Overview: Maternal and Child Health in Resource Poor Settings or: The World is Not Flat HSERV/GH 544...
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Transcript of Overview: Maternal and Child Health in Resource Poor Settings or: The World is Not Flat HSERV/GH 544...
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Overview: Maternal and Child Health in Resource Poor
Settings
or: The World is Not Flat
HSERV/GH 544Winter Term 2012
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Session Objectives
• Define key terms used to describe MCH problems globally
• Provide an overview of where maternal and child deaths are occurring and trends over time
• Present an overview of underlying causes for limited improvements in maternal and child health
• Present an overview of direct medical causes of maternal and child deaths and introduce strategies to reduce mortality
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Why focus on MCH?
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MCH terms / indicators
Definitions, Child:
NMR = Neonatal mortality rate (deaths in 1st 28 days of life/1000 live births)
IMR = Infant mortality rate (deaths 0-11 months/1000 live births)
U5MR = Under 5 mortality rate (aka CMR=child mortality rate) (deaths 0-4 years/1000 live births)
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MCH terms / indicators
Definitions, Maternal:Maternal death = Death of a woman while pregnant or up
to 42 days after pregnancy from any cause except for accidental or incidental causes
MMR = Maternal mortality ratio = pregnancy-related deaths per 100,000 births
LTR = Lifetime risk of dying of a pregnancy-related cause (usually expressed in terms of odds, e.g. 1/74 = for every 74 women, 1 will die of maternal causes)
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LTR Maternal Mortality, 2008
Source: Trends in Maternal Mortality 1990-2008. WHO, UNICEF, UNFPA and The World Bank.
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MCH terms / indicators
Definitions (continued):
CBA = Child-bearing age = generally 15-49 years of age
TFR=Total fertility rate (expected pregnancies per woman CBA)
CPR=Contraceptive prevalence rate = proportion of married* women of CBA using contraception
*entered into sexual union
Interventions = “biologic agent or action intended to reduce morbidity or mortality”– Prevention or Treatment
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MCH terms / indicators
Common abbreviations
ANC = Antenatal care (variously defined)
HCW = Health care workers
SBA = Skilled Birth Attendant (doctor, nurse or midwife)
TBA = Traditional Birth Attendant
CHW = Community Health Worker
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MCH terms / indicators
Terms related to economics and equity
GNI PC=Per capita gross national income
Ratio of richest 20% to poorest 20% -- Measure of equity/inequity in health indicators and intervention coverage
Measure of equity/inequity in health indicators and intervention coverage using Wealth quintiles
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Millennium Development Goals
• MDG4: Reduce U5MR by two thirds• MDG5: Reduce MMR by three quarters
Between 1990-2015
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Trends in Child Mortality: Not on Track to Meet MDG4
Based on data from the Interagency Group for Child Mortality Estimates
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Are MDG 4 & 5 realistic / attainable?
• Majority of maternal and child deaths are preventable with interventions that are already available and currently recommended for wide scale implementation.
• Despite worldwide failure to meet MDG 4 & 5 without massive acceleration, a few countries are demonstrating that it can be done.
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Where do the maternal deaths occur?
.
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Where do the child deaths occur?
Source: Levels & Trends in Child Mortality. UN Inter-agency Group for Child Mortality Estimation. 2011
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Where do the child deaths occur?
Source: Levels & Trends in Child Mortality. UN Inter-agency Group for Child Mortality Estimation. 2011
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MMR # Maternal LTR AnnualDeaths Maternal MMR
Death ReductionBolivia 180 470 150 -5.8 on trackPeru 98 600 370 -5.2 +progressGhana 350 2600 66 -3.3 +progressKenya 530 7900 38 1.8 no progressSudan 750 9700 32 -0.5 insuff progIndia 230 63000 140 -4.9 +progressTimor-Leste 370 160 44 -3.2 +progressUSA 24 1000 2100 3.7Sweden 7 5 11,400 -1.6
Inequities Within Regions
Source: Trends in Maternal Mortality: 1990 to 2008, WHO, UNICEF, UNFPA and The World Bank. 2010.
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Inequities Within Countries
Source: Skolink. Global Health 101.
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Progress in Reducing Maternal and Child Deaths is also Unequal
MMR (per 100,000 live births), 1990 to 2008
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Reducing MMR:Much Variation Between Countries
Source: Hogan et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–23
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Source: Levels & Trends in Child Mortality. UN Inter-agency Group for Child Mortality Estimation. 2011
Reducing U5MR: Not all Countries are Equal
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What Drives Inequities Across and Within Countries?
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Determinants
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Socio-political-economic factors and policies
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MMR GNI PC Annual MDG5(USD) MMR
Reduction Bolivia 180 4640 -5.8 on trackPeru 98 8930 -5.2 +progressGhana 350 1660 -3.3 +progressKenya 530 1680 1.8 no progressSudan 750 2030 -0.5 insuff progIndia 230 3550 -4.9 +progressTimor-Leste 370 3600 -3.2 +progressUSA 24 47360 3.7Sweden 7 39730 -1.6
GNI PC and MMR / MMR Reduction
Source: Trends in Maternal Mortality: 1990 to 2008, WHO, UNICEF, UNFPA and The World Bank. 2010.
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GNI PC and MMR
Source: Markle. Understanding Global Health.
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Economic growth and U5MR
Source: Save the Children
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Race / Ethnicity and Child Health
•Burden of low birth weight in US – highest among low income and populations of color
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Child Mortality:↑2x poverty, ↑2x rural, ↑3x lack
maternal education
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Poverty and Child Mortality
• In 18 of 26 developing countries with substantive declines in U5MR, inequality in U5MR between the poorest 20% and the richest 20% either stayed the same or increased.
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Percent of women who have a final say in decision making regarding their own health
Source: WHO Report on the Social Determinants of Health
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Access to Care: SBA
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Equity and Access to Care: SBA
Source: 2005 World Health Report. WHO.
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Equity and Access to Care: Malaria Interventions
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Fall in the standardized death rate per 100,000 population for nine common
infectious diseases in relation to specific medical measures for the United States, 1900-1973 (Source: McKinlay , J. B., & McKinlay, S. M. (1977). The questionable contribution of medical measures to the decline of mortality in the United States in the twentieth century. Milbank Memorial Fund Quarterly. Health and Society, 55 (3), 405-428.)
But remember -- technology is not the only answer….
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Maternal Health Problems
• ~200 million pregnancies / year
• ~75 million unwanted pregnancies
• ~20 million unsafe abortions
• ~350,000 maternal deaths
• 1 maternal death = 20 maternal morbidities
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What are the medical causes of maternal deaths?
Most causes can be prevented with treatment by SBA in facilities
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Current approaches to reducing maternal mortality
• Antenatal care
• Improving skills of birth attendants– Traditional birth attendants (TBAs)– Skilled professional attendant at delivery
(SBAs)
• Emergency Obstetric Care (EmOC)
• Postpartum care
• Family planning
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Why do so many women lack skilled birth care?
1. Delay in decision to seek care– Lack of understanding of complications– Acceptance of maternal death– Low status of women– Socio-cultural barriers to seeking care
2. Delay in reaching care– Geography (mountains, islands, rivers) – no realistic access– Poor transport & organization
3. Delay in receiving quality care– Shortages of supplies, personnel, transport to higher facility– Poorly trained personnel with punitive attitude– Finances
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Child Health Problems
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7.6 Million Child Deaths in 2008:Equivalent to a tsunami every few days
Undernutrition = underlying cause >1/3 of deaths
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Two-thirds of child deaths can be averted with interventions that are
already available and recommended for wide scale coverage.
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However…Poor progress in increasing coverage of many basic interventions
Data from African countries. Reproduced from UNICEF ChildInfo website: http://www.childinfo.org/pneumonia_progress.phpand based on UNICEF global databases, 2009.
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Summary
• Maternal health problems are often not predictable and may require facility based medical interventions
• Many common child health problems can be dealt with via community-based public health strategies
• Newborn health problems require a mixture of the two approaches
Photo: WHO/C Black
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Summary
• Aggregate statistics (e.g. national MMR or U5MR) are insufficient
• Strategies needed to reach most vulnerable populations with interventions
• Necessary to impact determinants and socio-political-economic policies that drive health in order to make deeper and long-lasting impact on MCH