7/01

1. 7/01

2. Number of maternal deaths in 1995:world estimate (515,000) N=515,000 Source: WHO/UNICEF/UNFPA estimates of Maternal Mortality in 1995, WHO 2001.

3. Proportion of Maternal DeathsBy Direct Cause N=515,000 Source: WHO wall chart “Maternal Health Around the World” WHO, Geneva, 1997.

5. NeonatalPeriod PerinatalPeriod What Can be Done to Improve Maternal/Perinatal Health and Survival? PRE-PREGNANCY PREGNANCY DELIVERY POST NATAL 0 22Weeks 7 Days 28 Days 42Days BIRTH Postpartum/ Newborn Care Preconception Care Antenatal Care Intrapartum Care Nutrition Infection Control Family Planning Safe Delivery EOC EmOC Nutrition Infection Control Danger Signs Identify/Manage Problems Nutrition Infection Control Family Planning Identify/Manage Problems

6. Essential Obstetric Care (EOC), Basic(BEOC) and Emergency Care (EmOC)

7. Successful Models of Safe Motherhood:Features of Service Delivery Configurations

8. MODEL 1: Rural China: MMR 115 (1995) MODEL 2: Malaysia: MMR 50 (1970s) MODEL 3: Malaysia: MMR 43 (1980-90s) MODEL 4: US: MMR 12; Mexico City: MMR 114 (1988)

9. Program/project Examples and MMR

12. Causes of Direct Obstetric Maternal DeathsMexico City, 1988-1989MMR=114 Source: Bobadilla, et al, 1996

13. Preventable Maternal Deaths by Responsible Factor and Health Institutions (%) Mexico City, 1988-1989 Source: Bobadilla, et al, 1996

14. Types of Physician Errors in Preventable DeathsMexico City, 1988-1989 Source: Bobadilla, et al, 1996

15. -------------- 2 ----------- 3 4 Push and Pull of Maternity Care Midwife Model ---------------------------- 1

16. Lessons Learned: Quality of Safe Motherhood Care and Maternal Mortality • Reducing maternal mortality takes time • Many changes are involved, including quality of services • Socioeconomic inputs have been underestimated • No evidence that model 1 can result in MMR<100 • Models 2-4 can achieve MMR<50

17. MotherCare Framework STRATEGIES TO REACH OBJECTIVE(PROCESS) OBJECTIVE (OUTCOME) GOAL (IMPACT) Increased availability and access to services Increased % of pregnant women receiving skilled care during antenatal, delivery and postpartum periods Reduced Maternal & Perinatal Mortality Improved quality of services Improved knowledge & decision-making in community

18. Strategy: Increased availability and access • Indicators: • 1 CEOC + 4 BEOC sites/500,000 pop • % hospitals with C section+ Blood transfusion • % poorest quintile using SBA • Target: Every woman have access to skilled birth attendant • Context specific

19. MotherCare Framework STRATEGIES TO REACH OBJECTIVE(PROCESS) OBJECTIVE (OUTCOME) GOAL (IMPACT) Increased availability and access to services Increased % of pregnant women receiving skilled care during antenatal, delivery and postpartum periods Reduced Maternal & Perinatal Mortality Improved quality of services Improved knowledge & decision-making in community

20. Provider-oriented interventions to improve Quality of Maternal Care: • Clinical skills training • Training in client/provider interaction • Critical self-review or feedback via case review, routine monitoring, criterion-based clinical audit.

21. Options for “Training” to improve maternal care: • In-service training in specific skills; • Pre-service training in specific skills; • Distance education/ programmed self-instruction.

22. Training Objectives: • Common objectives: • Increaseknowledgeof specific subjects; • Develop or increasecompetencefor specific skills; • Less frequently stated objectives: • Maintenance of skills over time; • Routine implementationof newly acquired skills

23. QUESTION TRAINED N=24 BASELINE N=25 Septic abortion 96% 88% Identify probable placenta previa 65% 46% Severe pre-eclampsia in labor 100% 100% Identification of breech 91% 88% Management of prolonged labor 83% 63% Frequency Distribution of Correct Answers in Knowledge Test, MotherCare Guatemala Source: Training Evaluation Report, MotherCare Guatemala, June 1999

24. Quality of Care Skills Assessment1999 Guatemala Bolivia Indonesia Significant P<0.05

25. Absolute (%) Mean Scores in Application of Skills by Training Status, MotherCare Guatemala Source: Training Evaluation Report, MotherCare Guatemala, June 1999

26. Lessons Learned Quality of Care Lesson: Key skills can be improved via in-service competency-based training But, some skills remain weak: • Guatemala: breech; newborn resuscitation; internal bimanual compression; manual removal of the placenta • Bolivia: partograph; bimanual compression

27. Lessons Learned-Quality of Care • Score for skills began low and were still low post-training: Bolivia: trained 57 -74%; untrained 39-52% Guatemala: trained 41-92%; untrained 25-58% • Participation of doctors remains crucial although they are difficult to involve in training • Doctors affect other’s performance (e.g. use of the partograph) • Doctors rotate among different services (Guatemala, Bolivia) • Separate group of doctors covers night shifts (Guatemala) • Staff turnover is high Guatemala: All staff rotate due to personnel shortage Bolivia: Approximately 72% turnover in providers Conclusion: In-service training program is not a substitute for two to three year midwifery training program

28. MotherCare Framework STRATEGIES TO REACH OBJECTIVE(PROCESS) OBJECTIVE (OUTCOME) GOAL (IMPACT) Increased availability and access to services Increased % of pregnant women receiving skilled care during antenatal, delivery and postpartum periods Reduced Maternal & Perinatal Mortality Improved quality of services Improved knowledge & decision-making in community

29. Strategy: Improved knowledge and decision-making • Indicators of coverage (facility registers) • % women with skilled birth attendant (excludes TBA) • C section rate (pop based) • Met Need: • % women with complications being treated at EOC facility

30. Strategy: Improved knowledge and decision-making • Process indicators (pop-based): • % women/men with knowledge of obstetric danger signs • % women who intend to use skilled birth attendant

31. Factors Constraints Potential Interventions “Environmental” (Ecological, Political, Economic) Physical access to services (lack of roads; bad condition of roads) Advocacy; road building; road maintenance Community Maternities Lack of transportation Contracts with available transportation; ambulance service; radio communication Economic Lack of economic resources; lack of time Communal bank; revolving fund; income-generating activities Cultural (Knowledge & Beliefs) Lack of knowledge of “danger signs” Communication/BCI Social (Interactions, Norms) Husbands oppose Communication/BCI Sociocultural/ Organizational Fear of hospital; shame Communication/BCI Training; Hospital Norms Perceptions of quality of care; Actual quality of supplies & care Communication/BCI Training Community Strategies: use of skilled birth attendantConstraints and Interventions--MotherCare Guatemala

32. Baseline Levels of Awareness of Danger Signs Sources: MotherCare & PMM Network, 1996-8

33. Barriers to Improving Recognition • Pregnancy is considered anormalevent in most countries • Some obstetric complications lack distinguishing characteristics along acontinuum between normalcy and emergencythat triggers alarm, and • Beliefsassociated with major obstetric complications in different settings affect the interpretation of theirseverityand the decisions torespond appropriately

34. Questions to Measure Knowledge of Danger Signs • Can you tell me what kind of problems can happen to a woman during labor and during the birth? • Unprompted responses • Have you also heard of these things happening? • Prompted responses

35. Possible Answers • Waters break too early • Bleeds a lot during birth after baby born • She has a fever • Takes too long before she can push the baby out • She faints • She has fits or convulsions • The afterbirth (placenta) does not come out • Baby dies before coming out • Other (specify)

36. Improving Pregnant Women’s Knowledge of DangerSigns through Counseling at Health Centers & Posts, MotherCare Guatemala Source: Patsy Bailey (FHI), 2001

37. Coverage: Guatemala, Bolivia, Indonesia 1995-1999 Guatemala

38. Met Need:Guatemala & Bolivia Guatemala Bolivia

39. Conclusions: Use of Skilled Birth Attendant and Met Need • The pattern of birthing is slow to change when use is low. Structural efforts seem to increase use of skilled birth attendants and met need more than communications efforts (but this could be dependent on base levels). • From the Guatemalan experience, building a referral system with TBAs does not appear as useful as communicating danger signs and where to go directly to women. • However, there is the suggestion that trained TBAs can be more selective in whom they refer.

41. CHINA MODEL 1 MODEL 3 & 4

43. China

44. Maternal-related statistics, Tonghai and Huaning, Yunnan, China 1999

45. Hospital Delivery Rate in Huaning and Tonghai Counties, Yunnan, China Source: County MCH Station, MIS, Tonghai and Huaning County, 1990-1999

46. Policy Guides the Way, China • MMR—to be halved by 2000 • Promotes increased coverage for maternal and child health • Increasing hospital delivery for rural women • Health education for at least 85% of pregnant women • Use of modern delivery method for 95% of births with village doctor (clean perineal area, clean hands, clean cord care)

47. Policy Guides the Way, China • Regulations—National and provincial • Established responsibilities of the MCH institutes • Quality of care standards • Equipment necessary for family delivery • Personnel allowance • Medical aid to the poor

48. China: MCH Network

49. Health Care Infrastructure, Tonghai and Huaning, Yunnan, China 1999

50. Accountability for performance, Tonghai and Huaning, Yunnan, China • Accountability • Contracts based on indicators of performance (preventive/curative) • Systematic Management Rate (SMR) • % systematic management pregnant women (SMPW) = 5 ANC, 3 PNC, 3 cleans + booklet to women • % hospital delivery • decreased MMR • Scores related to employment, promotion, subsidies