborative. The goal is to establish fully functioning local EOC systems (defined as a province or region with a referral facility that provides complete EOC to the surrounding health districts in its catchment area, including community-based services) in one or more regions of each of the three countries. Indicators to measure improvement include: 3 coverage indicators; 5 indicators of quality of prenatal, delivery, postpartum, and newborn care; 3 indicators of the management of complications; 2 mortality indicators; and 1 user satisfaction indicator. The EOC Improvement Collaborative is linking teams at the provincial and district levels across countries through meetings, e-mail communication, and the Internet, to facilitate sharing of best practices and innovations. Over a 12–14 month period, teams participating in the Collaborative are expected to make significant gains in the quality and availability of essential obstetric care. The QAP will also work with national officials 48 to develop and implement strategies to scale up the improvements from the initial collaborative sites to the entire country. [Source: Bornstein and Marquez, 2004.] 3.6 COMMUNITY INVOLVEMENT While it is crucial to address health systems, it is also important to involve communities in efforts to improve maternal health through complementary strategies such as community mobilization and behavior change interventions. One goal of these activities should be to ensure that appropriate health-seeking behaviors become part of local social and cultural norms. Most women in developing countries continue to deliver outside of health facilities, and thus most maternal deaths occur in the community, and not in health facilities. Women and their families may sometimes fail to recognize serious or life- threatening obstetric complications, or wait too long to seek help when a problem occurs during labor or delivery. Moreover, lack of planning deliveries with skilled attendants for routine births, inadequate preparation in the event of emergencies, and resistance to planning ahead in some cultures all can lead to delays that increase women’s chances of dying from maternal deaths. Timely use of appropriate medical care in the event of an obstetric emergency can mean the difference between life and death. Involvement at the community level can have an enormous influence on whether women seek health services. Community mobilization is important for generating demand for, access to, and use of maternity care services. One area in which community mobilization can be valuable is in increasing birth preparedness (birth planning) and complication readiness, helping a family to know where or from whom to seek help, and providing access to funds or transportation during an emergency, thereby addressing many of the delays (deciding to seek care, and reaching services) that contribute to maternal morbidity and mortality. Increasing community awareness of signs of emergency obstetric complications and motivating families to seek services can also help improve women’s chances of survival (Kwast, 1995). Birth preparedness is a key component of globally accepted safe motherhood programs and is widely promoted by international agencies. To ensure the success of such approaches, they should be adapted to specific local contexts with community involvement throughout the entire process. There is growing evidence that well-designed behavior change interventions can be effective in producing a desired change in order to achieve a health objective (Fishbein, 1995; Middlestadt et al., 2003). These interventions do not focus on increasing knowledge alone, but consider a number of contextual factors such as the behaviors of family and community, that also influence individual behavior change. One type of behavior change intervention is behavior change communication (BCC), which is designed to promote, elicit, support, and stimulate specific behavior change via communication (Fishbein, 1995). In the context of maternal health, BCC strategies can play a key role in promoting certain attitudes, knowledge, skills and capacity. Behavior change communications strategies that use various reinforcing messages through multiple channels that target both men and women can be effective in promoting healthy 49 behaviors that help improve maternal health outcomes. Community engagement, ownership and empowerment are critical to sustaining behavior change. Although it may take some time to achieve changes, behavior change is an important element of an effective maternal health program. Bangladesh In 1998, CARE with partners (Government of Bangladesh [GOB] and UNICEF) implemented the Dinajpur Safe Motherhood Initiative (DSI) focusing on promoting birth planning, community mobilization and enhancing the social aspects of quality of EmOC services. Women and their families were provided with key information and messages that allowed them to make decisions and take action to ensure healthy outcomes. Results showed an increase in knowledge of pregnancy danger signs among women (44% of women in the intervention area knew 3 or more of the 5 pregnancy danger signs), and a national birth-planning card was adopted by the GOB MOH and is being distributed throughout the MOH program. CARE also worked with communities to develop support systems (CmSS). These groups mobilize collective community action to provide support for pregnant women in accessing EmOC services during obstetric emergencies. At the end of the project, 70% of the villages had established a CmSS. There was a positive correlation between the number of CmSS and the use of obstetric services – as the number of CmSS's grew there was also a rise in use of EmOC services. [Annex 7] Guatemala In Guatemala, the Maternal and Neonatal Health program Communities and households working together to save lives, implemented by the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, is a social and behavioral change (SBC) program aimed to increase maternal health outcomes. Using participatory approaches, households and communities have been able to form emergency response action plans that are proving effective in reducing the barriers men and women faced in accessing maternal/reproductive health care. Using community dialogue, participatory leadership and collective self-efficacy as central to the SBC, the team used the “Community Action Cycle” and the “Communication for Social Change” approaches to build commitment to support evacuation during obstetric emergencies. The SBC approach achieved visible results: 99 communities were involved in the process, over 90% of which have formed committees. Half of the communities have secured transport, 40% have emergency funds, and 33% have emergency plans in place and 11% of the communities have put their plans into action during emergencies. [Annex 7] Ethiopia The Home Based Life Saving Skills (HBLSS) program developed by the American College of Nurse-Midwives is a family-focused, community-based program which aims to reduce maternal and newborn mortality in settings where home birth with unskilled attendants is the norm and mortality is high, by encouraging safe, culturally acceptable, and clinically feasible emergency behaviors in the home setting. Key findings from a review of the Ethiopia field-test site include: successful skills transfer and retention, and appropriate case management of PPH; exposure to HBLSS training in the community was estimated at 38% with strong community support; and large improvement in performance scores for some of the topics presented in the HBLSS training activities (e.g., 129% increase in knowledge and skills on the topic “too much 50 bleeding after birth”, and 182% increase on the topic “baby is sick”). The program has also helped to establish a lifesaving link between the community and the formal healthcare system. [Annex 7] 3.7 MONITORING AND ADVANCING PROGRESS 3.7.1 Measurement Issues Strengthening maternal health services and improving quality of care depends on good health information systems that include regular surveillance and monitoring of selected key indicators and setting final and interim targets (Goodburn, 2002). The UN Millennium Development Goal to improve maternal health targets the reduction of maternal mortality by three-quarters by 2015; this target assumes that maternal mortality is accurately measured (Graham and Hussein, 2004). Although estimates of maternal mortality have been useful in getting maternal health on the policy agenda, relying on this target to monitor progress in achieving the MDG to improve maternal health is inherently problematic given the difficulty in accurately measuring maternal mortality. In an ideal situation, maternal mortality could be monitored through vital registration (Starrs, 1998). However, in most developing countries, no comprehensive vital registration records are available, and even in developed countries (where good vital registration systems exist), causes of maternal death are often misclassified. There are a variety of other approaches that have been developed to measure maternal mortality including the use of indirect and direct sisterhood methods, reproductive age mortality surveys (RAMOS), and censuses (Box 14). Nonetheless, monitoring the progress of maternal health programs by measuring change in maternal mortality levels has proved challenging over the years. Maternal deaths are frequently underreported, misclassified, and are relatively rare events (WHO, 1999; Wardlaw and Maine, 1999). Measuring a significant change in maternal mortality in the short-term is difficult, since the method would require following a large population, can be expensive, and can take several years to show an effect (i.e., to determine if fluctuations are due to interventions or to chance). Box 14: Reproductive Age Mortality Study (RAMOS) The Reproductive Age Mortality Study (RAMOS) is an approach to measuring maternal mortality and involves identifying and investigating the causes of all deaths of women of reproductive age. This method has been applied effectively in countries with good vital registration systems to calculate the extent of misclassification and in countries without vital registration of deaths, such as Egypt, Honduras, and Jamaica. Successful studies in countries lacking complete vital registration data use multiple and varied sources of information to identify deaths of women of reproductive age, as no single source identifies all the deaths. Subsequently, interviews with household members and healthcare providers, along with reviews of facility records, are used to classify the deaths as maternal or otherwise. The RAMOS approach is considered to provide the most complete estimation of maternal mortality; however it is quite complex and time-consuming to undertake, particularly on a large scale. Source: AbouZahr and Wardlaw, 2003a. 51 The demand for data and indicators to monitor and evaluate the progress of maternal health programs has led to increasing reliance on alternative methods to address the measurement issue. For example, WHO and UNICEF have developed a model to estimate levels of maternal mortality using country data and adjusting for underreporting and misclassification (AbouZahr and Wardlaw, 2003a). These methods cannot be used to measure short-term trends given their wide margins of uncertainty. Consequently, another proposed method for tracking maternal health is the use of process indicators, which has received growing support within the international community. Process indicators, most of which can be built into the health information system, reflect changes in key activities or “processes” that ultimately have an effect on the maternal outcome. Compared to outcome indicators, data for process indicators are generally easier to collect and more readily available (MEASURE Evaluation Project, 2003). For example, monitoring and evaluation of maternal health programs may also be accomplished with the use of data routinely recorded in facility-based birth registers (e.g., maternity, surgery, and discharge registers). Studies from Guatemala and Benin have shown that data routinely collected from birth registers in health facilities are a potentially important source of existing information that may be used to estimate maternal health and facility- based quality of care indicators (Valladares et al., 2003; Kodjogbé, Fourn and Stanton, 2003). The set of six UN Process Indicators for monitoring obstetric services, issued by UNICEF, WHO, and UNFPA in 1997, were developed based on an understanding that most maternal deaths could be prevented if women were to receive prompt, adequate treatment for major obstetric complications. The indicators describe the major pathway to reducing maternal mortality in terms of the availability, use, and (to some extent) quality of emergency obstetric care (Table 4). Many programs now rely on the UN Process Indicators for program monitoring and where they have been used, the findings have often demonstrated how poorly health services meet the needs of pregnant women (UNICEF/WHO/UNFPA, 1997; Goodburn, 2002). These findings can be used to mobilize governments, development partners, and communities to act to address maternal health. Additionally, the use of process indicators can have a major influence on a country’s policy. For example, surveys using the UN Process Indicators in Morocco showed that the availability of Comprehensive EmOC facilities in rural areas was below the minimum acceptable level recommended by the United Nations (Goodburn, 2002). As a result of the survey findings, the Moroccan government began to train surgeons in obstetric procedures in order to address the unmet need for EmOC. Because dramatically reducing maternal mortality and meeting the MDG target is contingent upon ensuring that EmOC is available, accessible, and properly utilized, Freedman and others (2003) have argued that measuring progress towards achieving this MDG must also use the first of the UN Process Indicators to assess EmOC coverage: number of functioning Comprehensive and Basic EmOC facilities per 500,000 population (Freedman et al., 2003). 52 Table 4: The Six UN Process Indicators Process Indicator Minimum Acceptable Level 1. Amount of essential obstetric care ƒ Basic EmOC facilities ƒ Comprehensive EmOC facilities For every 500,000 population: At least 4 Basic EmOC facilities At least 1 Comprehensive EmOC facility 2. Geographic distribution of facilities The minimum level for indicator 1 should be met in sub-national areas (i.e., facilities must be well distributed at the provincial or district levels) 3. Proportion of all births in basic EmOC and comprehensive EmOC facilities At least 15% of all births in the population should take place in either basic or comprehensive EmOC facilities 4. Met Need All women (100%) estimated to have obstetric complications should be treated at EmOC facilities 5. Caesarean sections as a percentage of all births Caesarean sections should account for not less than 5% and not more than 15% of all births in the population 6. Case fatality rate CFR among women with obstetric complications in EmOC facilities should be less than 1% Source: UNICEF/WHO/UNFPA. 1997. Tanzania, Peru To strengthen monitoring of EmOC services using UN Process Indicators, CARE worked with health facilities in Tanzania and Peru to improve the accuracy of data collection and analysis. The project helped facility staff to develop or review existing obstetric registers to ensure they capture key information. In Peru, before project interventions, about 20 different registers were used for data collection, whereas all health care facilities in the district now use only 3 registers. In Tanzania, at baseline, registers and client records were poorly maintained and very few complications were recorded in the Operations Room register. With project support, the staff improved their data collection approaches and developed one logbook to collect information on complications. Project interventions are still ongoing in both countries. [Annex 8] Kenya, Rwanda, Southern Sudan, Uganda Baseline needs assessments on EmOC service availability and utilization carried out by UNICEF – ESARO showed that in all 4 countries, coverage of Basic EmOC was well below UN recommended levels. These findings have been useful in influencing governments and donor program policies and priorities in reducing maternal mortality. The Uganda national EmOC roll-out plan prioritizes ‘fixing the missing EmOC signal functions’. In NEP Kenya, results guided EmOC program implementation in one of the poorest provinces. The UN Process Indicators have been added to the Kenya Service Provision Assessment 2004 as a way to institutionalize them into the regular information system. In Rwanda, the priorities are to upgrade district hospitals and selected health centers. In Southern Sudan, EmOC will be one of the key elements in rehabilitation of the health system after peace. [Annex 8] Another useful approach to monitoring maternal mortality using process indicators has been carried out by the Unmet Obstetric Needs Network. In this approach, the concept of unmet obstetric need (UON) refers to the discrepancy between what the health care system should do to deal with the obstetric problems in a given population and the care it actually provides. The measure of UON estimates the number of women needing a major 53 obstetric intervention for life-threatening complications who did not have access to appropriate care. These estimates can be useful in comparing need and availability in different geographic regions (using mapping), identifying regions where UON is highest, and targeting expenditures on service improvements. The UON indicator also enables program planners to monitor progress in service development and impact on maternal health (UON Network website, 2005). The UON Network, which was launched in 1997, brought together ministries of health, development agencies, scientific institutions, and practitioners who want to map unmet need for “major obstetric interventions for absolute maternal indications” as a starting point in improving maternal health care and the overall functioning of health care systems (Dubourg et al., 2000). Mali A national retrospective survey on the unmet need for major obstetric surgery using the Unmet Obstetric Need Approach was carried out in Mali in 1999. In Koutiala, the district health team decided to carry on monitoring met need for several years in order to assess their progress over time. The first prospective study (1999) estimated that more than 100 women in need of obstetric care never reached the hospital and probably died as a consequence. This surprising result shocked the district health team and the resulting increased awareness of service deficits triggered operational measures to tackle the problem. The Unmet Obstetric Need study in Koutiala district was implemented without financial support and only limited external technical back-up. The appropriation of the study by the district team for solving local problems of access to obstetric care may have contributed to the success of the experience. Used as a health service management tool, the study and its results started a dialogue between the hospital staff and both health center staff and community representatives. This had the effect of triggering consideration of coverage, and also of the quality of obstetric care. [Source: Guindo et al. 2004.] Monitoring the status of maternal health goes beyond measuring the level of the problem. Given the limitations of quantitative indicators of maternal health, it is also important for policy makers and program managers to understand why maternal deaths occur, what can be done to prevent them, where things are going wrong, and what can be done to rectify them (WHO, 2004a). An understanding of the underlying factors that lead to maternal deaths in a particular setting is necessary for designing appropriate maternal health programs. WHO recently published a manual designed to help gather such information using methods such as community-based maternal death reviews (verbal autopsies); facility-based maternal death reviews; confidential enquiries into maternal deaths; surveys of severe morbidity (near misses); and clinical audits (WHO, 2004a) (Table 5). 54 Table 5: Approaches for Generating Information on Maternal Health Name Operational definition Prerequisites Community- based maternal death reviews (verbal autopsies) A method of finding out the medical causes of death and ascertaining the personal, family or community factors that may have contributed to the deaths in women who died outside a medical facility. Requires co-operation from the family of the woman who died and sensitivity is needed in discussing the circumstances of the death. Facility-based maternal death reviews A qualitative, in-depth investigation of the causes of and circumstances surrounding maternal deaths occurring at health facilities. Deaths are initially identified at the facility level but such reviews are also concerned with identifying the combination of factors at the facility and in the community that contributed to the death, and which ones were avoidable. Requires co-operation from those who provided care to the woman who died, and their willingness to report accurately on the management of the case. Confidential enquiries into maternal deaths A systematic multi-disciplinary anonymous investigation of all or a representative sample of maternal deaths occurring at an area, regional (state) or national level. It identifies the numbers, causes and avoidable or remediable factors associated with them. Requires existence of either a functioning statistical infrastructure (vital records, statistical analysis of births and deaths, human resources, recording clerks, etc.) or nominated professionals in each facility to regularly report maternal deaths to the enquiry. Surveys of severe morbidity (near misses) The identification and assessment of cases in which pregnant women survive obstetric complications. There is no universally applicable definition for such cases and it is important that the definition used in any survey be appropriate to local circumstances to enable local improvements in maternal care. Requires a good-quality medical record system, a management culture where life-threatening events can be discussed freely without fear of blame, and a commitment from management and clinical staff to act upon findings. Clinical audit Clinical audit is a quality-improvement process that seeks to improve patient care and outcomes through systematic review of aspects of the structure, processes, and outcomes of care against explicit criteria and the subsequent implementation of change. Where indicated, changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in health care delivery. It must be possible to identify relevant cases from facility registers and retrieve the case notes. Health care personnel must feel able to openly discuss case management and be willing to envisage the application of revised protocols of care. Source: World Health Organization, 2004a. 3.7.2 Research Efforts Finally, progress in maternal health requires ongoing research that continually strives to help improve programming and policies. Many lifesaving technologies are already available to save women’s lives. Nevertheless, to achieve greater public health impact and improve health outcomes, it is important to continue research efforts that concentrate on gathering evidence and identifying the most effective and cost-effective approaches that work in settings with resource-constraints. Such research is important for policy reforms and for setting program priorities, especially because data related to maternal 55 health are scarce. In addition, more emphasis should be given to identifying strategies that improve maternal health based on proven effectiveness rather than on theory alone. Adequate evaluation of the effectiveness of strategies, in real-life conditions, may be a cost- and time-efficient way to select approaches for large-scale program implementation and replication, thereby accelerating progress towards improving maternal and reproductive health (Miller et al., 2003; Better Births Initiative, 2002). The results of updated systematic reviews of research can help policymakers, health professionals, and users of maternal health services make more informed decisions about the best care that is appropriate for a particular problem (Better Births Initiative, 2002). Box 15: The Initiative for Maternal Mortality Program Assessment (IMMPACT) IMMPACT is a global research initiative whose ultimate goal is to improve maternal health and survival in developing countries by providing evidence of the effectiveness and cost-effectiveness of safe motherhood intervention strategies and their implications for equity and sustainability. Improving the evidence base for decision-making will enable health gains for women, babies and families; social and economic gains for the wider community; and enhanced methods and capacities for vigorous evaluation of health programs. In the absence of a stronger evidence-base, decision-makers in poor countries will continue to allocate scarce resources to safe motherhood initiatives without proven benefits for the world’s poor. The main phase of IMMPACT, which began in September 2002, is an extensive seven-year program of primary and secondary research with three core objectives: 1) development of methods and tools for measuring and attributing health outcomes; 2) evidence of effective and cost-effective strategies; and 3) capacity strengthening for evidence-based decision-making and rigorous evaluation The outputs are interdependent and constitute the building blocks for the seven-year program. The tools developed by IMMPACT can be used to provide a continuous source of evidence, so IMMPACT itself will not need to be replicated. Providing realistic methods for measuring trends and differentials of safe motherhood strategies will allow policy makers to track the effects of initiatives within and beyond the health sector. Further, stronger in-country capacity will ensure that this evidence, together with the enhanced methods and tools, are utilized both within and well beyond the duration of IMMPACT. IMMPACT is currently working in Burkina Faso, Ghana, and Indonesia. Activities will ultimately be in up to eight developing countries across three continents. IMMPACT is coordinated by the Dugald Baird Center for Research on Women’s Health at the University of Aberdeen, in the United Kingdom. Funding for IMMPACT comes from the Bill and Melinda Gates Foundation, DFID, USAID, and the European Commission. For more information, contact: Dugald Baird Centre for Research on Women’s Health, University of Aberdeen 44.1224.553429 (tel); immpact@abdn.ac.uk; http://www.abdn.ac.uk/immpact 56 Bangladesh, Ghana, Jamaica, Malawi, Mexico The SAFE (Skilled Attendance for Everyone) International Research Partnership, coordinated by the University of Aberdeen, aims to improve skilled attendance at delivery by providing new knowledge on skilled attendance in developing countries. As part of the study (September 2000– February 2003), a strategy development tool was formulated as a resource document for program managers to systematically gather and interpret information and to plan for strategies to increase the proportion of skilled attendance. A secondary analysis of demographic and health survey data indicated that delivery care appeared to be improving in the countries studied, although national trends mask substantial variations among different groups of women, and inequity may be increasing. Studies on women’s reports of their birth attendant show potential for incorrect identification, documenting the need for methodological developments in this area. A new composite measure of skilled attendance (the skilled attendance index) was developed and revealed that few deliveries may meet the many criteria required for skilled care. [Annex 8] Box 16: Better Births Initiative – Improving Health through Evidence-Based Obstetrics The Better Births Initiative (BBI) aims to ensure that clinical policies and procedures used in essential obstetric services are grounded in reliable research evidence. The initiative is targeted at health care providers and assists them in understanding research evidence, making decisions about best practice, and establishing implementation procedures to assure change. The BBI is aimed at middle and low- income countries, where resources for health care are limited and where better services will help reduce maternal mortality. Good quality obstetric care needs good infrastructure, trained staff, equipment and drugs. Many governments and donors are striving to establish and maintain these services. The Better Births Initiative complements these efforts, and helps to ensure that the procedures staff use are based on the most reliable research evidence. Policymakers, managers, midwives and doctors all have a role to play in effecting change towards evidence-based practice. The Better Births Initiative focuses on particular areas of obstetric practice which are frequently deficient, where it is reasonable to expect people to change, and where any resource implications of the change are probably realistic and affordable. Source: Better Births Initiative, 2002. 3.8 PARTNERSHIPS AND COLLABORATIONS The challenge of achieving the Millennium Development Goal to improve maternal health requires commitment, support, coordination, and inputs from a range of partners, including donor agencies, governments, non-governmental organizations, international assistance agencies and health providers. Key players should work together to promote maternal health, sharing their diverse strengths and skills. Partnerships that focus on advocacy efforts are central to raising awareness on the high human and economic costs associated with poor maternal health. Strong advocacy can help set priorities, stimulate research, mobilize resources, and share information. Advocates can use information to increase knowledge and motivation, and build capacity. Furthermore, advocates can use data to hold governments accountable for government- signed documents such as the 1994 ICPD Program of Action. Although advocacy efforts 57 have been successful in family planning, there are relatively fewer networks working specifically to improve maternal health (POLICY Project and MNH Program, 2003). In January 2004, the Partnership for Safe Motherhood and Newborn Health was established as an expanded initiative to promote the health and survival of women and newborns in the developing world. The Partnership aims to reinvigorate and expand the global Safe Motherhood initiative to address maternal death and disability. Building on the opportunity provided by the Millennium Development Goals, the Partnership will create synergy among stakeholders working to ensure all women and newborns enjoy the right to safe pregnancy outcomes. The Partnership will aim to strengthen and expand maternal and newborn health efforts within the broader goals of poverty reduction, equity, and human rights, and in particular, will address the enormous health disparities that exist between urban and rural populations and between rich and poor. Two key priorities of the Partnership will be: 1) ensuring that safe motherhood and newborn health are addressed in national development plans, sector-wide approaches, Poverty Reduction Strategy Papers, and other resource allocation mechanisms at the country level; and 2) advocating for greater attention to, funding for, and action on safe motherhood and newborn health at the global level. General membership is open to any/all groups active in safe motherhood and/or newborn health who work nationally, locally, regionally, or globally in one or more of the following areas: advocacy; country-level implementation; strengthening capacity (i.e., training, research, policy development, technical assistance); and resource mobilization/allocation. [For more information on the Partnership for Safe Motherhood and Newborn Health, visit their website at: http://www.safemotherhood.org.] The White Ribbon Alliance for Safe Motherhood (WRA) unites individuals, organizations, and communities to build public awareness and act as a catalyst for action to promote safe motherhood and ensure that women do not have to die during pregnancy and childbirth. This grassroots movement builds alliances, strengthens capacity, harnesses resources, and inspires action to save women’s and newborns’ lives worldwide. WRA members are a diverse group including U.N. organizations, local and international NGOs, medical practitioners, government representatives, community and faith-based organizations, students and individuals committed to the health and well being of women and their families. All Alliance members are committed to promoting safe motherhood and to making pregnancy and childbirth safe for all women worldwide through innovative partnerships and collaborations and sharing resources and information. [Annex 9] FIGO Save the Mothers Initiative. The International Federation of Gynecology and Obstetrics (FIGO) is the only world-wide organization representing national societies of obstetricians and gynecologists. In 1997, FIGO established the Save the Mothers Initiative to expand its activities in the area of safe motherhood. The aim is to mobilize the obstetric and gynecological community in developed and developing countries to work in partnership to demonstrate the most cost-effective way to save mothers’ lives. The initiative focuses on the following four elements to reduce maternal mortality: 1) skilled attendance at all births; 2) basic EmOC at peripheral units; 3) comprehensive 58 EmOC in referral hospitals; and 4) rapid transport of all women in need of special care. Save the Mothers Initiative is the first concerted effort on the part of obstetricians, collectively as a profession, to address the issue of safe motherhood (Benagiano and Thomas, 2003). [For more information on the Save the Mothers Initiative, visit their website at: http://www.figo.org/sav-moth.asp.] 59 4. CONCLUDING REMARKS This paper brings together a wide array of promising approaches to improve maternal health that are being carried out by a range of organizations with extensive knowledge and impressive program experience in the field. Readers are encouraged to contact the various agencies and organizations for more detailed information on the promising approaches. While the collection of promising approaches is not exhaustive, it portrays the importance of sharing experiences of what works. What is clearly reflected in these approaches is that success in addressing maternal health issues and strengthening the supply-demand nexus requires support and involvement from stakeholders at all levels – from women themselves, their families, communities, nongovernmental organizations, governmental organizations, medical institutions, bilateral and multilateral agencies, other development partners, and policymakers. This paper also reflects the enormous enthusiasm and support that exists among these stakeholders to give high priority to maternal health, and to strive towards improving health outcomes for women. Achieving the MDG to improve maternal health will remain elusive until there is political will and action to implement programs that are based on proven and effective interventions and strategies. More investments by governments are necessary to strengthen weak health systems, expand coverage, ensure adequate human resources, improve program management, address supply chain issues, and institute better monitoring and evaluation. It is especially critical that these maternal health programs reach the poorest households and reduce the existing inequalities in utilization of services. Governments need to provide safety nets for the poor and target poor regions in order to achieve universal coverage. Such efforts will take time, and there are no quick fixes and easy solutions (WHO, 2004b). 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