23 May 2015 Delivering safer motherhood – sharing the evidence Vincent De Brouwere Institute of...
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Transcript of 23 May 2015 Delivering safer motherhood – sharing the evidence Vincent De Brouwere Institute of...
April 18, 2023
Delivering safer motherhood – sharing the evidenceVincent De Brouwere
Institute of Tropical
Medicine, Antwerp
On behalf of all
Immpact teams
2
Acknowledgements
• The ITM Antwerp Immpact team- Hilde Buttiëns- Bruno Marchal- Yvette Jacob
• Wendy Graham, PI, and Aberdeen team• The Centre Muraz (Burkina Faso), Centre for Family Welfare
(Indonesia), Nogutchi (Ghana) teams who produced the results in collaboration with teams from north institutions (University of Aberdeen, London School of Hygiene and Tropical Medicine, Johns Hopkins, Institute of Tropical Medicine Antwerp)
• Carine Ronsmans (especially for the slides of the Lancet series presentation graciously provided)
• Donors: Bill & Melinda Gates Foundation, DFID, USAID, EU
- Pascale Baraté- Anne Vriens
- Dominique Dubourg
3
The problem of maternal death is large
• A woman dies each minute -- day in, day out
• Maternal mortality is the public health indicator with the greatest gap between rich and poor countries
4
1 in 30,000 die in Sweden compared to 1 in 16 in sub-Saharan Africa
Maternal death in SwedenMaternal deaths in sub-Saharan Africa
Women who survive Maternal deaths in sub-Saharan Africa Maternal death in Sweden
7
Immpact Framework Of Objectives
SUPERGOALMaternal mortality and morbidity reduced
GOALWomen receive timely care which is appropriate, effective and acceptable to their
needs arising from pregnancy, childbirth and the puerperium
PURPOSE Policy makers and programme managers practise evidence-based decision-making
for safe motherhood
OUTPUT 2New evidence of effective
and cost-effective strategies
OUTPUT 3Stronger capacity for
evidence-based decision-making and rigorous outcome evaluation
OUTPUT 1Enhanced methods and tools for measuring & attributing outcomes
8
Output 1: Methods and Tools
•About 30 different tools generated to measure:- Maternal outcomes- Perinatal outcomes- Process - Factors influencing health systems- Outcomes after pregnancy- Economic outcomes- Policy making process- Functionality of health centres
10
Guiding principles for maternal mortality work programme
1. Promote multiple measurement approaches (to increase the armoury of tools)
2. Increase efficiency of data capture (to address in-country capacity constraints & large
sample sizes needed)
3. Improve reliability of data (to promote awareness that quality matters)
4. Focus research and development effort (to build on promising existing tools & innovate)
© Immpact
11
Work programme innovations in phase I
POPULATION BASED ESTIMATES
INSTITUTIONAL ESTIMATES
CAUSE OF DEATH
CAPACITY STRENGTHENING
1. Sampling at service sites (SSS-health facilities; SSS-markets)
2.MADE-IN/MADE-FOR
Rapid Ascertainment Process for Institutional Deaths (RAPID)
Barriers and facilitators to reporting facility and community deaths
Computer algorithm for causes (InterVAM)
E.g. CALpackages
Census workshop
Secondary research:
Familial Technique;
Profiles;
Meta-analytic methods
13
Exploring alternative sampling sites – Burkina Faso
“Sampling at shopping sites”- market places
Proof of principle trial of SSS-M compared to household survey
Market survey was quicker and also cheaper (3US$ compared to 11US$)
© Immpact© Immpact
14
Results from SSS-M compared to alternatives
MM ratio(per 100,00 live birth)
% maternal deaths among all deaths to women of reproductive age
SSS-M (Ouargaye; 2003/04) 397(254 - 540)
26.9%
Immpact census: deaths in household (Ouargaye; 2003/04)
400(343 – 457)
26.4%
Immpact census: direct sisterhood method(Ouargaye part; 2003/04)
332(246 - 418)
18.0%
DHS (National; 1999)
WHO/UNICEF/UNFPA (National, modelled; 2000)
484
1000(630 -1500)
22%
37%
15
Work programme innovations in phase I
POPULATION BASED ESTIMATES
INSTITUTIONAL ESTIMATES
CAUSE OF DEATH
CAPACITY STRENGTHENING
1. Sampling at service sites (SSS-health facilities, SSS-markets);
Rapid Ascertainment Process for Institutional Deaths (RAPID)
Barriers and facilitators to reporting facility and community deaths
Computer algorithm for causes (InterVAM)
E.g. CALpackages
Census workshop
Secondary research:
Profiles;
Meta-analytic methods
2. MADE-IN/ MADE-FOR
Familial Technique;
16
What is MADE-IN/MADE-FOR?
Maternal Death from Informant (MADE-IN)
Village-based informants identify maternal deaths among women of reproductive age
Maternal Death Follow On Review (MADE-FOR)
Follow-up interviews with families confirm cause of death
18
Work programme innovations in phase I
POPULATION BASED ESTIMATES
INSTITUTIONAL ESTIMATES
CAUSE OF DEATH
CAPACITY STRENGTHENING
1. Sampling at service sites (SSS-health facilities, SSS-markets);
2. MADE-IN/ MADE-FOR
Rapid Ascertainment Process for Institutional Deaths (RAPID)
Barriers and facilitators to reporting facility and community deaths
Computer algorithm for causes (InterVAM)
E.g. CALpackages
Census workshop
Secondary research:
Familial Technique;
Profiles;
Meta-analytic methods
19
Computer algorithm for causes (InterVAM)
InterVAMa model for determining pregnancy-related causes of death from verbal autopsies
21
Ghana: Delivery Fee Exemption policy
• 2003: pilot trial in four regions
• 2005: extension to the whole country in public, private-for profit and private not for profit sectors
• Results:- 11% increase of skilled care utilisation- Better access of poor women
• ButBut: erratic funding is a threat to sustainability and credibility of the policy
• Other barriers still remain i.e. geographic, transportation and cultural
22
Quality of care before and after the introduction of the free delivery policy (average score in 2003 and 2005)
Before fee exemptions After fee exemptions
Maximum score: 44
Ghana
23
• Reduction of geographic barriers:
- By 1996: 54.000 village midwives posted in each village
- Immpact 2005: • Urban area well covered• Only 29% of villages covered• Where there is a village
midwife, this halves MMR
Indonesia: Village midwifes
24
Village midwifes efficacious, but…
• Identify on time obstetric complications
• Facilitate the decision to refer early
• Help the family to organise the transfer
• But knowledge, skills and quality of care still insufficient
25
0,0%
2,0%
4,0%
6,0%
8,0%
10,0%
12,0%
14,0%
richest poorest Rural area
C-s
ect
ion
s ra
te
1997 2003
Indonesia: contrasted improvement
Better strategy can be to combine reduction of
geographic and financial barriers to
skilled care
C-Sections
Accouchements professionnels
0%
20%
40%
60%
80%
100%
richest poorestRural area
Pro
po
rtio
n
Of
del
ive
ries
wit
h h
ealt
h
pro
fess
ion
als
1997 2003
Institutional deliveries
Caesarean sections
26
Trends of institutional deliveries
Year
% o
f In
stitu
tio
na
l B
irth
s
2001 2002 2003 2004 2005
01
02
03
04
05
06
07
0
DiapagaOuargaye FCIOuargaye non FCI
30%
Burkina: Community mobilisation
27
Access to life saving interventionsCaesarean rates per 100 births in the two
districts under study
28
OP2: Summary findings
Ghana• Removing financial barriers increased institutional
deliveries but financing must be sustained• Accompanying measures required
Indonesia• Addressing geographic barriers increased skilled
attendance at delivery• Financial barriers remain
Burkina Faso• Community mobilisation increased institutional deliveries• Geographic and financial barriers remain for hospital
care In all settings, quality of care is an issue
29
OP3: Capacity strengthening
• Involvement of country technical partners has improved national research capacities
• Key policymakers and stakeholders must be involved in setting health and research priorities and translating results
30
Capacity-Strengthening Challenges
• Balancing international research and national interests
• Managing the tension between the need for fast results and the need to establish new competencies.
• Balancing short-term need of research with long-term need of partner institutions for sustainability
31
Conclusion
• Direct causes of maternal deaths are avoidable provided there is a functioning health care system and a comprehensive approach of maternal health
• Main challenge is the human resources: competent, available in an appropriate working environment
• This health care system depends on the societal development
- Pressure to get quality care- Functioning logistics- Women’s empowerment- Equity