Service delivery
strategies to improve
maternal health
Mar 2010
Dr. Marge Koblinsky PhD
Sr. Women’s Health Advisor
JSI
Talk outline
Reducing maternal mortality: what is effective?
Lancet 2006: A new strategic focus
Bangladesh – Why is the MMR so low?
-Matlab (E Chowdhury et al)
-Khulna vs Sylhet
Indonesia — Why does the MMR remain so high?
Human resources
Public private sectors
Work in progress:
Multi country analysis: pub/priv facility for birth
Conclusions
Lancet 2006: A new strategic
focus…..
All women should be able to deliver in
primary level health facilities (health
centres) with midwives (SBAs) working in
teams:
 More efficient (achieving high coverage)
than skilled attendants in the home or
hospital
 Most effective (impact on mortality) because
skilled attendants can provide proven single
interventions
Bangladesh: Why MMR declined?
India
Rajshahi
223
Sylhet
471
Dhaka
320
India
India
Khulna
351
Chittagong
325
Barisa
387l
Area
Population
GDP Per Capita
GDP growth rate
Population in
poverty
MMR
Use SBA
Csection
144 thou sq km
140 million.
US$ 388
5.26%
44.3%
322/100,000 LB
13%
3.5%
N

Source. HDR 2005; BMMS 2001, BDHS 2004
GIS unit, ICDDR,B
KM
0
20 40 60 80
Myanmar
Projection of MMR in Bangladesh 1976-2015
6.0
4.0
3.0
75% of MDG
2.0
1.43 /1000 LB
1.0
Projection
National Sisterhood
2015
2012
2009
2006
2003
2000
1997
1994
1991
1988
1985
1982
1979
0.0
1976
Per 1,000 live births
5.0
National Verbal Autopsy
Current declining rate = 3.2% annually (1999-2015)
Required declining rate = 5.1% annually (to achieve MDG target)
Courtesy: Mahbub Elahi Chowdhury
BMMS 2001
Map of Matlab Study Area
BANGLADESH
Govt. Service Area
Legend
Rajshahi
Sylhet

ICDDR,B Hospital

ICDDR,B Subcenter

Dhaka
@

Matlab
Khulna
Chittagong
Barisal
Govt. Service Area
Bay of Bengal

ICDDR,B Service Area
Main rivers
Divisional boundaries

N


GIS unit, ICDDR,B
KM
0
1
2
3
4
Matlab Home-Based Strategy, 1987-1995

In each block (20,000) 2 midwives
were posted 24 hours on call
- Conduct home deliveries
- Refer complicated deliveries
- Provide ANC & PNC

Other duties included:
- Organize community meetings, train
health workers, TBAs, organize
referrals, FP
Support systems
- Rickshaw/boat, porter
- Matlab clinic,
•
- Comm serv--immuniz, ORS
No charges
Matlab Facility-Based Strategy, 1996 to date
 In each block, 2 midwives
posted in an upgraded Basic
EOC facility
 Services were better organized
 consistent supplies
 separate labor room
 improved links with Matlab
Hospital
 treat children’s problems
 No charges
Matlab Clinic– BEOC Centre
 Lady medical officers
 Assisted vaginal deliveries
possible
 No charges
• Referrals linkages
 District hospital
 EmOC facility at
Matlab
•
Backed up by transportation
Speed boat/rickshaws/boats
Ambulance in Matlab
Trends in maternal mortality over time
500
Mortality fell by 54%
Maternal deaths per 100,000 pregnancies
400
Mortality fell by 68%
Bangladesh national
300
200
100
ICDDR,B area
Government area
0
76-80
81-85
86-90
91-95
96-00
01-05
76-80
81-85
86-90
91-95
96-00
01-05
Maternal mortality and use of skilled care at birth
over time by areas
ICDDR,B area
600
Government area
100
500
80
70
400
60
300
50
40
200
30
20
100
10
0
0
76-80
81-85
86-90
91-95
96-00
Maternal deaths
01-05
76-80
81-85
86-90
91-95
% of births with health professional
96-00
01-05
% of births with health professional
Maternal deaths per 100,000 pregnancies
90
50.0
Total deaths = 173
40.0
% of used skilled care
30.0
n =10
20.0
n =16
n =17
n =31
n =26
n =9
n =29
n =16
10.0
1987-1993
1994-1999
Reduction of mortality
For CEmOC - 26% per year
BEOC & referral - 8% per year
No care - 8% per year
p value for interaction between time and type of care <0.01
2000-2005
No care
BOC &
referral
CEmOC
No care
BOC &
referral
CEmOC
No care
0.0
% used skilled care
n =19
BOC &
referral
20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
CEmOC
Mortality per 100,000 pregnancies
Pregnancy-related mortality and use of skilled care at
birth, over time in the ICDDR,B service area
At individual level
At low level of skilled attendance (about 10%):

Selection of high risk women in EmOC

Midwives/hospitals cannot save these women (women
may have more severe complications; may have poor
quality of care)
At the highest level of use of skilled care (about 40%):

Maternal mortality among those using care remains
high (150 at BEOC; 720 at EmOC)

Maternal mortality among those not using skilled
attendance is much lower (60/100,000)
Similar patterns are observed for perinatal mortality but
selection effects are less strong
Place of birth in the Matlab surveillance area
2007-2008 (n= 4817 births)
2000
1800
1600
1400
1200
1000
800
600
400
200
0
Home
ICDDR,B
health centre
ICDDR,B
clinic
Thana health
complex
No referral
Public
Hospital
Chandpur
Private
hospital
Chandpur
Hospital
beyond
Chandpur
Referral via ICDDR,B
62% births in facility; 44% ICDDRB facilities (BEOC level); 19% other hospitals (20% pub,
57% private, 23% beyond Chandpur)
C section—7.5% overall; 22% pub, 70% priv
Huda, F et al 2009
Bangladesh
India
Rajshahi
223
Sylhet
471
8% doc
4% csec
Dhaka
320
MMR by division
2003
India
India
Khulna
351
17% doc
8% csec
Chittagong
325
Barisa
387l
N

GIS unit, ICDDR,B
KM
0
20 40 60 80
Myanmar
Geographic distribution of CEmOC
facilities in Bangladesh
Divisions
Dhaka
Chittagong
Rajshahi
Khulna
Barisal
Sylhet
Total
Public
NGO
Priv
CEmOC facilities/
500,000
population
9.5
5.6
6.3
12.7
5.1
4.7
7.8
1.1
0.4
6.3
3
6
1
2
5
CEmOC Facilities with CSection and Blood by type
and division (%)
% of facilities
100
80
60
40
20
0
Dhaka
Chittagong Rajshahi
Public
Khulna
NGO
Barisal
Sylhet
Total
Private
 Cs and BT available in 60, 80 and 90% of public, NGO and private facilities respectively
 In 1/3 of public facilities, Cs not available mostly due to unavailability of ob/anesthetists
 Among divisions Cs and BT most available in Khulna and least in Sylhet division
Professional assistance
during birth and MMR:
Indonesia
Why is the MMR so high?
Bangladesh
Population (mil)
Income
Rural %
Density (pop/Km2)
TFR
Midwives
Obs
Anes
vs
Bangladesh
150
low
74
920
2.7
5000
900
860
Indonesia
Indonesia
225
med
48
119 (17000 is)
2.8
80,000
2100
750
Maternal Death per 100.000 Live Birth
Maternal Mortality Ratio Indonesia
1990-2015
Estimated by Unicef,
WHO, UNFPA, The
Worldbank
500
Year 2005 : 420
400
390
334
307
300
200
IDHS 2007:
Preliminary result
Financial crisis
Village
midwife
program
228
Decentralization
102
100
Target M DG 5
by 2015
1990-1994
1993-1997
1998-2002
Year
2003-2007
2015
Assistance during delivery
IDHS 1987 & 2002: Increase
in SBA from 35% to 66%,
especially among the two
poorest quartile (2007-73%)
 Gap between rich and poor
narrowing, but access of the
poor still very low
100
SBA among 60% of
the poorest is very low
% deliveries with a skilled attendant
90
80
70
60
50
40
30
20
10
0
Poor
Low
middle
Middle
Upper
middle
Rich
Access to Emergency care: C-Section
Trend of Cesarean Section
1986 – 2002 by wealth quartile
8.00
7.00
% Caesarean sections
6.00
Among the poorest 80% CS is less than
1% compared to 3.6% in the richest
quartile (2007 overall-6.8%)
5.00
4.00
3.00
2.00
1.00
 Catastrophic effect in the ‘almost poor’0.00
group
Lower 80%
Rich
2500
100
90
Maternal deaths per 100,,000 live
births
2000
80
70
1500
60
50
1000
40
30
500
20
% births with HP among women with recent birth
MMR by presence/absence of health professional and wealth quartile, and
proportion of births with HP by quartile, Serang, Pandeglang, Indonesia, 2004-6
10
Poorestt
Lower middle
Kematian Ibu per 100,000 live births
Upper Middle
Tanpa
NAKES
Dengan
NAKES
Tanpa
NAKES
Dengan
NAKES
Tanpa
NAKES
Dengan
NAKES
Tanpa
NAKES
0
Dengan
NAKES
0
Least Poor
% kelahiran dg Nakes
MMR 1.9 times higher with SBA; only amongst richest is MMR same
Ronsmans et al 2009
with/without SBA but still over 200
In-patient costs at different
types of facilities ($US)
Public
Hospital
Normal
Delivery
C
section
Military
Hospital
IND-DRG
(class C-A)
82-89
163
70-154
340-435
494
128-282
Indonesia: Why is MMR high?
Most women use midwife for birth, little access to
emergency care due to lack of availability of skilled
providers, costs and insurance issues
Costs of birthing




Variability and lack of transparency of fees for hospitals
Many private facilities/providers will not accept insurance for poor
Public hospitals may not treat until they receive card
Midwife is not reimbursed for woman’s care if she refers to hospital
Quality of care
 Regulations govern who can treat patient; no control over private sector,
 No coordination between midwives and hospitals; between District
Health Office (FH) and Governor’s office (where hospitals/doctors report)
 Low availability of obs in facilities (not clear re anes)
Private sector and its role in
delivery care among
countries, Asia and Middle
East
Amanda Pomeroy
Marge Koblinsky
Soumya Alva
Growth in the private sector, Asia
Total Facility Births, by Facility Type, Asia
Private
Govt
NGO
90
70
60
50
Second Year
80
First Year
% of all births (bar height indicates total facility births)
100
40
30
20
10
Ne
pa
l
bo
di
a
Ca
m
h
ad
es
Ba
ng
l
Ph
ili
pp
in
es
In
do
ne
sia
In
di
a
*
0
*India facility rates are for three years preceding the survey, because the 1998 data do not have information on births five years preceding survey. For all
other countries, these rates are for all births five years preceding survey.
All DHS data; first time point was chosen to be from the fourth round of DHS survey collection (1997-2003) while the second time point was chosen to be in
the fifth phase (2003-Present).
Growth in the private sector, Middle East
Total Facility Births, by Facility Type, Middle East
% of all births (bar height indicates total facility births)
100
Private
Public
NGO
90
80
70
60
50
40
30
20
10
0
Yemen First Yr*
Yemen Second Yr
Jordan First Yr
Jordan Second Yr
Egypt First Yr
Egypt Second Yr
All DHS data except Yemen 2nd year (PAPFAM 2003); first time point was chosen to be from the fourth round of DHS survey collection (1997-2003) while
the second time point was chosen to be in the fifth phase (2003-Present). The first year of Yemen (1997) data is not split by facility type. Jordan: 20022007, Egypt: 2000-2008.
By Facility Type, Breakdown of Births by Type of Delivery, by Year,
Bangladesh
100%
90%
80%
70%
60%
Percent Change in
Private C-sections:
51%
50%
40%
Percent Change in
Public C-sections:
54%
30%
20%
10%
Ye
ar
ea
r
Pr
iv
at
e2
nd
st
Y
Pr
iv
at
e1
Ye
ar
bl
ic
-2
nd
Pu
Pu
bl
ic
-1
st
Ye
ar
0%
Shift from normal to csection in both pub and private
Natural Delivery
C-section
By Facility Type, Breakdown of Births by Type of Delivery, by Year,
Indonesia
100%
90%
80%
70%
60%
50%
40%
Percent Change in
Public C-sections:
41%
30%
20%
Percent Change in
Private C-sections:
43%
10%
Pr
iv
at
e2
nd
Ye
ar
ea
r
st
Y
Pr
iv
at
e1
Ye
ar
bl
ic
-2
nd
Pu
Pu
bl
ic
-1
st
Ye
ar
0%
Natural Delivery
C-section
Increase in csections in public and private sectors but as 78% of fac births are
private, hence most of csec are in priv sector
Conclusions

Bangladesh






Access to EmOC is a must!
SBAs bypassed in densely pop areas where EmOC available;
may not be skilled to manage cx
Specialists (or those trained in surgery/anes) not available in
rural public facilities
Increase in EmOC private facilities and use
Expenditure for birthing care high
Asia



Private sector use is growing
Dualism allowed (Bangladesh, Indonesia, Nepal, some
states/India); FTEs in Govt few; Doctors have large debts from
med school
Csection use high in private sector, depends on access
(distance, costs, insurance coverage)