INTRODUCTION

1. A Model for Integrating Social Interventions into PHC in order to reduce Maternal and Neonatal Mortality In South Africa Focus: Trace the underlying conditions that expose women to the risk of reproductive ill-health and mortality & the associated neonatal mortality in South Africa. and Recommend solutionsto minimize their vulnerability as a result of their social position.

2. INTRODUCTION • Women still die from pregnancy and child birth challenges - little improvements in maternal health in SA. • MMR increased from 150/100 000lb in 1990 to 154.1/100 000 lb in 2015 (against MDG target 38/100 000 lb)-The official MMR is the major indicator of socio-economic conditions and health care however SA MMR reports only iMMR. • Community maternal deaths, especially rural ones, where more than 55% women resides are excluded • In addition, there has been inconsistent, contradicting reporting of maternal deaths by different sources. • Estimates vary from the MMR of 154/100000 lb to 702/100 000 lb during the reporting period Uncertainties, misunderstandings and disagreements in the estimation of the South African MMR.

3. INTRODUCTION • Neonatal survival chances are directly linked to the maternal health status and outcomes; • NMR continued to be higher than the MDG target of 7/1 000 lbfrom a baseline of 21/1 000 lb. • UNICEF 2015:15/1 000 lb; WHO 2015:19/1 000 lb; The Saving Babies reports (SA) 2010 - 2011: 21/1 000 lb; • Holtz 2017 reported the SA NMR stands at 23/1000 lb. • Like MMR, disagreements in the estimation of the SA NMR. Neonatal deaths account for approximately 40% of all deaths in children under 5.

4. NEONATAL MORTALITY RATES, BY POPULATION GROUP • Table 1: % Distribution of Neonatal Deaths and Perinatal Deaths by Population Group (2014).

5. PROBLEM High MMR – a major public concern in SA • Cumulativeinadequateattention to women’s reproductive health needs resulting in inability to cope with pregnancy and child birth. • Deprivationof women’s social and health needs channeled through many paths until they die from direct causes such as anaemia, hypertensive disorders, infections etc. • Social Norms that subject women to gender-based inequalities both in society and health service delivery points • Potential or actual emotional, physical and sexual violence. • Povertytends to affect Black, rural girls and women by subjecting them to malnutrition, communicable diseases and inadequate health care. ROOTto poor maternal health outcomes – should be found in the socio-cultural factors preventing girls and women from accessing basic needs

6. PROBLEM • Other social determinants of health are closely related to health outcomes: e.g. unequal power relations that women experience in virtually all life circumstances (channelled through class, education, gender, income, occupation, race, and residential location). • Attempts: solutions to complications related to pregnancy and child-birth through narrowly defined quick fix medical technical interventions instead of improving overall WH & RH specifically. • Failure to recognise RH as an organising central concept to delivering integrated RMNCH package along the continuum of care …such care is provided by families and communities and not limited to health facilities

7. THE OBJECTIVES OF THE STUDY Premise of study: Broader approach based on intergrating social interventions into PHC could be a more effective approach to improving reproductive outcomes. Focus: overall women’s health as a priority along the continuum of Female Reproductive Health Care OBJECTIVES were: • To identify and describe the structural determinants, social determinants and direct factors which affect female reproductive morbidity and mortality rates. • Study and analyse different models describing social determinants and direct factors of female reproductive ill-health and mortality and models for reducing it; • Construct an alternative model that links structural determinants, social determinants and direct factors which affect female reproductive morbidity and mortality, and reproductive health outcomes in South Africa; such a model must be context- and needs-based. • Clarify the policy and programme implications of such an alternative model.

8. PROCESS OF DEVELOPING A MODEL ASSUMPTION: Empowerment of women has the potential to improve their social and life circumstances as these impact on their health. Empowerment in this study refers to improving: • Level of education • Employment • Income • Decision making power of women. Informed by available relevant literature: the analytical framework of the social determinants of health by CSDH WHO (2007) was identified and found to be suitable for the study. Framework included women empowerment in relation to maternal and child health at policy- setting level

9. PROCESS OF DEVELOPING A MODEL The analytical framework of the social determinants of health including women empowerment in relation to maternal and child health at a policy-setting as adapted from WHO (2007).

10. KEY POINTS OF THE FRAMEWORK • Socio-economic and political context: produce social stratification • Structural determinants and socio-economic position of women (the social determinants of inequities): define people along hierarchies of power; determine class, prestige and access to resources. • Intermediary determinants/social determinants of health: determines material circumstances such as housing, income, consumption, available food , social environment, behavioral factor, health system which dictates access and differences in exposure and vulnerability. The SDH framework frames health as a social phenomenon and enables approaches that deal with health, risk to health, ill-health and the consequent mortality, from the root

11. PROCESS OF DEVEDLOPING A MODEL • PRIMARY HEALTH CARE (PHC) also studied: In1994, SA adopted PHC as policy guideline: PRINCIPLES • Equity on the basis of need, • Affordable access to needed services, • The sustainability of PHC services, and • Empowerment of people alongside efforts to help them to be more self-determining. • Participation …Constitutes the first element of a continuing health care process ( WHO 1978, quoted in SA DoH 1997).

12. PROCESS OF DEVELOPING A MODEL : PHC and SDH • SA PHC informed by theAlma-Ata PHC model provided health services but also addressed the underlying social, economic and political causes of poor health • PHC seeks to address the range of social determinants of health which incorporate inter-related circumstances of poverty, wealth and income distribution as well as discrimination associated with sexism, gender and powerlessness The PHC, like the SDH model, holds that for people to be healthy, they need: • basic material requisites for a decent life, • to have control over their lives • a political voice and participation in decision-making processes. • SDH fits well with the PHC approach as both are informed by the social model of health

13. PROCESS: STUDY DESIGN; METHODS • Literature included studying relevant models to identify gaps and developing a research design for the study. • Multistage qualitative study design: use of interview guides; purposive sampling (24 research participants); face-to-face individual interviews held. •  Analysis of National Policies- Women’s Reproductive Health Needs • Analytical framework of social determinants of health was used as an appropriate framework and a tool for analysing the relationship between the determinants of health/ill-health, including lack of empowerment of women and risks to reproductive health outcomes at the level of the household, community and society.

14. PROCESS: STUDY DESIGN; METHODS • MULTISTAGE QUALITATIVE INTERVIEWS

15. PROCESS: STUDY DESIGN; METHODS ANALYSIS OF NATIONAL POLICIES ON RH

16. FINDINGS: WOMEN AT RISK Reproductive Health Status of the Women at Risk • Age at first pregnancy: • Mean age at first pregnancy, 19 years. • Birth Intervals, Pregnancy and delivery management; • Four (4) women hospitalised during pregnancies and/or confinements - immediate threats included high blood pressure, anaemia, obstetrical haemorrhage and previous caesarean section

17. FINDINGS: WOMEN AT RISK • Use of contraception • All did not use contraception hence they fell pregnant; thus pregnancies were unintended and mistimed, pointing to unmet need. • However, tended to accept pregnancies • 50% : used contraception before, whereas • 50% : never used contraception.

18. FINDINGS: WOMEN AT RISK • HIV status • 3 - had a known HIV-positive diagnosis • all indicated that they only discovered HIV-positive status during ANC visits for the current pregnancies This points to the possibility that true prevalence of HIV/AIDS in SA is possibly being underestimated as not all people at risk do not go for testing.

19. FINDINGS WOMEN AT RISK • The risk group began their motherhood early in their lives, exposing them to the risk of additional vulnerability associated with poor developmental status, subservient position in society and social exclusion • THUS…inability to secure adequate and quality prenatal and obstetrical services when they needed them • Risk group entered their reproductive years already disadvantaged Early childbearing, their poverty, their static view of life and apparent acceptance of their circumstances all exacerbated their situation

20. FINDINGS: VERBAL AUTOPSIES • Povertyjudged by poor socio-economic background, and • Health system issues such as poor quality and incompetent health staff as the determinants of female reproductive ill- health and mortality

21. FINDINGS:EXPERTS • Poverty • HIV/AIDS a major contributor • Inattention to reproductive health and violation of reproductive rights, • Powerlessness of women, • Absence of policies that should guide action, and non-implementation of the policies that have been developed • Health System issues such as incompetence, bad attitude, and poor interpersonal relationships of health professionals in the reproductive health units, as well as a lack of equipment

22. FINDINGS:NGOS • Gendered and cultural norms: • Socio-political issues: • HIV/AIDS • Poverty: leads to malnutrition, vulnerability inaccessible health services

23. KEY- MESSAGE The Root to persistent reproductive ill-health and premature death of women is structural poverty and unequal distribution of material and health care resources

24. DOCUMENTANALYSIS • Population Policy ( PP) • Maternal, Neonatal, Child and Women’s Health (MNC&WH) • Both policies silent on how, let alone who and when: Socio-economic position of the majority of women such as employment issues, education of the girl child, nutritional status and self-esteem, autonomy and self-determination will be addressed.

25. GAPS IDENTIFIED FROM DOCUMENT ANALYSIS • Access, Community participation; Integration of services, not addressed, • Services are still organised vertically, hence implementation is a challenge • Coordination between departments for addressing the empowerment position of women, is lacking.

26. GAPS IDENTIFIED FROM DOCUMENT ANALYSIS Strategic Plan MNC&WH in South Africa 2010-2015 • Mentions vaguely that high quality care services will be provided in the health delivery units: does not state how. Elements of quality care not defined. • Participation of women: Missing • Emphasis on the curative approach; assuming that it is the individual who become sick, rather than the social, economic and environmental factors which cause illness • top-down approach; focuses on the health systems, health reduced to health care; doctors and nurses assumed to be the providers and the community, the recipient

27. GAPS IDENTIFIED FROM DOCUMENT ANALYSIS Population Policy • Presented in gender-neutral terms; Does not question unequal relations between men and women and latter’s subordinate position as responsible for reproductive outcomes. • Policy silent on Men’s responsibilities in reproductive matters.

28. AN ALTERNATIVE MODEL

29. AN ALTERNATIVE MODEL • Model rests on 3 pillars • Coordinated, multi-sectorial, interdisciplinary and integrated approach • Empowerment and social participation of women • Access to quality health care in cases of pregnancy, delivery and post-natal period in the Primary Health Care centres: Quality care should be defined

30. IMPLEMENTING THE MODEL VISION & GOAL • Vision: Changing the Notion: Mind shift from disease-specific thus curative interventions to the fact that poor RH outcomes are products of social, economic and cultural factors, working through intermediate factors to trigger the direct factors to cause ill health, complications and deaths of women, before, during and after pregnancy • Goal: Reduce poverty and inequality, empower women, propose policy that guides action

31. ADDRESSING THE STRUCTURAL AND INTERMEDIARY DETERMINANTS OF WOMEN’S ILL-HEALTH AND MORTALITY • Reduce structural poverty • Equal distribution of resources and health care, pointing to the need for a broader approach. • Increasing Job Opportunities • Women Empowerment through Inter-sectoral collaboration • Tackling malnutrition

32. ADDRESSING THE DIRECT DETERMINANTS OF REPRODUCTIVE ILL-HEALTH AND MORTALITY AT SERVICE LEVEL • Shifts from curative to preventive services and integration • Strengthening PHC & Health Promotion • National Reproductive Health Team: • Re-conceptualise HIV and AIDS • Ensure accessibility of TOP • Strengthening IEC

33. CONCLUSION • Female Reproductive Health Status is not only affected by biological factors BUT a product of social and cultural factors that are interrelated, suggesting application of social analysis models to address negative reproductive outcomes • The failures and problems in reproduction of human beings are a result of social inequalities from health and social policies which do not complement each other in practice.

34. CONCLUSION • Poverty, remains a single major determinant of poor reproductive outcomes: • To reduce risk to maternal mortality and neonatal deaths, there is a need to: • Reduce the poverty, • Address and improve the living conditions of women and • Meeting the basic needs of women

35. I THANK YOU