Objectives of the Day

Have a general overview of Global trend of MMR

Describe the current Millennium Development Goals in relation to reproductive, maternal and child health.

Identify causes and contributing factors of maternal mortality and strategies for prevention

Explain the components of reproductive health, MISP and Comprehensive packages.

Getting to know you

Stand up if you have a RH service in your programmeRemain standing if that service includes:ANCSupport to skilled birth attendantsEmergency obstetric servicesFamily planningPost abortion careIntroduce yourself and why you are at the the

position you are at.

Activity

In pairs define on stick and stick on wall under heading.

Maternal death

Maternal mortality ratio

Maternal mortality rate

Reproductive health

Everything you know about the Milleniumdevelopment goals

Definition of Maternal Death

Maternal death is the death ofa woman while pregnant orwithin 42 days oftermination of pregnancy,irrespective of the durationand the site of thepregnancy, from any causerelated to or aggravated bythe pregnancy or itsmanagement, but not fromaccidental or incidentalcauses

Source WHO

Maternal mortality is defined asthe death of a woman whilepregnant or within 42 daysafter termination ofpregnancy from any causerelated to or aggravated bythe pregnancy or itsmanagement. This includesdeath as a complication ofabortion at any stage ofpregnancy

Source UNFPA

4

Maternal Mortality Ratio

Annual number of deaths of women from pregnancy related causes per 100,000 live births

( MDG ratio)

Maternal Mortality RateNumber of maternal deaths in a given period

per 100 000 women of reproductive age during the same time-period.

Millenium Development Goals

Why Who Where When What ?

Can you list them?

Why?

Millennium Declaration to eliviate poverty

Who?United Nations - 189 Member States

What?

The new international framework for measuring progress towards sustaining development and eliminating poverty.

8 Measurable goals to be reached by 2015 Eradicate extreme poverty and hungerUniversal primary education Promote gender equity and empower women Reduce child mortality by 2/3rds Reduce maternal mortality by 3/4 Combat HIV/AIDS malaria and other diseases Ensure environmental sustainability Global partnership for development

MDG5

Target

Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

equivalent to an annual decrease of about 5.5 percent; and access to universal reproductive health care by 2015.

Achieve, by 2015, universal access to reproductive health

Indicators

Maternal mortality ratio

Proportion of births attended by skilled health personnel

Contraceptive prevalence rate

Adolescent birth rate

Antenatal care coverage (at least one visit and at least four visits)

Unmet need for family planning

9

MDG additional

the proportion of all births assisted by skilled attendants should

reach 90% globally

at least 60% in countries with high rates of maternal death.

MDG 4

Reduce by two

thirds the mortality rate

among children under five

Indicator

Under-five mortality rate

Infant mortality rate

Neonatal mortality rate

Proportion of births attended by skilled health personnel

Target

11

Definition of Reproductive Health

Reproductive health is a state of complete physical, mental and social well being and not merely the absence of disease and infirmity, in all matters relating to the reproductive system andto its functions and processes.

12

Right?

• In groups of four translate this in to a right

Reproductive Health Right

• Recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.

• It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence”

• To have a satisfying and safe sex life, the capabilityto reproduce and the freedom to decide if when and how often to do so.

In summary

• A healthy, safe sex life

• Every pregnancy wanted and safe

• Every child wanted and healthy

• ( Line up progress against this in the country where you work)

Global Trend in MMR

16

Global Context

• 340,000 maternal deaths occur each year, 1000 maternal deaths per day, one every minute

• 8 million women suffer serious illness or disability ( 2 million obstetric fistulas).

• Decrease of 34% since 1990.

4 million newborns die each year

• Neonatal mortality rate countries has remained unchanged at about 30 deaths per 1000 live births.

• 19 of 68 priority countries on track for MDG 4

Access to modern contraceptives has increased 52 – 62% but is only 22% in SSA.

17

Maternal Mortality Ratio in 2005(per 100,000 live births)

18

Current status

99% of maternal deaths occur in developing countries, 65% in 11 countries 50% in fragile states

Roughly 50% maternal deaths occur in SSA and 30% in Asia

Maternal mortality ratio in developing countries is 450 maternal deaths per 100,000 live births

SSA is 824, Asia 329, Latin America132 9 in developed countries

The lifetime risk of death from maternal causes in sub-Saharan Africa is 1 in 16 South-East Asia 1 in 58 1 in 4000 in industrialized countries

Any thoughts on the 11 countries?

11 countries?

Afghanistan Bangladesh DRC Ethiopia India Indonesia KenyaNigeria Pakistan Sudan Tanzania

Global decline 1990 - 2008

MDG aims for a global decrease per year of 5.5% Currently the decline is 2.3%

90 countries = > 40% (Equatorial Guinea (–73%), Eritrea (–69%), Cape Verde (–58%), Ethiopia (–53%) and Rwanda (–51%)

67 countries = < 40% 5 countries = 0 change (S. Leone, Malawi, Angola, Niger,

Tanzania, Mali) 23 countries increased. (Botswana (133%), Zimbabwe

(102%), South Africa (80%), Swaziland (62%), and Lesotho (44%).

(CAUSES??)

Causes of maternal deaths

22

4 Too s

Too young

Too soon

Too many

Too old

Too Young Too Soon

50% deaths from unsafe abortion in Africa are in adolescents. (2003)

Children 10 – 15 years are x5 more likely to die in childbirth

15 – 19 yrs = x2 more likely.

More than 100 million mostly-curable sexually transmitted infections occur each year in young people aged 15 to 24.

50% new HIV infections occur in young people.

Too Many ( Too old)215 million women who wanted to are not using FP.

25% WCBA in SSA 75 million unintended pregnancies 44 million end in induced abortion.

Contraceptive use has increased in all developing regions,

Remains low in sub-Saharan Africa, 22%

Fertility rates have decreased. Remaining high in East and central Africa and in lowest quintiles in certain countries, Columbia, Philippines.

Abortion

Unsafe abortion = 75,000 deaths each yearHigh proportion of deaths in displaced camps45 million unintended pregnancies are

terminated each year 20 million women sought unsafe abortion. 40% of all unsafe abortions are performed on

young women aged 15 to 24. 1 in 5 women who have an unsafe abortion,

suffers a reproductive tract infection; some leading to infertility.

The Three Delays leading MM

First Delay - delay in deciding to seek care Late recognition, fear

of hospitals, cost, permission from decision maker

Second Delay –reaching care facility Bad infrastructure,

lack of transport, cost

Third Delay – obtaining care at health facility Poor staffing (few & lack of

training), fees, lack of blood, supplies & surgical capacity

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Underlying causes

Access to ANC. In high MMR countries <30% women access ANC.

ANC 1 increased to 64 - 79%.

absence of skilled health personnel during childbirth,

lack of services able to provide emergency

obstetric care and deal with the complications of unsafe abortion, and

ineffective referral systems.

Skilled birth attendance

0

20

40

60

80

100

120

world N. Africa SSA S.America E. Asia S/. A C.Asia W. Asia D. Regions

1990

2007

Skilled birth attendance

60 million women give birth outside a health facility. 50 million without skilled care.

44% births attended by skilled health personnel in sub-Saharan Africa

42% in Southern Asia in 2007

skilled birth attendance at delivery has increased in all developing regions.

Medical causes

Too young Too soon Too many Too oldDelay to choose

care

Late recognition/ lack of

knowledge

Delay to reach care

Poor infrastructure

Delay to obtain care

Lack of skilled birth attendance

Strengthening Health Systems

Health workforce

Service delivery

Leadership/governance

Financing

Medical products

Information

Improved health

Improved efficiency

Social and financial risk

Responsiveness

Overall goals/outcomesSystem building blocks

Access

Coverage

Quality

Safety

The WHO health system framework (WHO, 2007)

HR

Mainly in Africa, shortages estimated at 2.4 million doctors, nurses and midwives.

WHO countdown to 2015 – 341000 midwives, nurses, doctors are required by 2015.

The shortage is especially acute in countries characterized with high MMR and high TFR, which typically have fewer health personnel

The percentage of births attended by qualified health personnel is also low in these countries relative to other groups of countries

Lack of Investment

Maternal health has not emerged as a political priority.

Unintended loss of focus on family planning services within the broader ICPD agenda

HIV/AIDS-related expenditure prioritized at the expense of RH

Underlying causes

• Trends in female literacy

• Trends in female empowerment

• The five countries with the lowest female literacy rates (Afghanistan, Niger, Chad, and Mali) all have maternal mortality ratios (MMR) over 800 deaths per 100,000 live births.

• Afghanistan

• Only 13% of women can read, compared to 43% of men

Raise study on ODA 2003 - 6

$20.8 billion disbursed to 18 conflict-affected

countries,

2.4%, was allocated to RH. This translates to $1.30 per capita per year.

1.7% was disbursed to support family planning activities

46.7% to support HIV/AIDS control efforts.

Countdown to 2015

MMR high or very high in 56 of 68 countries

Gaps:

1. contraceptive availability & uptake,

2. skilled birth attendance,

3.management of newborn &childhood

illness

4. equity gap

37

Key Initiatives CEDAW Convention on the Elimination of Discrimination Against

Women ( 1981) Save Motherhood Initiative ( 1987) ICPD Programme of Action of the 1994 International Conference for

Population and Dev. Status of Women Bejing Declaration 1995 Millenium declaration (2000) Partnership for Maternal, Newborn, and Child Health (PMNCH)

(2007) UN Joint Statement on Maternal and Neonatal Health (UN-

MNH/H4) ( 2009) UNHRC 2010 Resolution on maternal health. Musoka Alliance G8 summit Canada (2010) Global Alliance (2010)

CEDAW Convention on the Elimination of Discrimination

National policies ensure equality of men and women, of human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field.

the obligation to eliminate discrimination at all levels of the educational system

Safe Motherhood

All women have access to contraception to avoid unintended pregnancies

All pregnant women have access to skilled care at the time of birth

All those with complications have timely access to quality emergency obstetric care

World Bank, WHO and UNFPA consensus that a majority of maternal deaths and morbidity could have been prevented with access to simple interventions

40

ICPD Programme of Action of the 1994 International Conference for Population & Dev.Status of Women Bejing Declaration 1995

Strong emphasis on womens rights and equity

Female education

Protection for female children

Sexual and reproductive health rights

Family planning and it’s relationship to MMR.

Partnership for Maternal, Newborn, and Child Health (PMNCH)

Evidence based high impact intervention to reduce maternal , child and neonatal mortality

To raise $30 billion to support this over two years

Partnership of governments, NGOs and academic institutes, private and government donors.

UN Joint Statement on Maternal and Neonatal Health (UN-MNH/H4)

WB, UNFPA, UNICEF, and WHO, are working with country governments to ensure that core interventions for addressing maternal and neonatal health are addressed within the national health plans.

World Bank (2009), Implementation of the World Bank’s Strategy for Health, Nutrition and Population (HNP) results: Achievements, Challenges and the Way Forward, Washington DC: World Bank

Manifesto For Motherhood Coalition

2009 UK gov. and global partners signed a global consensus:

Every birth safe, every newborn and child healthy .

Muskoka Initiative

From G8 summit Canada.

Member states commit an additional $5 billion between 2010 and 2015 to accelerate progress toward the achievement of goals 4 and 5.

focussing in the countries with the greatest needs while continuing to support those making progress;

supporting country-led national health policies and plans that are locally supported;

High MMR countries

health system strengthening unmet need for family planning. comprehensive, high impact and integrated interventions at the

community level, across the continuum of care, sexual and reproductive health care and services, including

voluntary family planning; health education; treatment and prevention of diseases including infectious diseases; prevention of mother-to-child transmission of HIV; immunizations; basic nutrition and relevant actions in the field of safe drinking water and sanitation.

Global Alliance

Public Private partnership Gates Foundation, USAID, DFID, AUSAID.

5 year commitment to

Increased family planning

Skilled birth attendance

DFID Framework for Results 2011

save the lives of at least 50,000 women in pregnancy and childbirth and 250,000 newborn babies by 2015 enable at least 10 million more women to use

modern methods of family planning by 2015, contributing to a wider global goal of 100 million prevent more than 5 million unintended

pregnancies support at least 2 million safe deliveries, ensuring

long lasting improvements to maternity services, particularly for the poorest 40%.

Pillar 1 Empower women and girls to make healthy reproductive choices

Pillar 2 Remove barriers that prevent access to services, particularly for the poorest and most at risk.

Pillar 3 Expand the supply of quality services

Pillar 4 Enhance accountability for results at all levels

Political & legal framework

Financial barriers Service coverage Data and information

Girls education Innovative transport & referral

Human resources Accountability between citizens & providers

Economicopportunity

Discrimination.Adolescent friendly

commodities Accountability for quality

Social change Support in emergencies ( conflict natural disaster)

QA International agencies accountable for outcome

Gilrs and womens’ wider action

Diversity of providers

Information

DFID’s Focus

Prioritizing RMNH

Adolescent health focused on pregnancy prev.

EOC services

Family planning

Maternal nutrition

Poverty reduction

What services?

The five core aspects of reproductive and sexual health are:

1. improving antenatal, perinatal, postpartum and newborn care;

2. high-quality services for family planning, including infertility services;

3. eliminating unsafe abortion; 4. combating sexually transmitted infections including

HIV, reproductive tract infections, cervical cancer and other gynaecological morbidities;

5. promoting sexual health.

Services through a Mortality Lens

Antenatal, childbirth and postpartum services attendance at every birth of skilled health personnel and

comprehensive emergency obstetric care to deal with complications effective referral systems PMTCT abortion services at primary health care level. For those women who suffer complications of unsafe

abortion, prompt and humane treatment through post-abortion care

Family planning STI SGBV

A full sexual and reproductive health package

includes:

Family planning/birth spacing services

Antenatal care, skilled attendance at delivery, and postnatal care

Management of obstetric and neonatal complications and emergencies

Prevention of abortion and management of complications resulting from unsafe abortion

Prevention and treatment of reproductive tract infections and sexually transmitted infections including HIV/AIDS

Early diagnosis and treatment for breast and cervical cancer

Promotion, education and support for exclusive breast feeding

Prevention and appropriate treatment of sub-fertility and infertility

Active discouragement of harmful practices such as female genital cutting

Adolescent sexual and reproductive health

Prevention and management of gender-based violence

Source UNPFA

53

CMR

• to reduce by two thirds, between 1990 and 2015, the under-five mortality rate;

• Perinatal mortality

• Neonatal mortality

• Child mortality

Trends

10.8 million deaths worldwide of children under five each year 4 million during the first seven days of the

neonatal period. 2.7 million infants are stillborn. Neonatal mortality rate (death in the first 28

days) in developing countries has remained unchanged since the early 1980s at about 30 deaths per 1000 live births.19 of 68 priority countries on track for MDG 4

Causes of neonatal mortality

Preterm, 25%

Asphyxia, 24%

Tetanus, 6%

Diarrhoea, 4%

Congenital, 6%

Other, 7%

Sepsis/

pneumonia,

28%

Source: Opportunities for Africa’s Newborns, 2006. Based on vital registration for one country and updated modeling using the CHERG neonatal methods for 45 African countries using 2004 birth cohort, deaths and predictor variables.

56

Proven community interventions

Immunization Vit. A + zinc Promotion of breastfeeding and advice on weaning Hygiene promotion Promotion of clean delivery Tx of childhood pneumonia, malaria, diarrhoea Homebased neonatal care IPT malaria for women and infants Iodine supplementation Diagnosis and tx of syphilis PMTCT

DFID MNH interventions

Community based management of neonatal pneumonia Community newborn package TT2 ANC Skilled birth attendance Treatment of pre-eclampsia Emergency neonatal care Steroids for preterm birthManagement of maternal sepsis Antibiotics for premature rupture of membranes PPH management.

Further evidence required

Positive deviance for malnutrition

Prenatal calcium

Neonatal cord care with antiseptic

Neonatal resuscitation

Ice breaker

• Find out who has made the longest journey?

• Who has the best dinner plans?

• Who has the most unusual hobby?

• Find the weirdest thing anyone has eaten?

• Who knows what 'Ephebiphobia ' is a fear of?

12 January 2010

HAITI

Background In 2007 the population of Haiti was 9.7 million. Poorest country in the western hemisphere, Ranks 149/182 on the UNDP Human Development Index

2007. 55% of the population lived in households that were below

the extreme poverty line of US$ 1 per person per day. Annual population growth rate during 1995-2000 was 2.1%. 64% pop. live in the countryside, 21 % in the metropolitan

area of Port-au-Prince , and 15% in other urban areas. Progressive urbanization without corresponding employment and government systems has led to a high level of urban slum, gang culture and management of areas , criminal activity and violence.

The main income in cities is small business, service and manual labour in urban areas and in rural areas agriculture rice and bananas and small business.

A sizable percentage of professionals and qualified technicians contribute to the Haitian diaspora ,

Monthly remittances sent to families in Haiti account for 8.3% of household income.

Water and sanitation are major issues in Haiti, with 45% of the population lacking access to safe water in 2009 and 83% of Haiti’s total population without access to improved sanitation (WHO/CCS).

In 2007, 47% of the population lacked access to basic health care, with the majority of the population seeking care from traditional healers.

An estimated 40% of households experience food insecurity, manifested by low birth weight and nutrient deficiencies.

Adolescents

Adolescents 40% pop is < 15 years old, and only 5% is over 65. Adolescents and youth accounted for 8% of the deaths in the country. HIV/AIDS was the leading cause of death in this age group (5.8% of all certified deaths). Among the 10 leading specific causes of death on this population group were:• assault and homicide, • tuberculosis, • typhoid, • causes related to maternity (35/ 100,000 maternal deaths in the age group 10-24 years in 1999).

The fertility rate in girls aged 15-19 years was 80 per 1,000 in 2000. The prevalence of sexually transmitted infections in adolescent males 15-19 years old was 9.9%. In one survey, 18% of the females and 33% of males stated that they had used a condom in their

last sexual encounter. Violence and sexual abuse are very frequent in this population group (70% of adolescent girls and

women have been exposed to violence of some sort).

Maternal Health The maternal mortality rate in 2000 was 523 per 100,000 live

births, a 15% increase relative to 1995.

Maternal causes of death included problems related to arterial hypertension and eclampsia , as well as complications of labor.

78% pregnant women had prenatal checkups with a health professional in the cities but 40% in rural areas.

Adults (20-59 years): The fertility rate is in decline, estimated at 4.4 children per woman in 2009.

The crude birth rate 33 per 1,000 population

Of all women with a regular partner in 2000, 22% were using a modern method of contraception and 5.8% a traditional method.

HIV AIDS

An estimated 120 000 people in Haiti are living with the virus

47 health centres (7%) providing antiretroviral treatment in Haiti, with over 19 000 undergoing treatment with antiretroviral treatment (ART).

HIV/AIDS infection affects 4.5% of the Haitian population.

Every year there are some 13,000 pregnant women who are HIV-positive,

NUTRITION

Recent surveys found an acute malnutrition rate of 12% and severe malnutrition of 2.5% No studies on PLW.

Prevalence of anaemia is reported high, 30 – 50% in studies in pregnant women and 30% in school age children.

A 1997 study of household and maternal determinants of vitamin A and iron status showed severe stunting in 31% of the sample, and wasting in 4%.

In 2000, the prevalence of exclusive breast-feeding for 0-5 months was 49%.

Health Services

The Ministry of Public Health and Population encompasses 10 national bureaux

4 coordinating units, addressing infectious and communicable diseases, EPI, nutrition, and hospital safety.

49 hospitals 371 health posts, 217 health centres coverage of health services was estimated at only about

40% nationally In 2009, there were >250 additional implementing partners

in the health sector, further challenging health coordination (WHO/CCS).

Hospital and clinical facilities in Port-au-Prince have long been compromised by infrastructural deficiencies, electrical blackouts, water problems, and general impoverishment.

HRH

Haiti, before the earthquake, had the lowest number of health workers per population (2.5/1000 population) and the lowest ratio of nurses to physicians (1 to 1.4) of any country of the Americas. 5.9 doctors/nurses , 6.5 health professionals per 10,000 people.

There are considerable rich-poor discrepancies (especially regarding deliveries in safe settings)

The lack of access in rural as opposed to urban areas is high, including the lack of motorised transport

Community participation in health care is limited

Earthquake!

Stats

230,000 deaths

Population displacement, 3 million

1.6 million in 250 camps in Port au Prince

Grand Goave & Petit Goave

4000 amputees

Destroyed 8 hospital 200 health centres, school of nursing and midwifery.

60% health centres and health posts in affected areas.

One of the three midwifery schools

One nursing school were destroyed.

14% of the health workforce died,

4000 health workers were homeless.

Transport very difficult roads are blocked,

fuel prices high ambulance services are operational but limited and arrival times are long

300 camps in urban areas, not all are covered for basic services.

Communities are managed by urban gangs community involvement is ad hoc.

Rural areas difficult to reach

Humanitarian response

• Strong health and nutrition cluster coordination

• 400+ members mean that coordination is very difficult. Not all members are aware of humanitarian reform.

• 20 field hospitals for surgical and general care

• A number of agencies are providing mobile clinic services but mainly in Port au Prince and no-one knows for how long

The Main PMC Diagram

88

In groups

Goal

Specific objectives

Results

The Minimum Initial Service Package

(MISP)

“All migrants, refugees, asylum

seekers and displaced persons

should receive basic education and

health services”

Impact of conflict on women’s health

Increase maternal deaths– DRC mortality survey (2005) showed maternal

mortality ratio 1,174 per 100,000 live births in eastern Congo vs 811 in western Congo1

Increase in abortionUNFPA estimates that unsafe abortion

contributes between 25 and 50% of maternal deaths in conflict affected settings

Increase in levels of Gender Based Violence, including intimate partner violence

Family planning needs not met

–Unmet need for family planning in IDP camps in northern Uganda is 58%, compared to national average of 40.6%

Data on effect of conflict on HIV are equivocal

–No clear effect of conflict or displacement on HIV prevalence5

MISP

Minimum

Initial

Service

Package

Basic, limited RH

for use in emergency, without site-specific needs assessment

services to be delivered to the population

supplies and activities, coordination and planning

93

Minimum Initial Service Package

Prevent sexual violence and assist

survivors

GOALDecrease mortality,

morbidity and disabilityin crisis affected

populations

Reduce transmission of HIV

Prevent excess maternal and newborn morbidity and

mortality

Plan for integrated comprehensive

RH services

Ensure health cluster/sector

identifies lead RH agency

Service Package

Outreach system for SGBV and obstetric care Clinical care of survivors of SGBV or referral. Standard precautions Safe blood transfusion Condoms Clean delivery kits, skilled delivery. Access to BMONC & EONC services. ANC PNC STI + ARV + PMTCT FP Post abortion care Safe abortion care

IFM RH Principles

CoordinationQuality of careCommunicationCommunity participationTech. and managerial capacityAccountability Human RightsAdvocacy

Coordination

Health Cluster system

RH lead agency

RH Officer.

RH working group

Gender working group

HIV working group

Quality of Care

Service coverage ( facilities, HR, Drugs and Equipment)

Adherence to protocols

Quality info to beneficiaries.

HIS + ANALYSIS

Beneficiary feedback

Communication and Community Participation

• Info on service provision

• Key messages on prevention

• Campaigns

• Client counseling

Technical and Managerial capacity Building Accountability Advocacy

Train

Supervise

Monitor

Evaluate

HIS

HAP

Back to Haiti – Aceh Camp

Urban camps

50,000 people in urban area

Poor housing conditions, crowded, managed by

urban gangs

Exposed areas

Mobile clinic urban areas

Rural villages Petit Goave

Six mobile clinics 12 sites.

Priorities for MISP services.

Urban

Rural areas.

• Community Participation

• Male and female community health workers

• TBAs.

• Womens’ groups

• Youth groups

• Communtiy elders.

• Local NGOs.

Key intervention/s per cause

Bleeding

Infection

Eclampsia

Obstructed labour

Unsafe abortion

Indirect Causes

Oxytocin /misoprostol,mannual compression

Antibiotics Tetanus toxoid

Mag. Sulphate

Partograph CEOMC

Family planning

Iron, ITNs IPTp

113