State of the World's Midwifery 2014 - Zanzibar: Achieving MDG 5
Publication date: 2014
United Republic of Tanzania - Zanzibar Achieving MDG 5 Maternal Mortality Zanzibar, a large island in the Indian Ocean and a semi-autonomous part of Tanzania, in 2013 had a population of 1.3 millioni and about 180 maternal deaths. While there has been some progress made in reducing the maternal mortality ratio, Zanzibar is currently not on track to reach the 75% reduction in the MMR required by the MDG5. According to Zanzibar’s routine HMIS data, in 2013 the island had a MMR of 310 per 100,000 live birthsii. A concerted effort will be required to reach the MDG goal of an MMR of 130 (or about 75 annual deaths) by 2015. Almost 70% of all maternal deaths in Zanzibar are due to just three conditions - hemorrhage, eclampsia, and sepsisiii. An estimated 30 of these deaths are among adolescentsiv. Family Planning and Maternal Health v,vi,vii,viii In addition to a 75% reduction in the MMR, MDG5 also calls for universal access to reproductive health care by 2015. The following shows current coverage with key reproductive services in Zanzibar. Family Planning 12.4% of women in Zanzibar use modern family planning methods, 35% of married women have an expressed unmet need for family planning. Antenatal Care 68% of pregnant women have at least 4 antenatal care visits. Skilled Delivery Care As measured by the latest national survey, 53.7% of the annual 59,000 births in Zanzibar were assisted by a skilled attendant.v Estimated Impact of Universal Access to Reproductive Health Family Planning Providing women with access to family planning and making it possible for them to decide how many children they want and when to have them, reduces the overall number of deaths by reducing the number of women dying due to pregnancies they never intended to have. Meeting only 25% of the unmet demand for family planning in Zanzibar, i.e., supplying 17,000 additional women with access to family planning would reduce the number of unintended pregnancies by over 6,000 and deaths related to unintended births and abortions, which are particularly high among unintended pregnancies, by about 15. Maternal Health Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. The following interventions and drugs tackle the four top causes of maternal deaths in Tanzania: Prevention and management of hemorrhage/treatment of postabortion complications - Oxytocin/Misoprostol: Prevention and management of eclampsia with Magnesium sulfate Prevention and treatment of sepsis with Clean delivery kits and antibiotics Number of Maternal Deaths that Could be Prevented Providing all women with the required maternal health medicines and supplies would prevent an additional 90 deaths, reducing the annual number of deaths to about 80 and the MMR to about 140, making it possible for Zanzibar to come extremely close to its MDG target of 130 deaths per 100,000 live births. Essential Drug Requirements and Costs Maternal Health Drugs For Universal Coverage Drug and commodity requirements to provide the care detailed above would cost approximately $160,000, $50,000 for additional FP supplies and $110,000 for maternal health (detailed calculations are available in Annex 1). Required health system investments Additional investments will be necessary to strengthen countries’ logistics systems and to ensure that health providers (both at facility and community level) know how to administer these drugs. Annex 1. Methodology The following describes the methodology used to arrive at the impact and cost estimates in the factsheet. Maternal Mortality The number of current annual maternal deaths was based on data from Zanzibar’s HMIS system. Deaths Prevented through Family Planning The number of unintended pregnancies averted was calculated by comparing the number of pregnancies that would have happened if the 17,000 (25% of the about 70,000 women with currently unmet need in Zanzibar) had not been able to access contraception to the number of pregnancies that would occur if these women used contraception (i.e. only experienced pregnancies due to failure of their chosen method). It was assumed that 40% of all women would have gotten pregnant if not using contraception. The average failure rate of contraceptives was estimated to be 3%. Based on regional data collected by the Guttmacher Institute for its 2014 update of “Adding It Up” it was estimated that only about 53% of unintended pregnancies would be carried to term, 33% would be aborted and 14% would end in a miscarriage. Note: Family planning reduces the absolute number of maternal deaths in a country but since it reduces both nominator AND denominator of the Maternal Mortality Ratio (defined as deaths per 100,000 live births) the reduction in maternal deaths caused by family planning is not reflected in the MMR. The estimated reduction in number of deaths required to achieve the country’s MMR goal differs therefore slightly depending on the assumption made about the number of births. The estimate in the opening paragraph uses the current number of births, while the estimate in the Estimated Impact paragraph is based on a lower number of births (originally projected number of births minus unintended births averted through the provision of contraception to women with unmet need). Deaths Prevented through Maternal Health Interventions It was assumed that half of the women currently covered by skilled birth attendance, i.e. about 27%, had access to the three live-saving drugs. This coverage was then scaled up to 100%. The following effectiveness data were used in estimating the expected reduction in maternal deaths: Intervention Effectiveness Source 1. Hemorrhage Prevention - Oxytocin 62% Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. In: The Cochrane Library, Issue 1. 2. Hemorrhage Prevention - Misoprostol 43% 30% less effective than oxytocin Gulmezoglu AM, Villar J, Ngoc NTN, et al. WHO multicentre randomized trial of misoprostol in the management of the third stage of labour. Lancet. 2001; 358:689-695 3. Hemorrhage Treatment - Oxytocin 80% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 4. Eclampsia Management - MgSulfate 43% Cochrane Database Syst Rev. 2010 Nov 10 5. Sepsis Prevention - Facility Births 60% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 6. Sepsis Prevention - Home Births 60% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 7. Sepsis treatment - Antibiotics 80% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 8. PAC management - Misoprostol 50% The MMR after FP and MH scale-up was calculated by dividing the remaining number of maternal deaths by the number of births expected at the new contraceptive prevalence level (current 59,000 annually minus 3,400 averted through increased use of family planning). Cost Estimates Family Planning Unit costs for the different supply methods were taken from UNFPA’s RH Interchange database and multiplied by the amount required to provide one couple-year of protection (CYP). It was assumed that 15 cycles of the pill, 120 condoms or 4 injectables would provide one CYP. IUDs and Implant were assumed to provide 3.5 years of protection or CYPs. Their cost was thus divided by 3.5. The RHInterchange price for implants ($18.80) was replaced with a cost estimate per implant of $8.50 to reflect the recent price reduction seen, but not yet reflected in the database, due to the introduction of Sino- Implants. Drug and supply cost for male and female sterilization came from calculations carried out by the Guttmacher Institute for its Adding It Up 3 publication using UNFPA’s RHCT costing tool with updated 2013 price. It was assumed that new users would adopt methods based on the current modern method mix. Cost Estimates Maternal Health Interventions Based on WHO treatment guidelines the following drugs and supplies were costed using drug prices from both the MH International Drug Price Indicator and the UNICEF Supply Catalogue. Hemorrhage Prevention and Treatment Sepsis Prevention and Treatment Pre-Eclampsia/Eclampsia Treatment i 2012 National Housing Census. ii WHO. 2014. Maternal Mortality 1990-2013. iii WHO and UNICEF. 2012 Countdown, Country Profiles iv Based on: Blanc et al. 2013. New Findings for Maternal Mortality Age Patterns: Aggregated Results for 38 Countries. PLoS ONE 8(4): e59864. v Tanzania DHS 2010 vi 2012 National Housing Census. vii Tanzania DHS 2010. viii Tanzania DHS 2010.