Picture: Robert Yates / Department for International Development

1. Choice for women: wanted pregnancies, safe birthsPublic consultation on reproductive, maternal and newborn health in the developing world to inform the UK Government’s forthcoming Business Plan Picture: Robert Yates / Department for International Development

2. Our mission • Improving reproductive, maternal and newborn health in the developing world is a major priority for the UK Government. • DFID is developing a new Business Plan, which will determine our contribution towards achieving Millennium Development Goal (MDG) 5 to improve reproductive and maternal health as well as reducing newborn deaths (thereby contributing to MDG 4 to reduce child mortality). • The views and opinions expressed during this consultation exercise will be used by DFID to give us a greater understanding of where we should target our aid interventions. • The new business plan will be published tohttp://www.dfid.gov.uk/choiceforwomen Picture: Storyline / Storyline / Safe Motherhood Programme / Department for International Development

3. Get involved • How to use this presentation: please use this presentation to inform your thinking and structure your discussions - and then send us your responses either online where others can view them or downloading the template provided and emailing a completed version to us. • Duration: the consultation runs until 20 October 2010. • Enquiries: for enquiries about the consultation - please email: choiceforwomen@dfid.gov.uk • How to respond: for more information on the issues and questions, please submit your responses online on DFID’s website http://www.dfid.gov.uk/choiceforwomen. If you have difficulty accessing the internet or a low bandwidth connection, please download and complete the template response document and email it to choiceforwomen@dfid.gov.uk. Alternatively you can post your response to: AIDS and Reproductive Health Team, DFID, 1 Palace Street, London, SW1E 5HE, UK

4. Choice for women – wanted pregnancies • Investing in family planning is one of the most effective development interventions and the most cost effective way to reduce maternal mortality. • 215 million women in the developing world would like to delay or avoid a pregnancy (see map 1 on the next slide), but do not have access to modern family planning methods. Each year there are up to 75 million unintended pregnancies. • Young women’s unmet need for family planning is double that of older women. Adolescent birth rates are high, particularly in Africa (see map 2 on next slide). The youth population of the world is rising, so demand will increase. • Failing to prevent unintended pregnancy leads some women and girls to seek an abortion.Globally, 20 million of these abortions are in unsafe circumstances and result in up to 70,000 maternal deaths each year.

5. Map 1: Unable to choose: Unmet need for family planning source: White Ribbon Alliance, Atlas of Birth, 2010 Uganda (40%) Rwanda (38%) Ethiopia (34%) Ghana (34%)

6. Map 2: Mothers too soon: Adolescent pregnancies source: White Ribbon Alliance, Atlas of Birth, 2010 In Bangladesh, 65 percent of 20- to 24-year-old women were married before the age of 18. (source UNICEF). Adolescent girls and young women are at high risk of contracting sexually transmitted diseases or HIV. In Malawi and Ghana, around one third of girls reported that they were “not willing at all” at their first sexual experience.

7. Choice for women – safe births • More than a third of a million women die due to complications in pregnancy or childbirth each year. • Women and girls in Afghanistan and Sierra Leone have a 1 in 8 chance of dying in childbirth. Se map 3 on the next slide. • The few minutes and hours around childbirth is the time when the risk of death is greatest for both mothers and babies. • More than 3.5 million newborn deaths (more than 40% of deaths in children under 5 years of age) occur in the first month of life – up to 45% of these in the first 24 hours. See map 4 for newborn death rates. • Pregnant girls aged 15-19 are twice as likely to die in pregnancy and childbirth than women in their twenties. Those under 15 are 5 times more likely to die.

8. Map 3 11 countries account for 65% of maternal deaths – including India, Nigeria, Ethiopia, DRC, Afghanistan, Bangladesh, Pakistan, and Tanzania source: White Ribbon Alliance, Atlas of Birth, 2010 The 15 least developed countries that have been affected by conflict during the years 2000 to 2006 have worse indicators than non-conflict affected countries

9. Map 4 source: White Ribbon Alliance, Atlas of Birth, 2010

10. The importance of the continuum of careMost maternal and newborn deaths are preventable if women and babies have access to a functioning “continuum of care” (see below) - quality reproductive and maternal health services before and during pregnancy, during labour and after the birth. Women and girls fail to access the systems at critical points for ensuring that every pregnancy is wanted and that every birth is safe and baby healthy (see figure 1 on following slide). Reproductive, Maternal and Newborn Health Pre pregnancy (adolescent girls and women – and men – of reproductive age) Pregnancy & Birth Newborn Birth to 28 days Child Up to 5 years (infant 1 month to 1 year) CONTINUUM OF CARE Family Planning Safe Ante natal Safe Post-birth Newborn Child Within wider SRHabortion care delivery care care Health The continuum of care through to child health is important. DFID invests significantly in child health in a number of ways – please go to the Consultation website for more information.

11. Figure 1: Important gaps in coverage of key services for women and girls – the example of Tanzania Source: Wendy J Graham & Ann E Fitzmaurice, Immpact, University of Aberdeen Data sources: Countdown to 2015 (2008) Report; Tanzania DHS 2004-05 All women: 68 Priority countries 100 80 60 40 20 0 X X X X ANC Skilled birth attendant DTP3 (child) Contraception % uptake x x x x x x x Tanzania: all women x x x x x Tanzania: poorest women

12. Question 1. What should we aim to achieve? We want to improve women’s control of their reproductive lives and to save mothers’ and newborn lives. What should we be trying to achieve? Things you might like to consider include: • Reduce the unmet need for family planning • Reduce the number of unsafe abortions • Reduce the adolescent fertility rate • Increase the number of births attended by skilled birth attendants • Increasing newborn survival • Increase the availability of prevention of mother-to-child transmission (PMTCT) services • Improve maternal nutrition • Reduce the prevalence of malaria in pregnancy • Do you have any other ideas to share with us? Picture: ALAFA / Franco Esposito

13. Question 2. Which interventions, or combination of interventions, should we prioritise to have the most impact? Things you might like to consider include: • Comprehensive family planning • Better safe abortion services • Antenatal and post natal care services • Skilled birth attendance • Maternal nutrition interventions before and during pregnancy • Emergency obstetric care • Newborn care • Exclusive breastfeeding • Prevention and treatment of malaria for pregnant women • PMTCT services, at and after birth • HIV prevention with sexual and reproductive health services • Stronger health services to deliver quality services along the continuum of care • Do you have any other ideas to share with us? Picture: Storyline / Storyline / Safe Motherhood Programme / Department for International Development

14. Question 3. Where should we work? • Although family planning is a cost-effective intervention and provides good value for money, progress in meeting the unmet need for modern and effective family planning methods has been slow, especially in Africa and Asia where the unmet need is greatest. • The difference in the lifetime risk of maternal mortality between developed and developing nations is the largest of any health indicator. The chances of dying from maternal causes over a woman’s lifetime is 1 in 7 in Niger compared to 1 in 8,200 in the UK. • There are also substantial differences between and within developing countries in the ability of women to access quality care at the time of birth. The poorest women in all countries are those least likely to have skilled attendance at delivery. Should we prioritise where we work on the basis of: • The countries with lowest contraceptive prevalence rates? The countries with the highest unmet need for family planning? • Those with the highest absolute numbers of maternal deaths? Or those where the lifetime risk of maternal death is greatest? • Those with the greatest inequity in access to services between rich and poor? • Those countries classified as fragile states? • A combination of all of the above? By some other criteria?

15. Question 4: What are the most important approaches we should consider to tackle inequalities in reproductive, maternal and newborn health? There are huge and persistent inequalities in reproductive, maternal and newborn health outcomes between different socio-economic groups, different geographical areas, different ages and marginalised groups such as those living with HIV. What inequalities are most important to tackle, and how? You might want to consider: • Cash transfers and other mechanisms (like vouchers) to remove financial barriers faced by the poorest and offer choice where relevant. • Innovative and community based solutions, like transport for women in need of referral. • Making services women and girl friendly. • Better and more transparent data to track if results benefit the poorest • Other suggestions? (source: Countdown, 2010)

16. Question 5. How can we improve the realisation of women’s rights and women’s and girls’ empowerment? • Women’s lack of control over their own sexuality and fertility and their poor access to reproductive, maternal and newborn health services is closely linked to a general lack of respect for women’s rights, including their right to health. Which actions should we prioritise to address this? Options you might like to consider include: • Political commitment to girls’ and women’s health at all levels • Girls’ education, including post-primary • Women’s economic empowerment (income and employment opportunities) • Legal frameworks for girls’ and women’s rights • Reducing violence against girls and women • Girls’ and women’s participation and organisation for their own and their babies’ health • Social change (social norms, attitudes and practices that drive girls’ and women’s control over resources and own body) • Other suggestions

17. Question 6:Which neglected and sensitive issues should we prioritise in our work? • Pregnancy among adolescents aged 15-19 years of age has fallen since 1990 in all developing regions, but progress is slow. • About 19% of pregnancies globally end in induced abortion; unsafe abortion accounts for 13% of all maternal deaths. 70,000 women die as a result of unsafe abortion every year; many more are permanently injured. Lowering abortion-related maternal death is a key way to reduce maternal mortality given that nearly all maternal deaths from unsafe abortion are preventable. • In some societies, a strong preference for sons leads to sex-selected abortions and infanticides. In 2005, UNFPA estimated some 60 million missing girls in Asia. • Violence against women by a partner is a global public health problem and a human rights violation directly linked to women’s lack of status and power. • Female genital mutilation/cutting (FGM/C) is a human rights and a health issue for both mothers and babies. Complications in deliveries are significantly more likely among women with female genital mutilation/cutting • Obstetric fistula is a hole that occurs as a result of prolonged and obstructed labour. It is an injury that leaves women and girls leaking urine or faeces from the vagina, usually uncontrollably. WHO estimates that more than two million women are living with fistula in developing countries.

18. Which neglected and sensitive issues should we prioritise in our work? Options you might want to consider include: • Improving adolescents’ sexual and reproductive health and rights • Delaying age at first pregnancy • Improving access to safe abortion services • Infanticide of girl children • Reducing violence against girls and women • Addressing female genital mutilation/cutting • Addressing obstetric fistula • Any others?

19. Question 7. How can we deliver better results through multilateral aid? DFID currently supports work to improve reproductive, maternal and newborn heath in the developing world through the following multilateral organisations: • European Commission (EC) • United Nations Population Fund (UNFPA) • United Nations Children’s Fund (UNICEF) • The Joint United Nations Programme on HIV/AIDS (UNAIDS) • World Bank • World Health Organization (WHO) • Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) • UNITAID How can we deliver better results through multilateral aid? Who should we work with to improve reproductive, maternal and newborn health? Picture: Robert Yates / Department for International Development

20. Question 8. How should we work with private and other non-state actors more to deliver successful reproductive, maternal and newborn health outcomes? • The vast majority of DFID funding for health is currently channelled to public sector health services. The case for the public sector role in health is clear: the state needs to be involved in order to protect the public, avoid excessive costs and reach the poor. • Non-state actors include private for-profit companies and a wider range of informal for-profit healthcare providers, such as non-governmental, faith-based and community-based organisations. • We recognise the role of the private sector in health, for example in the provision of commodities and services. • Civil society organisations play an important role in increasing equity, empowerment and accountability in health.

21. Question 9. What are optimal models of service delivery for delivering reproductive, maternal and newborn health outcomes? • What can we learn from experience in delivering reproductive, maternal and newborn health outcomes around the world?

22. Question 10. How should we work in fragile and conflict affected states and humanitarian situations? Should reproductive, maternal and newborn health be included as part of the response to rapid onset emergencies? • You might like to consider • Working bilaterally to strengthen national health systems if possible and as appropriate in fragile states • Working through non-state actors to deliver reproductive, maternal and newborn health services, information and supplies • Work through multilateral channels to deliver improved reproductive, maternal and newborn health outcomes • Strengthening the humanitarian cluster system to deliver coordinated reproductive, maternal and newborn health services • Include reproductive, maternal and newborn health as part of a response to rapid onset emergencies • Are there other ways in which we could be working? Picture: Russell Watkins / Department for International Development

23. Question 11: What should we support in terms of knowledge, research and innovation? What are the key gaps in the global knowledge about how to improve reproductive, maternal and newborn health, and which should we seek to fill? How can we ensure existing research is used? You might want to consider: • Continue to provide funding for high quality research to improve reproductive, maternal and newborn health programmes, along with implementation or operational research to ensure findings are effectively translated into front-line programmes • Invest in data and information systems for registering births and deaths and for tracking results in developing countries • Support innovation and development of reproductive health commodities, including family planning methods • Improve the way that research findings are used and translated into policy and practice • Other suggestions?

24. Question 12. If we could do only one thing to improve reproductive, maternal and newborn health outcomes, what should it be and why?

25. Thank you for contributing

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