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How can we reduce avoidable deaths of mothers and babies?

UPecon-Health Policy Development Program4 May 2016

HPDP is a five-year United States Agency for International Development (USAID) health policy project (Cooperative Agreement No. AID-492-A-12-00016) implemented by the UPecon Foundation, Inc. It supports the DOH-led policy formulation process for scaling up Universal Health Care.

The UPecon-HPDP Health Sector Review research team is led by the following (in alphabetical order): Alejandro Herrin (UPSE Professorial Lecturer), Aleli Kraft (UPSE Professor), Carlo Panelo (UPM Professor), Rebecca Ramos, Orville Solon (UPSE Dean and Professor) and Carlos Tan. The following resource persons (in alphabetical order) were also consulted in the drafting of the HSR: Oscar Abadu, Gloria Balboa, Eduardo Banzon, Ruben John Basa, Vicente Belizario Jr., Esperanza Cabral, Joseph Capuno, Antonio Dans, Ernesto Domingo, Rhais Gamboa, Teodoro Herbosa, Jaime Lagahid, Mary Ann Lansang, Ella Naliponguit, Enrique Ona, Teodoro Padilla, Stella Quimbo, Mianne Silvestre, and Francisco Soria.

This document is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the sole responsibility of UPecon-HPDP and do not necessarily reflect the views of UPecon Foundation, Inc., USAID or the United States Government.

How can we reduce avoidable deaths of mothers and babies?

UPecon-Health Policy Development Program

PHAP and AIM Colloquium “Health for Juan and Juana: Moving Forward with the Philippine Health Agenda”

Makati City, 04 May 2016

Outline of the presentation1. What are the trends and causes of maternal and neonatal deaths?2. What are indicative interventions to address maternal and neonatal

deaths?3. What are the challenges in addressing maternal and neonatal

deaths?4. What is the cost of indicative interventions to reduce maternal and

neonatal deaths?5. What might be a viable approach to implementation?

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MMR from the survey, Civil Registry, and the DOH

Civil Registry

DOH

DHS DHS

DHSFPS

FHSNNS

Maternal mortality ratios have failed to decline in the last 30 years

Sources: NDHS 1986, 1993, 1998; FPS 2006; FHS 2011; NNS 2015; Civil Registry (PSA); DOH administrative data (FHSIS)

Infant death rates declined in the 80s but have remained flat thereafter; neonatal death rates have similarly been flat in the last ten years

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Infant and Neonatal Mortality Rate ('000 live birth)

IMR (PSA)

NMR (PSA)

IMR (Survey)

Sources: NDHS 1986, 1993, 1998; FHS 2011; NNS 2015; Civil Registry (PSA)

Up to two-thirds of maternal deaths are avoidable

Data source: 2012 PSA Vital Statistics

% of All Deaths(n=1447)

Under 20(n=128)

20 - 24(n=255)

25 - 29(n=247)

30 - 34(n=299)

35 - 39(n=321)

40 above(n=197)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

35% 39% 35% 36% 33% 35% 33%

35% 28%31% 32% 35% 38% 40%

5% 6% 6% 5% 6%4% 4%

26% 27% 29% 28% 25% 23% 23%

AGE-SPECIFIC CAUSES OF MATERNAL DEATHS (2012)

Gestational HPN, Pre-eclampsia, and Eclampsia Hemorrhage (Antepartum, Intrapartum, and Postpartum)Indirect Causes Others

Up to three-fourths of neonatal deaths are avoidable

Data source: 2012 PSA Vital Statistics

All neonatal(n=12759)

Early neonatal(n=9898)

Late neonatal(n=2861)

0%

10%

20%

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100%

31% 26%

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31% 37%

13%

15% 17%7%

22% 20%30%

Causes of neonatal deaths, 2012

Infections Disorders Primarily Associated with Birth Weight and Gestational Age Disorders Primarily Associated with Intrapartum Event Others

Maternal and neonatal deaths can be avoided by delivering interventions in a continuum of care

LIFE-STAGE MATERNAL Interventions NEONATAL Interventions

Pre-pregnancy

Modern family planning

Pregnancy Antenatal Care, including screening and management of co-morbidities (e.g. hypertension and Infections) Birth PlanningFolic acid supplementation

Labor and Delivery

Clean and Safe Delivery, including CSCorticosteroids for preterm deliveryPartograph

Essential Intrapartum and Newborn Care (EINC)

Postpartum/Postnatal

Postpartum care and management of complications (e.g. hemorrhage)Postpartum family planning

Postnatal care, including management of complications (e.g. infections)

System intervention e.g. emergency transportation and communication

Maternal and neonatal careFamily planning

Reduction of avoidable

maternal and neonatal deaths

Use of modern FP reduces unintended pregnancies

If no reduction in UMFP

-20% UMFP -50% UMFP -70% UMFP No UMFP -

0.50

1.00

1.50

2.00 0.16 0.39

0.55 0.79

Scenarios on reducing unmet need for modern FP and avoided unintended pregnancies

Home RHU & other public Govt HospitalPrivate clinic/hosp Other Private Avoided unintended preg.

Del

iver

ies i

n a

year

(in

mill

ion,

201

6 es

t)

*Source of basic data NDHS, 2013

Good maternal and neonatal services can avert avoidable deaths• Improved quality of pre-pregnancy,

antenatal, intrapartum, and postpartum interventions could avert 71 percent of neonatal deaths, and 54 percent of maternal deaths per year (Bhutta, 2014).

• Intrapartum labor surveillance (including the use of partograph) can reduce neonatal deaths by 40 percent (Darmstadt, 2005).

• Among low- birthweight infants, kangaroo mother care can reduce neonatal mortality by 40 percent, hypothermia by 66 percent, and nosocomial infection by 55 percent (Black, 2016).

Potential impact of intervention packages

Doris Chou et al. BMJ 2015;351:bmj.h4255

Challenges

More than 20% of women have unmet need for modern FP and are at risk of having unintended pregnancies

All(N=27.13M)

15-19(n=5.31M)

20-29(n=8.7M)

30 or up(n=13.12M)

0102030405060708090

100

9 515 6

141

7 23

Unmet need for modern FP by current age of WRA (in %)

Unmet need: Spacing/Delaying Unmet need: Limiting Using to space/delay Using to limitWants to have a child/not sexually active

Data source: NDHS 2013; N=2016 Est counts of WRA

Up to a third of women deliver at home where interventions to avoid maternal and neonatal deaths are not available

All(N=2.2M)

Poorest(n=0.57M)

Poor(0.51M)

Middle(n=.45M)

Rich(.40M)

Richest(.29M)

0102030405060708090

100

28

5334

21 12 4

Place of delivery (in %)

Home RHU & other public Govt Hospital Private clinic/hosp Other Private

Data source: NDHS 2013; N=2016 Est counts of WRA

At least a third of patients in RHUs experienced potentially harmful delivery practices

Provincial Hospital District Hospital City Hospitals RHUs with birthing facility

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Fundal pressure EpisiotomyBathing of newborn within 6 hours of birth

Data source: UPecon-HPDP 2015 KPOM surveyData from public facilities only.

Only 22% of district hospitals can perform C-section, and less than 70% can provide blood transfusion

Provincial hospital District hospital City hospital Private hospital*0%

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100%

Performs CS Performs Blood transfusionData source: UPecon-HPDP 2015 KPOM surveyData for blood transfusion from public facilities only.

Only a fourth of private lying-in clinics have drugs for pre-eclampsia

Drugs/ Supplies AllFacilities (%)

PublicFacilities (%)

PrivateFacilities (%)

Oxytocin 94 86 95

Vitamin K 94 100 94

IV fluid 93 100 92

Magnesium sulfate 29 57 26

Source. UPecon-HPDP. 2014. Quality Assurance at Birthing Facilities: The Q@B Project Final Report

The cost of indicative interventions to reduce maternal and neonatal deaths

The financing gap to provide the package for the poor is P6 billion per yearSources. Philhealth, DOH, BLGF

Amount in billion pesosTotal Requirement 32

Maternal and Neonatal Care 30 FP services 2Available Financing 26

Philhealth 11DOH 3LGU 12

Financing Gap (6)

An approach to implementation – the case of Davao del Sur

*Digos City

*Davao City

The challenges in Davao del Sur• Number of poor women

with UMFP = 20,000

• Number of poor women delivering at home = 6,000

• Unserved families (mainly NHTS poor) are all over the province

• Facilities and providers capable of delivering the package are in Davao City and Digos

*Davao City

*Digos City

Identify, locate, and profile beneficiaries using the CCT platform

• Start with DSWD list• Engage ML/PL (in

addition to BHW) during FDS

• Identify the women with UMFP or pregnant

• Assist in developing health use plans for FP or FBD

• Assess and inform families of their Philhealth membership

Digos City

Davao CityLocate and assess providers vis FP and FBD services

• Determine what services are offered

• Determine load and which facilities can absorb additional cases

• Check Philhealth accreditation and participation

• Assess willingness and capability to provide services at no balance billing

Digos City

Davao CityMatch beneficiaries with providers• Inform families where

to avail of specific FP and FBD services

• Inform providers to expect visits from specific families

• Mobilize PLs and BHWs to navigate for families

Davao City

Digos City

Support innovations that address demand/supply gaps

o Emergency transportation and communication networks

Davao City

Digos City

Support innovations that address demand/supply gaps

o Emergency transportation and communication networks

o Halfway homes for expectant women

Medical Center Of Digos Cooperative Hospital, Inc. Baron Yee Hospital

Davao City

Digos City

Support innovations that address demand/supply gaps

o Emergency transportation and communication networks

o Halfway homes for expectant women

o Engage private providers outside the province

Sarangani RHU

Davao City

Digos City

General Santos City Hospital

Support innovations that address demand/supply gaps

o Emergency transportation and communication networks

o Halfway homes for expectant women

o Engage private providers to fill in service gaps

o Engage providers outside the province

Medical Center Of Digos Cooperative Hospital, Inc. Baron Yee Hospital

Davao City

Digos City

Support innovations that address demand/supply gaps

o Emergency transportation and communication networks

o Halfway homes for expectant women

o Engage providers outside the province

o Engage private providers to fill in service gaps

o Use Philhealth revenue retention to attract specialists

Provider

Monthly revenues from Philhealth (Php)

2005 2011 2012

MD 3,000 12,000 – 180,000

64,000-280,000

Non-MD 1,000 2,400 2,700

*Davao City

*Digos City

Monitor use of services • Using health use

plans • Direct feedback

during FDS

This combination of interventions improved use of FP and FBD services among poor women

PQBLD area Pangasinan* Quezon City* Batangas Leyte Davao Sur0

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Unmet need among in-union

Before using the CCT platform After using the CCT platform

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n FP

(in

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PQBLD Pangasinan Quezon City Batangas Leyte Davao Sur0

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FBD

Before using the CCT platform After using the CCT platforminterventions interventions interventions interventions

Unmet need for modern FP

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Outline of full Health Sector Review1. Introduction: Objectives and Timeframe of Analysis2. Background: Population, Health and the Economy3. Analysis: Financing, Service Delivery and Governance4. Analysis: Selected Health Concerns – maternal and neonatal

mortality, tuberculosis, HIV/AIDS, non-communicable diseases, and injuries

5. Integrated reforms in financing, service delivery and governance6. Reform implementation, organization and next steps