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Which interventions should we prioritise?
Where should we focus our efforts along the continuum of care (pre-pregnancy, during pregnancy and birth and after delivery) and why, in order to have an impact on MDG 5 by 2015? What do you think is most important to tackle in order of time priority?
Where appropriate please also indicate to which world region you are referring.
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Our thanks for all the comments submitted. All of the ideas and suggestions put forward will feed into our new policy, helping to shape the direction of our work.
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All are important, but pre-pregnancy is the most important. Meeting the unmet need for family planning, through the provision of services and the associated female education and empowerment programmes, should be the top priority in all development programmes, in order to help women,
families, the economy, and the planet. As UNICEF said: “Family planning could do more good to more people at less cost than any other technology”.
Prevention – family planning services and information – can have an impact at every stage and therefore should be made a priority. Through the promotion of family planning and smaller family size norms, we can improve overall reproductive health, pregnancies, births, and after delivery, because families will be able to make healthful decisions about what is best for them and for their bodies.
According to a United Nations Population Fund (UNFPA) press release from October 2009, world delegates came together to make family planning a priority in terms of improving maternal health:
“The meeting concluded with the adoption of the Addis Call to Urgent Action for Maternal Health that recommended specific steps to reach the goal by 2015, particularly the following key measures:
–Prioritize family planning, one of the most cost-effective development investments. ‘If we ensure access to modern contraception,’ affirmed the delegates, ‘we can prevent up to 40 per cent of maternal deaths.’
– Make adolescents a priority by investing in their health, education and livelihoods; and
– Strengthen health systems with sexual and reproductive health as a priority. If a health system can deliver for women, it is a strong health system that benefits all, according the participants.”
(UNFPA Website, http://www.unfpa.org/public/News/pid/4116)
While access to services is far from perfect and needs a significant investment, changing attitudes and behaviors with regard to family planning is key.
For example, Nigeria, which has some of the world’s worst maternal health indicators, has one of the highest birth rates in the world and a fertility rate of 5.7 children per woman. Ninety-two percent of married women do not use contraceptives and 55% of them say they never intend to (2008 Demographic and Health Survey). On average, the ideal number of children that women desire is 7, and men desire 9. Only 0.2% of Nigerians say they don’t use contraceptives because services are not available, and only 0.2% cite cost as a barrier.
Of all births in Nigeria:
87% were wanted at the time
7% were wanted, but not until later
4% were unwanted
Changing Nigeria’s demographic trends takes more than access to contraceptive services. It requires helping people understand the personal benefits in health and welfare for them and their children of limiting and spacing births. These demographic trends are not just unique to Nigeria, but are trends in most of the countries where maternal health needs to be improved.
Increasing knowledge and changing attitudes and behaviors are also key to creating sustainable change. Doing so also creates a population of people who are able to advocate for themselves and can pass on information to the next generation. It is also critical that these interventions are culturally sensitive and relevant. One of the most impactful behavior change communications approaches is the Sabido methodology for entertainment education, which uses long-running serial dramas on radio and television with characters that evolve into role models for the audience.
One of the advantages of using serial dramas, as opposed to documentaries or single-episode dramas, is that they allow time for the audience to form bonds with the characters and allow characters to evolve in their thinking and behavior with regard to various issues at a gradual and believable pace in response to problems that have been well illustrated in the story line.
Just as important, entertainment programs forge emotional ties to audience members that influence values and behaviors more forcefully than the purely cognitive information provided in documentaries. As described in the social learning theory of Stanford University psychologist Albert Bandura, vicarious learning from others is a powerful teacher of attitudes and behavior. Next to peer and parental role models, role models from the mass media are of particular importance in shaping cultural attitudes and behavior.
Serial dramas to promote reproductive health have been remarkable in that they have attracted no serious opposition in any country. This stems, in part, from the thorough research that has been done prior to the development of the programs to measure audience attitudes and norms with regard to these issues.
Characters for the serial dramas can then be developed who are very much like audience members, so that the show is in harmony with the culture. Through the gradual evolution of characters in response to problems that many in the audience also are facing, serial dramas can show adoption of new, non-traditional behaviors in a way that generates no negative response from the audience.
Because of the bonds that have been formed by this stage between audience members and characters, and because of the commonality of problems between characters and the audience, audience members tend to accept these changes, even though they may challenge cultural traditions. Because they deal with issues that are as sensitive as sexual relationships and reproduction, it is especially important that such programs are designed not to build opposition or cause a backlash.
Population Media Center (www.populationmedia.org) has produced and broadcast Sabido-style programs in 24 countries around the world and demonstrated a significant impact. For example, in Ethiopia, 63% percent of new clients seeking reproductive health services at 48 clinics reported that they were listening to one of PMC’s serial dramas. In Nigeria, PMC’s program “Gugar Goge” was reported as the primary motivation to seek health care services by 33% of family planning/reproductive health clients and 54% of obstetric fistula clients. In Rwanda, 24% of clients seeking help with preventing mother to child transmission of HIV cited the program as their reason for the clinic visit. PMC’s program in Rwanda also had a big impact on desired family size. At the time of the baseline survey the mean desired number of children for all respondents was 3.61 (females 3.73, males 3.44), and this decreased significantly to 2.94 by the endline survey, with both females and males showing similarly significant decreases (females 3.02, males 2.81).
The serialized dramas that PMC is using to improve people’s lives are highly cost-effective because of the huge audiences they attract and the strong impact they have on the public. In Ethiopia, PMC’s first long-running radio serial drama cost just 4 U.S. cents to reach each listener. Cost per listener of a similar program in Tanzania was 3 cents per year. The annual cost per adopter of family planning in Tanzania was 34 cents U.S., while the cost per person who reported that they changed behavior to avoid HIV infection as a result of listening to the serial drama was 8 U.S. cents.
Promoting family planning and smaller family norms through the use of successful behavior change communications programs is critical to improving maternal health and reproductive health worldwide.
I am a Paediatrician who has worked at different levels of care and both public and private sector hospitals very closely. Today there is no dearth of trained people or resources in India but to stregthen the links between private care porviders and government to reduce neonatal mortality which contributes significantly to child mortality in India. I was surprised to note that only having resources and trainined personnel does not always help , newborns dies in front of trained people due to system failures. I am surprised no formal neonatal transport program even a basic road transport have been developed by a large government hospital in Delhi. My calculations indicate that with all the manpower dotors, nurses, equipments, transport arrangements, recurring costs for such a program it should not cost more than a US $ 350000/year. This alone would save at least 1000 newborns/year. This cost is nothing comapred to biliions of dollars diverted to other ineffective programs. First is to develop the neonatal transport system then market it to link various private nursing homes, community hospitals (where most newborn are born or finally reach after being delivered at home)to refer sick newborns via this transport system in case people are not able to afford their services. Affordability should never let a baby die. Pilot project for this is very much feasible and deliverable. I hope someone with authority in India follows the idea simmering in my head from last five years.
DfID should aim to:
• Ensure complete household access to safe sanitation and drinking water;
• Ensure healthcare centres have adequate access to safe sanitation and drinking water for mothers giving birth, in order to secure a hygienic birth environment and keep the newborn baby clean;
• Prioritise the prevention of infections in healthcare centres as well as during homebirths, before, during and within the first days of the newborn’s life – for example by ensuring application of the “six cleans” approach, ensuring access to clean water and soap for improved hygiene of the birth attendant, the mother (before and after the birth) and the baby.
• Include access to safe sanitation and drinking water and hygiene promotion as part of a comprehensive package of interventions to improve maternal health and reduce the risk of haemorrhages:
- to reduce maternal anaemia (linked with worm infestation);
- to improve maternal nutrition (linked with diarrhoea and other gastrointestinal infections);
- to reduce the risks caused by fetching and carrying water before and after childbirth;
- to improve the overall health of women, for example by reducing the risks caused by short stature, associated with under-nutrition, itself strongly linked with access to safe sanitation and drinking water during childhood.
DFID can make a huge difference in improving global maternal health by prioritizing issues such as safe abortion that many donors shy away from. The evidence base supporting provision of safe abortion to protect public health is strong and growing, yet leadership in applying this knowledge is scarce. This is all the more tragic because deaths and injuries from unsafe abortion are completely preventable. When performed according to WHO-recommended standards (using vacuum aspiration or medical abortion techniques), abortion is very safe.
Action to protect women’s health and lives – and to honor their basic human right to self-determination in matters relating to reproduction – is especially needed in Africa, where most countries have very restrictive laws governing abortion and where unsafe abortion takes its greatest toll.
Let us ban abortion altogether. There is no “safe” abortion. The baby almost always dies from it, and where the baby actually survives the abortion, it is usually killed or left to die immediatly afterwards. Teh comes the post-abortion trauma where the mother accuses herself of having killed her child. The huge sums of money spent on abortion should be spent on support of motherhood and child care. This is a personal/universal reply.
1: Access to services
The whole is greater than the sum of the individual parts, and within reproductive and neonatal health the greatest impact occurs where there is an effective system which can be accessed by women as and when they need it. Many of the problems in pregnancy and childbirth can be neither predicted nor prevented, and therefore women need access to a continuum of care – in the community, in a secondary care institution; from family planning services and pre-conception care to the post-natal period. Accessibility involves more than just physical provision of services, and includes addressing the social and financial constraints.
From our members’ experience in Afghanistan, Bangladesh, Malawi and Nigeria (among others) the majority of deaths occur in the rural areas, often because there is very limited access to quality health care. Women in rural areas often delay accessing care because of family pressures, fear of the potentially ruinous financial costs and the general demands of daily living. They are delayed in getting to care facilities by poor transport infrastructure or lack of affordable transport, and often are delayed in getting care on arrival because the health facilities are too thinly stretched, with too many mothers seeking access to too few staff and treatment facilities. Most deaths occur at this last stage.(Trends in maternal mortality: 1990 to 2008 – Estimates developed by WHO, UNICEF, UNFPA and The World Bank (2010) ISBN: 978 92 4 150026 5)
2: Training of professionals
For that reason we would also emphasise the vital importance of high quality training for healthcare professionals and birth attendants. Sometimes training schemes, especially those run by governments, concentrate simply on numbers receiving theoretical instruction and getting a qualification at the end of the course, rather than insuring that those in training gain adequate clinical experience. We also need to invest in strategies to encourage these professionals to stay working in the areas of greatest need. These encouragements include resourcing postgraduate/post-registration training and continuing professional development, salary top-up schemes, etc.
Birth attendants in the local community need to be skilled to recognise normal pregnancy, labour and childbirth and as a result to be able to identify abnormality with an acceptable pathway to deal with such issues as anaemia, malnutrition, infection, ante partum haemorrhage, post partum haemorrhage, slow progress in labour, retained placenta, etc.
CMF would urge DFID to ensure that such training and ongoing support is provided by women who are familiar with, and have a willingness to learn about, local beliefs/ customs and traditional practices. Only from that point can there be mutual respect and an exploration of both traditional and ‘western’ midwifery practices with the potential for integration of the two where possible. This addresses the erroneous concept of ethnocentricity, and allows for mutual respect and flexibility without total abolition of centuries-old traditional practices.
Resources for these skilled birth attendants need to be current, culturally appropriate/acceptable and ongoing, with the provision of clean basic equipment, eg umbilical cord clamps and cutters. A basic method of documentation/record keeping needs to be agreed at a national level – this may not necessarily demand maths or writing skills but will be an understood method of communication.
3: Monitoring
The specific interventions needed to deal with the direct causes of maternal deaths are well documented, eg the crucial importance of the use of magnesium sulphate in eclampsia, and prostaglandins to treat post partum haemorrhage. However, in reality even basic equipment and drugs are often not in fact available in maternity units, although officially they are. Educational programmes are of little use unless change of practice takes place. CMF would urge DFID to ensure on site follow-up monitoring is in place for all medical facilities which receive funding.
4: Addressing female genital mutilation
Female Genital Mutilation is a major cause of morbidity and mortality among girls in North/Central Africa, This is not a religious expectation for any faith, but rather an age old tradition which needs to be challenged by personnel who recognise the rationale behind the practice, and who are able to negotiate with local and national leaders to reach a mutually acceptable conclusion. CMF would encourage DFID to work in particular with faith leaders in this region to address this issue.
5: Treatment and support of women with vesico-vaginal fistulae (VVF)
Another neglected area is that of vesico-vaginal fistulae (VVF) following traumatic child birth (and violent sexual assault), and its subsequent social stigma and isolation for affected women. While the incidence of this condition can be markedly reduced by access to good maternal health services, there still needs to be good care for those affected. We would cite the example of Heal Africa in Kagoma, DRC as a key example of a faith based organisation that has addressed VVF through surgical, social, psychological and spiritual interventions, and had a dramatic impact on the health and wellbeing of women. CMF would encourage DFID to identify and support such initiatives, as they help address some of the social attitudes towards women in many societies as well as addressing the direct physical needs, with a collateral benefit in terms of maternal health.
6: HIV treatment and prevention
Finally, recent research has re-emphasised that a major cause of the higher maternal mortality rates in Southern and Eastern Africa is the incidence of HIV – accounting for 9% of maternal deaths, or 60 deaths per 100,000 live births.( Hogan M C, Foreman K J, Naghavi M et al. Maternal Mortality for 181 Countries 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010:375:1609-23).
CMF urges DFID to put an emphasis on testing all pregnant women for HIV, and where this is not being done – because of the lack of service delivery to rural areas for instance – DFID should support partnerships between faith based organisations, including churches, and government. Further, as testing for HIV is not enough – all HIV +ve women should go onto prophylactic ARVs and women with CD4 counts below 350 should go onto HAART for their own disease – DFID should support community programmes which enable women in rural areas to access comprehensive testing and treatment.
Abortion should be a last resort if and when the life of the mother is in danger, as it leaves a heavy burden of guilt on the mother, which can lead to depression and psychological damage.
It would be better to focus on the education of young people of both genders to delay sexual activity until marriage and to give more support to young couples to take more responsibility as citizens and parents.
“•Safe abortion services and to make the consequences of unsafe abortion more widely known to ensure that abortion is safe, legal and rare”.
Rar is not really what is implied in other parts of this document. The norm for anything that is not prevented by contraception would largely seem to be the truth of the matter. Additionally, the western world would be a very good demonstration that availability of contraception and safe legal abortion do not make abortion rare in the slightest.
In terms of nutrition, DFID should take a comprehensive cross-sectoral approach in its programming when investing in the health of women and children by prioritising:
1. Pregnant and lactating women’s access to adequate and nutritious food, water and health services. Availability and access to adequate and nutritious food and adequate safe water, hygiene and sanitation (WASH) for pregnant and lactating women, and at health facilities. Adequate nutritious food and safe water for drinking, hygiene and sanitation should be comprehensively prioritized as deficiencies in both are prevalent in many developing countries, particularly sub-Saharan Africa and South Asia, the two regions seriously off-track in meeting the millennium development goals in maternal and child health.
2. Supplementation of pregnant and lactating women with micronutrients that have been shown to be most dependent on maternal intake. Anaemia is a big contributor to maternal mortality, the treatment of anaemia through supplementation is therefore a priority.
3. Routine de-worming of pregnant and lactating women should be prioritized and not limited to the under 24 months. Prevention of iron deficiency anaemia by using de-worming will contribute to reducing the mortality of women due to iron deficiency anaemia and maternal mortality as iron deficiency is a risk factor for maternal mortality, adding 115 000 deaths to mortality count.
4. Social protection for women during pregnancy and lactation should be prioritized.
5. Enabling women to breastfeed fully to contribute to reductions in under five mortality and give women an additional choice would also contribute to the woman’s ability to control her fertility. Full breast feeding can contribute to delayed ovulation and help women delay the next pregnancy, a natural family planning method where contraception is unavailable or unacceptable. An enabling environment extends to more than education and advocacy; it involves national policies and employment laws that are enforceable.
6. Primary school education should include health and nutrition education through the lifecycle. This may be the only time that the mothers and fathers of tomorrow learn about what a safe pregnancy is and may have a positive influence on children to apply positive pressure or encourage their parents to seek health care during pregnancy.
7. Ensure women in remote and rural areas have clean take home delivery packs and mosquito nets to take home with them to facilitate a more hygienic birth at home, where health services are not available or women or their families are resistant to centre-based deliveries. Additionally, Traditional Birth Attendants in the community should be trained to recognize emergency obstetric complications and be equipped to deal with basic emergencies and facilitated enabled to refer women for more advanced care. Their role should be officially recognized by the community and health care workers with the aim of improving working relationships with them for the benefit of women.
8. Remove the opportunity costs for women that prevent or minimize their willingness to access care.
Ensuring availability of Skilled Birth Attendants and access to Emengency Obstetric Care should be made the top priority. According to the evaluation of Maternal and Neonatal Programme Efforts Index (MNPI) Bangladesh received a rating of 53 out of 100 for its service capacity to provide Emergency Obstetric Care which was highest among the 49 developing countries. But the irony is that the country received only 3 for uptake of treatment for obstructed labour (MNPI, 1999). Research shows that access to obstetric care remains extremely poor mainly because of absence of services in UHFWC (Union Health & Family Welfare Centre) and high costs involved with transportation, medicine, unofficial payment for birth attendants and other health workers at Upazila Health Centres and District Hospitals. Unfamiliarity with the process of getting in touch with the district hospitals creates a series of difficulties including dependency upon brokers, receiving poor health services in private sectors despite paying more money which prevent women from receiving Emergency Obstetric Care. Besides, existing facilities are not properly utilized due to health professional’s apathy, and/ or negligence towards their duties (Khanum, S. M et.al (2003): Access to Primary Health Care Services of Rural Women in a Bangladesh Village, Joint research project between the University of Rajshahi, Bangladesh and University of Manchester, UK, funded by DFID)
It has been estimated that 350,000 women die each year all over the world resulting from unsafe delivery and complicated pregnancy (Trends in Maternal Mortality : 1990-2008 – estimates developed by WHO, UNICEF, UNFPA and the World Bank (2010) ISBN 978 924 150026 5). A large number of women develop disability caused by pregnancy related complications. All these deaths and disabilities could be prevented if the obstetric services were available.
We support a comprehensive approach to maternal and reproductive health. Among the interventions that are often underlooked but should prioritzed in this effort are:
- Comprehensive Sexuality Education. Full access to this knowledge should be considered a right for adults and youth alike.
- Youth Friendly Services – unless services are geared and directed toward youth, they will not reach the needs of one of the most underserved populations.
- Until we work towards access to safe abortion services, we will not be able to tackle the issue of maternal mortality completely.
A substantial proportion of maternal deaths occur in hospital and access to obstetric surgery and safe anaesthesia and basic critical care are essential to improve maternal and newborn outcomes. Provision of anaesthesia is a key component of safe obstetric and newborn care.
Poor provision of anaesthesia, or inadequate or erratic access, may be a factor in maternal deaths. Poor quality anaesthesia has been highlighted as high risk for patients in developing countries with mortality rates as high as 1 in 133 anaesthetics. Many anaesthesia-related deaths are preventable. In obstetric patients, deaths are often due to unresolved hypoxia or hypovolaemia in women undergoing Caesarean section. The third South African confidential enquiry into maternal deaths 2002-2004 reported anaesthesia to be one of the top four causes of avoidable death.
The anaesthetist is involved in the care of obstetric patients in the provision of safe anaesthesia for Caesarean section or instrumental delivery. Anaesthesia is required to facilitate surgery in the management of life- threatening obstetric conditions including haemorrhage, obstructed labour, ruptured uterus, retained placenta and genital tract trauma.
The role of the anaesthetist frequently extends beyond the operating theatre, where they play an important role in the emergency management of severe pre-eclampsia/eclampsia, in resuscitation, pre operative optimisation and post operative care, pain relief in labour, and in the high dependency care of all seriously ill women. In many settings, the anaesthetist acts as the peri-operative physician leading the medical management of sick obstetric patients.
Providing anaesthesia and basic critical care for essential surgery requires a trained workforce. Safe anaesthesia requires a trained provider (doctor, nurse or clinical officer) with access to equipment, drugs, disposables and essential facilities such as water, electricity, a blood bank and laboratory. The WHO has issued international guidelines for the staffing and equipment to be held in hospitals caring for pregnant women, and both the WHO and World Federation of Societies of Anaesthesiologists (WFSA) have produced guidelines on anaesthetic facilities that should be available. However the reality is that many hospitals are struggling to provide the most basic of these necessities – running water, electricity and oxygen.
Improvements in the safety of childbirth for both mother and baby are needed to improve the drive towards achieving MDG4 and MDG5. Anaesthetists (whether physician or non-physician) play a key role in the management of obstetric patients in hospital. Reducing the risks of poor quality or unavailable anaesthesia requires significant investment in the provision of anaesthesia services.
Members of the International Relations Committee of the Association of Anaesthetists of Great Britain and Ireland have worked with international colleagues to develop the ‘Safer Obstetric Anaesthesia Course’. This includes a ‘train the trainers’ course to develop local faculty. We are seeking funding to introduce this course in sub-Saharan Africa.