Reducing Maternal Mortality
What are the gaps in progress towards
achieving MDG 5?
Eilish McAuliffe, Centre for Global Health, TCD
eilish.mcauliffe@tcd.ie 16/6/10
Global Action on Maternal Health
•
•
Safe Motherhood – since 1987
MDG 5 - 75% reduction in the maternal mortality ratio (MMR) from 1990 to
2015
• White Ribbon Alliance
• Women Deliver – launched 2007
• Obama’s Global Health Initiative
• The Countdown to 2015 for Maternal, Newborn, and Child Survival
(an independent supra-institutional organisation, health-care professional
associations, donors, and governments, with The Lancet as a key partner.)
Yet 500,000 pregnancy-related deaths occur annually.
Without HIV this would have reduced to 281,500 by 2008
Latest estimates are for the first time showing significant decline from
526,300 in 1980 to 342,900 in 2008 (Hogan et al, 2010).
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Hogan et al. 2010 review
• 1980
• 2008
526,300 (446,400 – 629,600) 422/100,000 live births
342,900 (302,100 – 394,000) 251/100,000 live births
• yearly rate of decline of 1·5%.
• To reach MDG 5 target by 2015 needs a decline rate of 5.5% per
annum
• Without HIV would have a decline rate of 2.2% and Global MMR
estimate of 206/100,000 in 2008
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What’s happening in Africa?
• The proportion of global maternal deaths in subSaharan Africa increased from 23% (18–27) in
1980 to 52% (45–59) in 2008, resulting from
both the accelerated increase in the number of
maternal deaths in the early 1990s and declines
in Asia.
• Trends in MMRs, excluding deaths from HIV
infection, showed decreases during 1980–2008
in eastern and southern Africa, and a slower
decline in central and western Africa.
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In 1990–2008, countries with substantial
declines in MMR included:
Egypt
Romania
Bangladesh
India
China
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What accounts for improvements?
Four Drivers of Maternal Mortality are improving in most countries.
1. global TFR has dropped from 3·70 in 1980, to
3·26 in 1990 and 2·56 in 2008.
2. income per head (affects nutritional status of mothers & physical and
financial access to health care) has been rising
particularly in Asia and Latin America.
3. Maternal educational attainment, another strong correlate of
maternal mortality, has been rising—eg, average years of schooling of
women aged 25–44 years in sub-Saharan Africa increased from 1·5 in
1980 to 4·4 in 2008
4. the steady, slow, rise in coverage of skilled birth attendance could
have contributed to maternal mortality declines
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But…
Nairobi Study (Ziraba et al. Maternal mortality in the informal settlements of Nairobi
city: what do we know? Reproductive Health, 2009, 6:6 http://www.reproductivehealth-journal.com/content/6/1/6)
used data from verbal autopsy interviews conducted on nearly all female
deaths aged 15–49 years between January 2003 and December 2005 in
two slum communities covered by the Nairobi Urban Health and
Demographic Surveillance System (NUHDSS).
Findings
• Over 86% of maternal deaths and 96% late maternal deaths had sought
care at least once from a professional health care worker prior to death.
• About 62% of maternal deaths occurred in a health care facility compared to
only 31% of late maternal deaths
•
definition of maternal death, "the death of a woman while pregnant or within 42
days of termination of pregnancy, irrespective of the duration and site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes"
definition of late maternal death "death of a woman from direct or indirect obstetric
causes more than 42 days but less than one year after termination of pregnancy"
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“these numbers should now act as a catalyst, not a brake,
for accelerated action on MDG-5, including scaled-up
resource commitments.” (Richard Horton, Lancet, 2010)
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Funding
Although overseas development assistance for maternal, newborn, and
child health has increased, funding for this sector accounted for only
31% of all development assistance for health in 2007.
(Bhutta et al, Lancet, 2010: 375-2032-44)
calls to integrate maternal and child survival programmes into vertical
funding mechanisms for the MDGs, such as the Global Fund to fight
AIDS, TB, and Malaria. Editorial “The Global Fund: replenishment
and redefinition in 2010”. Lancet 2010; 375: 865
“Maternal, newborn, and child health offer a unique opportunity to give
the Global Fund a fresh and expanded mandate, rewarding its
already great success. New evidence of progress towards MDG-5
only underlines the importance of this more comprehensive
approach—a replenished Global Fund for all the health MDGs”.
(Richard Horton, 2010)
eilish.mcauliffe@tcd.ie 16/6/10
Systems approach
Countdown assesses progress every 2-3 years
uses WHO health-systems framework,
6 linked and overlapping components of a health
system
• service delivery,
• health workforce,
• information,
• medical products,
• vaccines and technologies,
• And financing and leadership or governance
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Supported by IrishAid and Ministry of Foreign Affairs Denmark.
eilish.mcauliffe@tcd.ie 16/6/10
• Health Systems Strengthening for Equity
(HSSE)
Ultimate aim – to improve quality and
coverage of EmOC.
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MMR estimates by country
Country
1980
1990
2000
2008
Malawi
632
(395-966)
743
(457-1127)
1662
(1034-2551)
1140
(675-1813)
Mozambique
411
(228-668)
385
(241-591)
505
(311-796)
599
(359-957)
Tanzania
603
(380-925)
610
(375-940)
714
(411-1162)
449
(273-721)
eilish.mcauliffe@tcd.ie 16/6/10
Sampling
Country
Malawi
No. of Facilities No. of Providers
84
631
(near national sample)
Mozambique
138
535
Tanzania
90
811
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System components
INPUTS
PROCESSES
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OUTCOMES/RESULTS
15
The Enabling Environment
PROCESSES
INPUTS
•Resources (WI)
 staff
 infrastructure
 drugs
 equipment
OUTCOMES/RESULTS
•Management support (WI)
•Workplace relationships (WI)
•Fair and just treatment (OJ)
 Supervision
In-service training
Promotion
•Job Satisfaction
• Matching capability and workload
(Burnout)
•Performance
WI = Work Index
OJ = Organisational Justice
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•Organisational
Commitment
16
Malawi
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17
Malawi
•Light for tasks
at night
•Access to
running water
(piped or
storage
container)
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18
Malawi
•Light for tasks
at night
•Access to
running water
(piped or
storage
container)
• Cord ties
•Sterile
gloves
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19
Malawi
•Light for tasks
at night
•Access to
running water
(piped or
storage
container)
• Cord ties
•Sterile
gloves
•Tetracycline
ointment
•Lignocaine
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20
Malawi
•Light for tasks
at night
•Access to
running water
(piped or
storage
container)
• Cord ties
•Sterile
gloves
•Tetracycline
ointment
•Lignocaine
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•Sterile gloves
•Soap
•antiseptics
21
Availability of items required for management of
obstetric complications, by facility
Malawi
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22
Most common missing items for management
of obstetric complications
Malawi
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23
Main providers of EmOC are
NPCs/MLPs
• 80% all CS in districts by NPCs
• Across all three countries NPCs are providing all
of the CEmOC signal functions, although not all
NPCs provide all of the signal functions
• No significant difference in post-operative
complications
• High Retention levels: Retention after 7 yrs: 88%
for NPCs vs. 0% for MDs (Mozambique)
• NPCs 3x more cost-effective (Moz)
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eilish.mcauliffe@tcd.ie 16/6/10
Cadres performing EmOC signal
functions in past 3 months
Country
Cadres
Malawi
Mozambique
Assisted Vaginal
Delivery
Removal of
retained products
Clinical Officers
88%
85%
Reg. Nurse
Midwives
67%
22%
76%
94%
73%
85%
60%
82%
24%
33%
Técnicos de
cirurgia
MCH nurse middle
level
Tanzania
Assistant Medical
Officers
Reg. Nurse
Midwives
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Tanzania: Cadres Actively Seeking other Employment
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
21.81
25.7
22.8
14.3
27.9
42.9
45.45
43.2
50.6
41.5
14.3
15.75
15.4
11.5
11.8
5.45
3.9
RGNS &
Midwives
Enrolled
nurses
Strongly agree
Neither agree nor disagree
Strongly Disagree
9.5
21.8
28.6
8.2
8.9
6.1
2.7
Assistants &
Aides
CO/AMOs
Agree
Disagree
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Doctors
Availability of supervision by type
70
60.3
60
50
40
37.9
32.3
29.6
30
20
6 3.6 4.1
10
0
Formal
On request
Malawi
28
15.2
8.9
19.8
14.515.8
8.6
3.6
No
Negativ e
superv ision
superv ision
Tanzania
0.7
Other
4.1
No response
Mozambique
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6.8
Views on current supervision
• “The way of doing supervision of health workers who are
providing emergency services during delivery is not
good, to be honest, we don’t have that close supervision
to tell them that you are supposed to do 1,2,3. There is
no good mechanism…” District Health Secretary
• “Sometimes with shortage of workers you go to
supervise but end up joining staff to work with
them…You have to be there with them to know their
problems, and stay with them to give them the feedback,
then help them to solve problems…but you are just
rushing the work.” RCH Co-ordinator
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Factors affecting job satisfaction
In Malawi, Mozambique and Tanzania,
substantial portion of job satisfaction
levels explained by providers’ perceptions of:
– Adequate supervision
– Support from management
– Adequate pay for work done
– Opportunities for career advancement
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Factors affecting job satisfaction
Management and formal supervisory support
outweighed concerns relating to pay
threefold
in their contribution to job satisfaction levels
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Facility attractiveness
• Facility index dissatisfaction score is formed from combined
standardized average scores for each facility on five scales:
• (i) job satisfaction (reversed),
• (ii) intention to leave,
• (iii) satisfaction with supervision (reversed),
• (iv) management support (reversed),
• (v) emotional exhaustion.
• High dissatisfaction facilities (in green): e.g. Edingeni Rural
Hospital, Machinga District Hospital,, Nkhatabay District Hospital,
• Middling facilities (closest to mean line): e.g. Embangweni
Hospital, Ekwendini Rural Hospital, Kasunga District Hospital,
Mchinji District Hospital.
• High satisfaction facilities (in black): Kaseye Community
Hospital, Mua Hospital, Phalombe District Hospital
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In Summary
• Much can be done to improve the
provision of EmOC
• Addressing problems in the delivery
system may have more immediate effect
than addressing socio-cultural issues or
attempting to manage migration.
• Many interventions required to improve
care are not expensive.
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What next?
• Development and sustainability of a supportive
supervision system (planned Tanzania &
Mozambique study)
• Targeted interventions (e.g. Resources, SCM,
HRM) to ensure equity in access to and quality
of EmOC.
• Review of pay structures and incentives for
NPCs and entire team
• Assessment of obstetric team dynamics,
decision making and impact on quality of care
(planned Malawi study)
eilish.mcauliffe@tcd.ie 16/6/10
With Thanks
• HSSE Team:
– Centre for Global Health, Trinity College, University of Dublin
– AMDD, Mailman School of Public Health, Columbia University,
USA
– Centre for Reproductive Health, College of Medicine, Malawi
– Ifakara Health Institute, Tanzania
– Dept. of Community Health, Eduardo Mondlane University,
Mozambique
– Realizing Rights: Ethical Globalization Initiative, USA
– Regional Prevention of Maternal Mortality Network, Ghana
• Funders:
• IrishAid
• Ministry of Foreign Affairs, Denmark
eilish.mcauliffe@tcd.ie 16/6/10