Determinants of Safe Motherhood

Economic and Political determinants of SafemotherhoodDr Olive Sentumbwe-MugisaFamily Health and Population AdvisorWHO

Intention of presentation

Present and discuss the dimensions and determinants of Safe motherhood

Dimensions implyHealth is something tangible Health can be measuredHealth can changeChange = increase or decreaseHealth status is unlikely to remain the same

Understanding the dimensions, determinantsWhat is health?What increases health?What decreases health?What keeps health the same?

Grouping of Determinants of Health

WHO Definition of Health

HealthA state

A state of mind everything that changes the mind, changes health

A state of body everything that changes the body changes health

A state of life everything that changes life changes health

Determinants of HealthHealth status is influenced by:Biology- Biologic and genetic endowmentHealth care( Availability and Quality )But to a much larger extent by what has been termed as the broader determinants of health called social determinants

Determinants of HealthGenes (race)Environment biological factors, physical factors and chemical factors(GEOGRAPHY WEATHER - ALTITUDE)Nutrition (QUALITY, QUANTITY OF FOOD AND WATER)Lifestyle pleasure, leisure, vices, occupationSocio-economic statusTime (Age)

Social determinantsIncome and social statusSocial support networksEducation/TimeEmployment/working conditionsSocial environments/politicsHousingPersonal health practices and coping skills

Social determinants cont---Healthy child developmentAccess to health servicesGender issuesPowerlessnessCulture and ethnicityImmigration/refugee status

How can we measure health?Degree of morbidity (physical+mental)

Degree of disability (physical+mental)

Degree of mortality

Death = zero health

Some of the factors that can change the mind, body and life?Stress,

Abuse (physical, emotional, sexual)

Deprivation (food, liberty, sex,)

Accidents

DeprivationImprisonment

EconomicFamily Planning:High Fertility and Low use of FP leading to large unaffordable families in terms of shelter, food and schoolingEnvironmental degradation leading to women walking and working harder to find food and firewood

Poor living conditions result into:Excessive workload and no restPoor shelter therefore exposed to diseases such as malariaPoor sanitation at times leading to worm infestations and diarrhoeaPoor cooking methods with firewood and charcoal stoves therefore smoke leading to chronic lung diseases starting with bronchitis

Fire Outbreaks

Poverty and women Smoked food -direct flame has also been associated with liver, pancreas disease as well as pharyngeal carcinomaFor some women in Kenya who have had to carry heavy loads on their backs tied around the forehead some bone disorders of the vertebrae have been recorded (KEMWA) and chronic osteoathritis

HIV and PovertySome women are forced into sex for food and clothingSome students trade sex for basic needs such as school fees , underwear and sanitary padsPoor shelter of slum dwellers force children to be exposed early to sexual activity of their parents so they also start experimenting

Overall HIV Prevalence in Uganda by Sex and Age

Sex for something conceptLeads to unwanted pregnancy as well in many young women and olderUnsafe Abortion and the possible related complications such as infection, chronic pelvic pain, infertility in the long run,excessive bleeding, death etcUganda has a very high prevalence of abortion at 54/1000

Maternal HealthThe Rural poor have high fertility because of poor access to FP services but also rural poor men desire large familiesRural poor women in this way have higher increased lifetime risk to pregnancy complicationsYet poor access to maternal health services due to poverty and longer distances

Why Women Die in Pregnancy & Childbirth: The Three Delays3rd DelayDelay in receiving care at the health facility1st DelayDelay in the Home2nd DelayDelay in Accessing the Health Facility

Delivery by skilled attendant and fertility:differences according to poverty-wealth index

Newborn HealthOverworked and poorly nourished women are likely to produce small childrenUnderweight babies will not do wellData shows that underweight is a risk to newborn survival

Adolescent PregnancyHigh amongst the rural poor for dowry (exchange of money for the girl) and cultural normsLow information about sexuality and no services Poor use of FP services amongst this age group-DHS 2000

Issues Relating to the health of AdolescentsHigh Proportion of Unintended PregnancyLess than 20% have access to Services High Secondary School Drop Out Rate- double tragedyHigh STI/HIV Infection RateLack of life and livelihood Skills

Average number of births per 1000 females age 1519 in various regions (UNICEF, 1998)

Adolescent contribution to maternal mortality40 44%

* Data from Mulago National Referral Hospital, 2005.* Maternal death review reports: Soroti, Hoima and Iganga, 2003.

Cancer of the cervixHigh prevalence of HPVLow knowledgeNo vaccine as it is unaffordableScanty cancer cervix screening servicesMost common cancer amongst women in Uganda

InfertilityManagement of Infertility is out of reach for many of the poor people in Uganda so therefore a double tragedy7% of couples known to be infertile in Uganda

Gender Issues in RHVesicle vaginal and Rectal Vaginal FistulaHigh prevalence amongst the rural poor because they cannot access services easily therefore when they get obstructed labour they cannot easily be assistedTherefore this remains largely a disease of poverty

Male Support for Womens HealthWhen women are economically empowered they can afford and access health services when they need them other than depending on handouts from their male spouses who may also be equally economically challengedSimilarly poor men take long to seek services because they cannot afford them usually therefore present with late signs difficult/expensive/too late to manage

Politics and womens healthThere is an apparent political good will to address the poor SRHR indicators in the region but also a blessing and sense of social responsibility from the international communityWe could take it from the ICPDThe Abuja declaration-15% for healthThe Road Map for MNHThe Maputo Plan of ActionThe First Ladies Forum and activities for Safe motherhood-White Ribbons Alliance

Launch of CARMMA24 countries so far have launchedUganda launched its forum on 5th May 2010The main purpose here is to engage the communities to play their parts in protecting and promoting womens health and ensure Safe motherhoodIt also aims at advocating to stakeholders to address service provision

UgandaThe Road Map has been signed by the PresidentMaking Pregnancy Safer is district evidence on how political will can make a differenceSome of the politicians involved used the interventions-Ambulances to gain further supportWhile the specialist in the refferral hospital could not be voted into politics because he was more valued as a health worker saving womens and childrens lives

Local Government Political supportWork plans addressed the local needs of women in their various villages as there was grassroot planning capturing issues which were affecting production in Soroti district One of these was health of women in relation to pregnancy- need for more health units and midwives and for sometime these two interventions were priotised in the local development fund

Political Support and Resource AllocationPolitical will important for Budget allocation to maternal health programmes at all levels as you have seenWe have involved the parliament to appreciate what the Road Map for accelerating the reduction of maternal and newborn deaths is and why more resources need to be put in health and for what interventions

Political Support and LegislationIssues of Safe Abortion Access for RAPE and Defilement

War, Civil Strife and maternal HealthHigh risk environment for women-RAPENo access to organised health services such as FP, ANC, delivery and Skilled careHowever when war, natural disasters are on, the first packages rarely include Reproductive Health needs yet the greatest at risk are women and children

SAMPLE OF MCH SERVICE DELIVERY POINT WITH IN A CAMP SETTINGPartitioning using papyrus Reeds.

High Population and HungerHigh Population density and therefore hunger is a common problem in the refugee camps.

Health Challenges of refugee/migrant women

During DisplacementH/Workers migrate to safer placesPeople engage more in sexual activities voluntarily or forced for food or even as a case of direct violence against young girls and womenHIV is likely to be on the riseThe traditional system for caring for pregnant women usually take over

Politics continuedPolitical stability is key for the desired multi-sectoral support to accelerate reductionCoordination and accountability is required at a very high level in order for health programmes to receive the inputs they need from Ministries of finance and other related service ministries

What about Global politics?Do we have examples in countries outside AFRICA where politics has influenced peoples Reproductive health?

Slow Progress of RH Indicators;Persistent InequalitiesCoverage Gap for key proven evidence based interventions

TRENDS OF THE REPRODUCTIVE HEALTH INDICATORS IN UGANDA

1987199520002006TFR UNMET FP CPR DELIVERIES(skilled)

ADOL PREG. MMRIMR Neonatal 7.333%

5%37%

44%

527122- 6.929%

15%38%

43%

50681- 6.935%

23%38%

32%

5058833/1000 6.742

24%42%

25

4357732

Coverage of Maternal/ Neonatal interventions along the continuum of care in AfricaSource: Opportunities for Africas Newborns based on State of the Worlds Children 2006, and DHS released since

Chart1

69

42

16

30

65

Coverage %

Sheet1

ANC (any)Skilled attendantPostnatal careExclusive breastfeeding (

Inequities in the coverage of some neonatal interventions among African countriesSource: Opportunities for Africas Newborns - base en 32 EDS

Chart2

4880

2581

Lowest

Highest

NNMR per 1000 live births

JLo

Regional breakdown of deaths for 192 countries

RegionAsphyxiaCongenitalPretermInfectionDiarrhoeaTetanusOtherTotalRegionSepsis/ pneumoniaTetanusDiarrhoeaPretermAsphyxiaCongenitalOthercheck

Afr26666868160.12575473086234075911032775846.41127930.5Afr27%10%4%23%24%6%7%0.3640955715

Amr35508.627364.380229.236039.91134.621739.1913679.1195694.91Amr18%1%1%41%18%14%7%0.3911803327

Emr1201965399813098517179821628.469652.134293.6602551.1Emr29%12%4%22%20%9%6%0.3460081643

Eur228261865644085.320392.51261.821374.357335.11115931.08Eur18%1%1%38%20%16%6%0.4210873391

Sear33385182064.443837439543338334.760125.694954.81443137.5Sear27%4%3%30%23%6%7%0.3539996709

Wpr13466542778.21621971084867480.3917778.538594.6511979.69Wpr21%3%1%32%26%8%8%0.4219655666

Total913714.62930211113417.51040772.4110598.93260996.74264703.613997224.78

SubregionAsphyxiaCongenitalPretermInfectionDiarrhoeaTetanusOtherTotal

AfrD12694131892.312251314217120938.359810.336104.9540370.8

AfrE13972736267.813503416645219820.750516.639741.6587559.7

Amr43.028866.4951205.78367.97410030.7187413.9997Puerto Rico - not sure which subregion this falls in

AmrA2994.826261.939834.91321.22001468.1221880.99

AmrB2191017816.35737725049.6517.405409.1039176.57132255.978

AmrD10560.73219.5412811.69601.12617.2151330.093003.7241143.985

EmrB10196.29157.9515893.610351.2484.989796.8433007.1549887.932

EmrD11000044840.111509216144621143.468855.231286.4552663.1

EurA2018.664465.815688.12838.30700849.10513860.002

EurB16867.58846.7128816.414793.61108.511072.314984.9476489.97

EurC3939.885343.469580.724760.53153.306302.0411501.0625580.997

Sear202.06342.8955172.201220.81823.169438.382157.4713757.0003

SearB29055.67460.7832039.519802.31336.151057.588264.0799015.98

SearD30459374560.740616237540936975.459029.786633.21343363

WprA486.7321089.011561.99197.09400233.1693567.995

WprB13417941689.21606351082897480.3917778.538361.4508412.49

Total913715.1838293020.98061113417.8141040770.7631110598.9344260996.6491264703.5943997223.919

JLo

1

JLo2

RegionSevere infectionTetanusDiarrhoeaPretermAsphyxiaCongenitalOthercheck

Afr27%9%3%23%24%6%7%100%

Amr

Emr

Eur

Sear

Wpr

Puerto Rico - not sure which subregion this falls in

JLo2

0.27

0.094

0.034

0.23

0.239

0.061

0.068

Afr

Asphyxia 24%

Preterm 23%

Diarrhoea 3%

Tetanus 9%

Congenital 6%

Other 7%

Severe infection 27%

General info

Under-five number of deaths, both sexes combined, WHO Member States and WHO 14 subRegions, 2004

As prepared for The World Health Report 2006.

whocodeCountry0-4 deathsyearU5MRates%Newborn dthsNewborn rates

1035Burkina Faso108180200420718.3%19796.9637936

1555DRC544414200420525.7%139914.39847

1260Madagascar84068200412625.6%21521.4105633

1280Mali135076200422025.9%34984.7591155

1330Niger182227200426216.7%30431.8288443

1370Rwanda71428200420321.7%15499.9128945

1390Senegal55777200413722.8%12717.1240831

1181170274866.397270.2327068939

Africa43

Africa463126626.2%1213391.6920.32475461440.6670083274

Amr39820243.7174014.2740.0465735334

Emr140063943.4607877.3260.1626935209

Eur23047444.3102099.9820.0273262463

Sear288012244.41278774.1680.342253713

Wpr76633347360176.510.0963983719

1

3736333.952

World1030703635%3607462.6

PretermCongenitalAsphyxiaSevere infectionDiarrhoeaTetanusOtherInfectionsNon-infectious

Madagascar (33)27625262679934

Rwanda (45)23627293389935

DRC (47)2672422411710137

Senegal (31)247233226610040

Burkina Faso (36)2252132212610046

Mali (55)195223151169947

Niger (43)1752330316710149

General info

0000000

0000000

0000000

0000000

0000000

0000000

0000000

Preterm

Congenital

Asphyxia

Severe infection

Diarrhoea

Tetanus

Other

Countries and their respective NMR (per 1000 live births)

Proportion of deahts (%)

B Faso

Burkina Faso

Asphyxia21

Congenital5

Preterm22

Infection32

Diarrhoea2

Tetanus12

Other6

Diarrhoeal_neoneo_tetanusneo_infectionneo_asphyxianeo_pretermneo_otherneo_congenital

21232212265

mafatd:yellow ones are corrected - see sheet "cong-corr"

DRC

DRC

Asphyxia

Congenital

Preterm

Infection

Diarrhoea

Tetanus

Other


41122242677


Madagascar

Madagascar

Asphyxia

Congenital

Preterm

Infection

Diarrhoea

Tetanus

Other


2626252776


Mali

Mali

Asphyxia

Congenital

Preterm

Infection

Diarrhoea

Tetanus

Other


51131221965


Niger

Niger

Asphyxia

Congenital

Preterm

Infection

Diarrhoea

Tetanus

Other


31630231775


Rwanda

Rwanda

Asphyxia

Congenital

Preterm

Infection

Diarrhoea

Tetanus

Other


3329272386


Senegal

Senegal

Asphyxia

Congenital

Preterm

Infection

Diarrhoea

Tetanus

Other


2632232467


Trends

Country19801990200020042015

Burkina Faso24621019619271

DRC21020520520570

Madagascar17516813712357

Mali30025022421985

Niger320320270259109

Rwanda21917320320359

Senegal21814813913750

Africa19818317216762

World11793827931

6262626262

Trends

0000000

0000000

0000000

0000000

0000000

Burkina Faso

DRC

Madagascar

Mali

Niger

Rwanda

Senegal

Year

U5Mr per 1000 livebirths

Inequities

000

000

000

000

000

Target 62/1000live births

Africa

World

MDG Target for Africa

Year

U5Mr per 1000 livebirths

Coverage

RegionResidenceMother's educationWealth QuintileSex

Low mortalityHigh mortalityUrbanRuralNo educationSecondary and higherLowestHighestMales45

Mali56801.4B Faso35391.1B Faso48391.2B Faso40361.1Females35

Madagascar23361.5Madagascar25301.2Madagascar46212.2Senegal50271.9

Rwanda35702Mali58711.2Mali70312.3

Senegal27562.1Senegal32461.4Rwanda66262.5

B Faso18543Rwanda31541.7Senegal45172.6

RuralUrbainRegion (highest)Region (lowest)Aucun nieau d'instructionNiveau d'instruction 2aire ou plusIndice de bien-etre plus faibleIndice de bien-etre plus eleve

B Faso3935541848394036

Madagascar30.325.135.823.445.921

Mali7158.180.155.77031

Rwanda53.531.170.334.765.526.4

Senegal4632562745175027

Inequities in coverage

LowestHighest

ANC (3+ visits)4880

Skilled attendant2581

Coverage

0

0

0

0

0

0

0

Inequalities


00

00

00

00

00

Low mortality

High mortality


00

00

00

00

00

Urban

Rural


00

00

00

00

00

No education

Secondary and higher


00

00

Lowest

Highest


0

0


00

00

Lowest

Highest


World

Antenatal care75

Tetanus toxoid47

Skilled attendance at delivery46

Delivery at facility44

Exclusive BF (0-6 months)23

Community-based case management of penumonia12

Treated bednets2

0

0

0

0

0

0

0

Reference materialsMDGsICPD plan of action The Road Map for Accelerated Reduction of maternal and newborn mortalityThe Maputo Plan of ActionThe MPS

How?Empowering communities to willingly make health protecting, health restoring and health promoting choices

EvidenceStrong advocacy skills ResourcesMultifaceted approach

ConclusionsHealth has many dimensionsIt is important to understand the different dimensions as they relate to the community one is servingEmpowering communities to make informed choices willingly to protect, promote and restore their own health is a major goal of all health systems.

Thank You

*Huts can burn and the fire can spread easily to surrounding huts this is usually due to the fact that women cook in the huts with all the household belongings including highly inflammable materials such as straw mattresses and clothes.**Across all age groups with the exception of the 0-4 age group, HIV prevalence was higher in females.***I will now concentrate on the reasons why women die as a result of pregnancy or childbirth related complications.By the end of this presentation I would like you to decide whether you have a role to play in the prevention of this tragedy in our country and hopefully by the of this workshop you will have committed yourself to prevent yet another death in your environment**This shows us that the rich women deliver less children and most of them 77.3% deliver with skilled attendants which implies that they have better pregnancy outcomes.*Various health units have been destroyed structurally and are too small to offer the different types of services required for the camp population. Therefore partitioning using local materials such as papyrus reeds has been undertaken by local communities in the camps.*Various humanitarian organizations bring in food and health services. This particular community was waiting for food

*High fertility, orphanhood coupled with insufficient family planning services and other reproductive health services increase the vulnerability of women to malnutrition and chronic maternal depletion syndrome, always tired and overworked Children also are vulnerable to mulnutrition,inadequate formal education and housing facilities as well as sanitation

*Data from DHS surveys in 47 countries, 10,048 neonatal deaths. A very high proportion of deaths occur in the first hours and days after birth. Prevention of these early neonatal deaths will require improvements in care at the time of birth and improvements in care in the early neonatal period.*Les inegalites entre la couverture de certaines interventions come le CPN et laccouchement assist entre les pays Africains est aussi importante et variable. Il y a des pays qui ont une couverture de CPN de 48% et dautres pays qui ont une une couverture presque 2 fois plus haute. En meme temps, la couverture des accouchements assistes par personnel qualifie peut etre aussi basse que 25% et aussi haute que 80% - ce qui fait une difference de plus de 3 fois entre quelques pays Africains.

Documents

Determinants of Safe Motherhood