Post on 27-Dec-2015
7/01
Organizing Delivery Care for a Safer Motherhood
Marge Koblinsky Director, NGO Networks for HealthNovember 5, 2001
Lessons Learned
Source: WHO/UNICEF/UNFPA estimates of Maternal Mortality in 1995, WHO 2001.Number of maternal deaths in 1995:world estimate (515,000)N=515,000
Chart5
0.5
0.42
0.04
0.01
Chart4
0.5
0.42
0.04
0.01
Sheet1
Africa (273,000)50%
Asia (217,000)42%
Latin America and Caribbean (22,000)4%
More Developed Countries (2,800)1%
Sheet1
0
0
0
0
Sheet2
Sheet3
Proportion of Maternal DeathsBy Direct CauseSource: WHO wall chart Maternal Health Around the World WHO, Geneva, 1997.N=515,000
Chart6
0.34
0.21
0.18
0.16
0.11
Sheet1
Hemorrhage34%
Infections21%
Abortions18%
Eclampsia16%
Obstructed Labor11%
Sheet2
Sheet3
PREGNANCY
DELIVERY
POST NATAL
PRE- PREGNANCY
0
22 Weeks
BIRTH
7 Days
28 Days
42 Days
Timing of Maternal and Perinatal Mortality
* Dashed line indicates that there are no data available to delineate exactly when these deaths occur.
Perinatal Death
3-14 Days if Tetanus
Maternal Death
What Can be Done to Improve Maternal/Perinatal Health and Survival?Antenatal CareIntrapartum CarePostpartum/ Newborn CarePreconception CareNutritionInfection ControlFamily PlanningNutritionInfection ControlDanger SignsIdentify/Manage ProblemsSafe Delivery EOCEmOCNutritionInfection ControlFamily PlanningIdentify/Manage ProblemsPREGNANCYDELIVERYPOST NATALPRE- PREGNANCY022 WeeksBIRTH7 Days28 Days42 Days
Essential Obstetric Care (EOC), Basic(BEOC) and Emergency Care (EmOC)
EOC (also Comprehensive EOC)
Comprehensive EOC
Basic EOC
EMOC
Surgical obstetrics
X
X
Anesthesia
X
X
Blood replacement
X
X
Management of problem pregnancies
X
X
Medical Treatment
X
X
X
Manual procedures
X
X
X
Monitoring of labor
X
X
Neonatal special care
X
X
Successful Models of Safe Motherhood:Features of Service Delivery Configurations
Who Delivers
-----------------Where Delivers---------------
Home
Limited EOC Facility
Full EOC Facility
Non-professional
Model 1:
Home deliveries by community member trained briefly
transport
referral support
Professional
Model 2:
Home deliveries by professional;
Transport
referral support
Model 3:
Professional provision of Basic EOC
Transport
referral support
Model 4:
Professional provision of Basic and Comprehensive EOC
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)
Program/project Examples and MMR
Who Delivers
-----------------Where Delivers----------------
Home
Limited EOC Facility
Full EOC Facility
Non-professional
Model 1:
China (rural)(115)
Fortaleza, NE Brazil (120)
Professional
Model 2:
Malaysia (1970s-early 1980s) (39)
The Netherlands (1955-1970)(70-12)
Model 3:
Malaysia (mid-1980s)(47)
Sri Lanka (30)
Model 4:
Sweden
United Kingdom (9)
United States (12)
Mexico City (114)
Causes of Direct Obstetric Maternal DeathsMexico City, 1988-1989MMR=114Source: Bobadilla, et al, 1996
Preventable Maternal Deaths by Responsible Factor and Health Institutions (%) Mexico City, 1988-1989Source: Bobadilla, et al, 1996
Institution
(n=deaths)
Responsible Factor
Physician
Hospital
Patient
PA1 (68)
93
16
37
PA2 (33)
82
33
38
SS1 (79)
80
8
10
SS2 (25)
68
16
12
Total (205)
83
16
22
Types of Physician Errors in Preventable DeathsMexico City, 1988-1989Source: Bobadilla, et al, 1996
Type of error
Percent
Wrong therapy
Error of surgical judgement
Error of diagnosis
Belated treatment
Error in administration of anesthesia
Poor prenatal care
Other
31
24
19
5
5
3
18
Total
100
Push and Pull of Maternity CareMidwife1Model----------------------------
MotherCare FrameworkReduced Maternal & Perinatal MortalityImproved knowledge & decision-making in communityIncreased % of pregnant women receiving skilled care during antenatal, delivery and postpartum periodsImproved quality of servicesIncreased availability and access to servicesGOAL(IMPACT)STRATEGIES TO REACH OBJECTIVE (PROCESS)OBJECTIVE(OUTCOME)
Strategy: Increased availability and accessIndicators: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 attendantContext specific
MotherCare FrameworkReduced Maternal & Perinatal MortalityImproved knowledge & decision-making in communityIncreased % of pregnant women receiving skilled care during antenatal, delivery and postpartum periodsImproved quality of servicesIncreased availability and access to servicesGOAL(IMPACT)STRATEGIES TO REACH OBJECTIVE (PROCESS)OBJECTIVE(OUTCOME)
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.
Options for Training to improve maternal care:In-service training in specific skills;
Pre-service training in specific skills;
Distance education/ programmed self-instruction.
Common objectives:Increase knowledge of specific subjects;Develop or increase competence for specific skills;
Less frequently stated objectives:Maintenance of skills over time;Routine implementation of newly acquired skillsTraining Objectives:
Frequency Distribution of Correct Answers in Knowledge Test, MotherCare GuatemalaSource: Training Evaluation Report, MotherCare Guatemala, June 1999
Absolute (%) Mean Scores in Application of Skills by Training Status, MotherCare GuatemalaSource: Training Evaluation Report, MotherCare Guatemala, June 1999
Lessons Learned Quality of CareBut, some skills remain weak:Guatemala: breech; newborn resuscitation; internal bimanual compression; manual removal of the placenta
Bolivia: partograph; bimanual compression
Lesson:Key skills can be improved via in-service competency-based training
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 trainingDoctors affect others 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 highGuatemala:All staff rotate due to personnel shortageBolivia:Approximately 72% turnover in providersConclusion: In-service training program is not a substitute for two to three year midwifery training program
MotherCare FrameworkReduced Maternal & Perinatal MortalityImproved knowledge & decision-making in communityIncreased % of pregnant women receiving skilled care during antenatal, delivery and postpartum periodsImproved quality of servicesIncreased availability and access to servicesGOAL(IMPACT)STRATEGIES TO REACH OBJECTIVE (PROCESS)OBJECTIVE(OUTCOME)
Strategy: Improved knowledge and decision-makingIndicators 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
Strategy: Improved knowledge and decision-makingProcess indicators (pop-based):% women/men with knowledge of obstetric danger signs
% women who intend to use skilled birth attendant
Community Strategies: use of skilled birth attendant Constraints and Interventions--MotherCare Guatemala
Baseline Levels of Awareness of Danger SignsSources: MotherCare & PMM Network, 1996-8
Barriers to Improving RecognitionPregnancy is considered a normal event in most countries
Some obstetric complications lack distinguishing characteristics along a continuum between normalcy and emergency that triggers alarm, and
Beliefs associated with major obstetric complications in different settings affect the interpretation of their severity and the decisions to respond appropriately
Questions to Measure Knowledge of Danger SignsCan 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
Possible AnswersWaters break too earlyBleeds a lot during birth after baby bornShe has a feverTakes too long before she can push the baby outShe faintsShe has fits or convulsionsThe afterbirth (placenta) does not come outBaby dies before coming outOther (specify)
Improving Pregnant Womens Knowledge of Danger Signs through Counseling at Health Centers & Posts, MotherCare GuatemalaSource: Patsy Bailey (FHI), 2001
Coverage: Guatemala, Bolivia, Indonesia 1995-1999Guatemala
Met Need:Guatemala & BoliviaGuatemalaBolivia
Conclusions: Use of Skilled Birth Attendant and Met NeedThe 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.
CHINA
MODEL 1 MODEL 3 & 4
China
Maternal-related statistics, Tonghai and Huaning, Yunnan, China 1999
-1990
1999-2000
Yunnan (GDP $536, 1999)
MMR
149 (1989)
101 (1999)
TFR
2.47 (1990)
2.20 (2000)
Tonghai (GDP= $700, 1999)
MMR
52
TFR
2.29 (1990)
2.10 (2000)
Huaning (GDP= $272, 1999)
MMR
84
TFR
2.40 (1990)
2.16 (2000)
Hospital Delivery Rate in Huaning and Tonghai Counties, Yunnan, ChinaSource: County MCH Station, MIS, Tonghai and Huaning County, 1990-1999
1
69.3749.28
66.5250.72
73.0356.67
78.360.78
80.750.61
85.1557.81
86.357.7
89.358.71
92.4959.95
92.4561.54
Tonghai
Huaning
Year
HDR(%)
Sheet1
%%%
1980
1981
1982
1983
1984
198555.0160.0
198660.5863.0
198766.7368.0
198866.7470.0
198967.6972.0
1990
199177.421865151100.0100.00100.098.045.944.9498.3996.002.983.04
199284.0114018479100.094.05100.091.146.124.9099.6484.813.093.00
199384.0812735756100.098.24100.0100.006.335.20100.00100.003.172.90
199486.2812106464100.0100.00100.0100.006.295.6099.8395.313.153.03
199593.57980277277100.0100.00100.099.286.435.34100.0098.923.213.05
199695.72957402402100.0100.00100.0100.006.705.20100.00100.003.203.10
199797.931159458453100.098.91100.0100.006.785.49100.00100.003.103.11
199898.671055373373100.0100.00100.0100.007.024.95100.00100.003.123.12
199997.43661304304100.0100.00100.0100.006.965.85100.00100.003.953.47
2000301300100.0099.676.3199.673.12
Sheet2
/
1973179116231332046
19741822892325037.0114.641093
1975185042240351237
197618829423571
197719163923563
197819449623604
197919659124675
198019873225459
198120200323406
198220523525478
1983207642288973538
1984210834299731888471.9186.25
1985213875331892099072.2772.34290
1986216998326742232575.7575.84436
1987221068353472300078.8675.072798
1988225850351612482987.4287.45637
1989229776179433396393137885.2183.15889
1990233385181434424202840279.479.416251
1991237079183268432782960580.980.985313
199224078118421344455306388282.005381
1993244503185477457233175486.3786.405024
1994247437186851475033376486.2786.2749023841580.87
1995250254188286489263415187.1887.181480
1996252866189746508813618288.1788.17321169531775
1997255630191150525713773687.6187.61159374432954
1998258451192554529493824985.5388.5886252033038
1999260617194897537573888986.3688.2253545933629351684.08
20003887087.12
-
Sheet2
014.64
086.25
077.9
083.98
075.07
077.78
080.18
081
085.01
083.48
086.47
087.44
088.37
087.82
087.33
086.38
086.5
Tonghai
Huaning
Year
CCR(%)
Sheet3
198069.9031.85
198151.7932.83
198274.9547.29
198381.0975.05
1984100.00100.004.182.8386.2139.10
1985100.005.11100.004.604.203.022.902.9487.9039.325.20
1986100.005.67100.005.564.222.992.983.0092.1344.875.58
1987100.0015.3899.1814.435.183.203.422.6496.7045.6117.42
1988100.0035.9397.2729.875.403.233.082.5897.6847.9036.03
1989100.0049.9199.4347.915.364.093.002.7296.9650.0062.07
199054.1152.314.532.5899.1197.7269.3749.2877.2754.1177.2756.74
1991100.0053.5398.3252.375.584.552.912.8999.0874.9666.5250.7282.4358.4482.4354.89
199283.5360.7288.7659.5884.7899.1573.0356.6788.5372.7375.7660.72
199391.8774.2292.3573.5989.2380.3378.3060.7891.8774.4977.9074.22
199492.4472.9792.7071.8792.6680.3780.7050.6192.4473.2779.3372.97
199593.3777.0992.9376.4094.9179.8885.1557.8193.3777.0935.6779.12
199695.6581.3795.4280.9995.8986.2486.3057.795.6580.8653.465.53
199796.2382.5596.2782.3597.2887.6989.3058.7196.2382.1665.7420.31
199896.1981.0796.1981.0398.7590.0692.4959.9596.1980.3170.7524.50
199996.2087.0396.2087.0397.8399.7492.4561.5496.5387.3672.9732.99
200087.2487.0093.1368.4587.2454.29
Sheet3
00
00
00
00
00
00
00
00
00
Tonghai
Huaning
Year
New Method Delivery Rate%
Sheet4
00
00
00
00
00
00
00
00
00
Tonghai
Huaning
Year
HDR(%)
Figure Hospital Delivery Rate in Huaning and Tonghai Counties
00
00
00
00
00
00
00
00
00
%
00
00
00
00
00
00
00
00
00
00
%
00
00
00
00
00
00
00
00
00
00
TonghaiCounty
Huaning County
Year
SMR(%)
Figure Systemic Management Rate in Tonghai and Huaning County, 1990-1999
00
00
00
00
00
00
00
00
00
00
Tonghai
Huaning
Year
HDR(%)
Figure Hospital Delivery Rate in Huaning and Tonghai Counties
1973
1974
1975
1976
1983
1985
1986
1987
1988
19896364721931697581412113915906739272539764
19907034826102792521560125716538086260033295
1991713090010445101291605139511507797272743278
1992738294510550105171720142211637906285044455
1993763299010835105361777148612098284297445723
1994780698611433107431853157613168549375448016
19958127102211742109461927161214248745338148926
19968509108312167113151967161215279150350150831
19978674112912472117572016166716229631360352571
19988864115112630117672035169417229692324152796
19999074112512654119542111172815439826374353758
2000
Policy Guides the Way, China MMRto 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)
Policy Guides the Way, China RegulationsNational and provincial Established responsibilities of the MCH institutes Quality of care standards Equipment necessary for family delivery Personnel allowance Medical aid to the poor
China: MCH Network
Three-tiered maternal and child health care network in rural China
: Administrative relationship; : Professional relationship
County Health Bureau
County
MCH Station
Specialist
County
Hospital
Specialist
Township/Town Health Center,
Doctors
Village Clinic
Village doctors
Health Care Infrastructure, Tonghai and Huaning, Yunnan, China 1999
Tonghai
Huaning
Health Care infrastructure
#
Per pop
Pop= 260,000
#
Per pop
Pop= 195,000
County Hospitals
2
130,000
2
97,500
THC
8*
32,500
5
39,000
Village VC
44
5,909
76
2,566
Village Doctor
153
1,699
207
942
TBAs
42
6190
115
1726
*T: 4 of 8 THCs- comprehensive hospitals
H: 2 of 5 THCs- comprehensive hospitals
Accountability for performance, Tonghai and Huaning, Yunnan, ChinaAccountability 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 deliverydecreased MMR
Scores related to employment, promotion, subsidies
Ensuring financial accessibility, Yunnan, ChinaMCH Prepay Scheme (at marriage registration)
Prepay for 5 ANC + 3 PNC + child health exams (complication coverage) Fee = 1 visit if not on scheme
Medicaid for Poor and High-Risk Pregnant Women Experimental stageinsurance for delivery (Delivery: $30 THC, $72 County MCH station, $124 County hospital)
How to transition to Model 2 and 3Develop strong policyMMR makes a difference! Bolivia, China, Egypt, Honduras, Indonesia, JamaicaIncrease availabilityCEOC facility 1/100,000 ChinaBEOC facility 1/30,000 China, Indonesia, ZimbabweSkilled birth attendant 1/1000 -1500 Indonesia, ZimbabweWell-connected front-line provider 1/1000-1500 ChinaMaternity waiting home 1/50,000 Zimbabwe, Honduras Increase financial accessibility Bolivia, China
How to transition to Model 2 and 3
Ensure referralUse risk approach based on clinical signs/symptoms China, Honduras, Indonesia, JamaicaLink levels of care through supervision ChinaPromote accountability ChinaTarget resources to needy areasBirthing centers, maternity waiting centers Honduras
MODEL 1 MODEL 2
INDONESIA
Assistance During Delivery, Indonesia 1991-1997Source: DHS 1991, 1994, 1997
Chart5
4.930.959.64.4
6.734.854.43.7
7.443.846.12.7
Doctor
Trained nurse/midwife or other health professional
Birth Attendant
Relative or other
Year
percentage
Chart7
2178.5
18.281.6
21.678.4
Health Facility
At home
Year
percentage
Place of Delivery, Indonesia 1991-1997
Chart9
2.25.26.1
0.91.93.5
1.22.84.2
1991
1994
1997
percentage
Characteristics of Delivery, Indonesia: Caesarian Sections 1991-1997
Sheet1
Health FacilityAt home
19912178.5
199418.281.6
199721.678.4
DoctorTrained nurse/midwife or other health professionalBirth AttendantRelative or other
19914.930.959.64.4
19946.734.854.43.7
19977.443.846.12.7
199119941997
Doctor4.96.77.4
Trained nurse/midwife/other health professional30.934.843.8
Birth Attendant59.654.446.1
Relative or other4.43.72.7
Urban: Delivery by caesarian sectionRural: Delivery by caesarian sectionTotal deliveries by caesarian section
19912.20.91.2
19945.21.92.8
19976.13.54.2
Sheet2
Sheet3
Place of Delivery, Indonesia 1991-1997
Chart5
4.930.959.64.4
6.734.854.43.7
7.443.846.12.7
Doctor
Trained nurse/midwife or other health professional
Birth Attendant
Relative or other
Year
percentage
Assistance During Delivery, Indonesia 1991-1997
Chart7
2178.5
18.281.6
21.678.4
Health Facility
At home
Year
percentage
Chart9
2.25.26.1
0.91.93.5
1.22.84.2
1991
1994
1997
percentage
Characteristics of Delivery, Indonesia: Caesarian Sections 1991-1997
Sheet1
Health FacilityAt home
19912178.5
199418.281.6
199721.678.4
DoctorTrained nurse/midwife or other health professionalBirth AttendantRelative or other
19914.930.959.64.4
19946.734.854.43.7
19977.443.846.12.7
199119941997
Doctor4.96.77.4
Trained nurse/midwife/other health professional30.934.843.8
Birth Attendant59.654.446.1
Relative or other4.43.72.7
Urban: Delivery by caesarian sectionRural: Delivery by caesarian sectionTotal deliveries by caesarian section
19912.20.91.2
19945.21.92.8
19976.13.54.2
Sheet2
Sheet3
Characteristics of Delivery, Indonesia: Caesarian Sections 1991-1997
Chart5
4.930.959.64.4
6.734.854.43.7
7.443.846.12.7
Doctor
Trained nurse/midwife or other health professional
Birth Attendant
Relative or other
Year
percentage
Assistance During Delivery, Indonesia 1991-1997
Chart7
2178.5
18.281.6
21.678.4
Health Facility
At home
Year
percentage
Place of Delivery, Indonesia 1991-1997
Chart9
2.25.26.1
0.91.93.5
1.22.84.2
1991
1994
1997
percentage
Sheet1
Health FacilityAt home
19912178.5
199418.281.6
199721.678.4
DoctorTrained nurse/midwife or other health professionalBirth AttendantRelative or other
19914.930.959.64.4
19946.734.854.43.7
19977.443.846.12.7
199119941997
Doctor4.96.77.4
Trained nurse/midwife/other health professional30.934.843.8
Birth Attendant59.654.446.1
Relative or other4.43.72.7
Urban: Delivery by caesarian sectionRural: Delivery by caesarian sectionTotal deliveries by caesarian section
19912.20.91.2
19945.21.92.8
19976.13.54.2
Sheet2
Sheet3
Trends in Proportion C-Sections Among All BirthsS. Kalimantan, 1997-99
Chart1
000
000
000
1997
1998
1999
A
Monthly admissions
South KalimantanBy district
All districtsBanjar BaruBKHSS
DateAll admissionsAbortionsDeliveriesMajor OCMOI/AMI+eclSectioAdmissionsMajor OCMOI/AMI+eclSectioAdmissionsMajor OCMOI/AMI+eclC-sectionAdmissionsMajor OCMOI/AMI+eclC-section
35400.05507438330341703518913262821341104555
35431.0422772572243142155681113221745564053
35462.040354261197274214871713201433452741
35490.0489703232322847202911124281942522823
35521.0500593522565177213962329138026144913
35551.050262330273517521290111932277114738511
35582.0449563072274452216912028161221503235
35612.0500523312514168220951624231347543649
35643.051062357255436822210417302316346135210
35674.04937730124332532351071623191343713427
35704.04956929726638423661122229461133902612
35735.04747629224126583638581839182212428110
35765.044459290214264016269610181422422944
35796.04626029325736741669114243020699247315
35827.0381442381893459141811423251643433147
35855.0435732622193953150771217221535514016
35886.047648297231356418892162918902544447
35916.0398422572003053135611121181443513937
35947.04696330724739691789013253117324734210
35977.0424682802232960166771024161511353243
36008.0419542802093661189921934201311423333
36039.0379632402144264156771825231734292334
36069.0456872592413142184861014231634543921
36100.043974256211314816973813241645442823
36130.043569139207245216176919271023433201
36161.0407591412023052148691118322145432201
36192.041378149216264415780713301832412904
36220.042482151226305815483725311722231423
36251.0469861602493054191881224241700221501
36281.048467167243275219198112114801473412
36312.06271142243253264204998191913021338148
36342.0616902753154770216106182626173411874710
36373.0528962062782855216101824422621795204
36404.04432313754166811121352476483423
36434.05242643362206951127342042422223
36465.0491249265718696921281424603818
Three-monthly admissions
South KalimantanBy district
All districtsBanjar BaruBKHSS
DateAll admissionsAbortionsDeliveriesMajor OCMOI/AMI+eclAdmissionsMajor OCMOI/AMI+eclSectioAdmissionsMajor OCMOI/AMI+eclSectioAdmissionsMajor OCMOI/AMI+eclSectio
Dec96-Feb97137520590172499154654228315270521012211112149000000000
Mar97-May97149119110057611301996272774572735411151601101627000000000
Jun97-Aug97145917099573312818865829053826241912165103924000000000
Sep97-Nov971462222890750961539643044670104429828588419000000000
Dec97-Feb981287163821660961734692413457735012141771071126000000000
Mar98-May98130916381665010417047323039675838710156123820000000000
Jun98-Aug981312185867679104190533259428367455412499916000000000
Sep98-Nov9812742247556661041545092363652704910131279078000000000
Dec98-Feb99125520642962580148466225275089499101278306
Mar99-May991377235478718871645362693070694223926336
Jun99-Aug99177130070591810718963630634698756573302071122
Sep99-Nov991458007449617355827231699758131215094514
Trends in met need
Major obstetric complications
BanjarBarito KualaHSS
19971099189413
1998966182419
19991072205447
Births1309760635036
1271963345374
1372864675474
19978%3%8%
19988%3%8%
19998%3%8%
Life threatening complications
BanjarBarito KualaHSS
19971753943
19981513435
19991222919
Births1309760635036
1271963345374
1372864675474
19971.34%0.64%0.85%
19981.19%0.54%0.65%
19990.89%0.45%0.35%
sectio
BanjarBarito KualaHSS
19972764779
19982594170
19992583248
Births1309760635036
1271963345374
1372864675474
19972.11%0.78%1.57%
19982.04%0.65%1.30%
19991.88%0.49%0.88%
A
5503034170
4222243142
4031972742
4892322847
5002565177
5022735175
4492274452
5002514168
5102554368
4932433253
4952663842
4742412658
4442142640
4622573674
3811893459
4352193953
4762313564
3982003053
4692473969
4242232960
4192093661
3792144264
4562413142
4392113148
4352072452
4072023052
4132162644
4242263058
4692493054
4842432752
6273253264
6163154770
5282782855
4432313754
5242643362
4912492657
All admissions
Major obstetric complications
MOI/AMI (+ eclampsia)
C-sections
Month/Year
Number of admissions
Trends in admissions in 7 hospitalsSouth Kalimantan (Dec 96-Nov 99)
351891326
155681113
14871713
202911124
213962329
212901119
216912028
220951624
2221041730
2351071623
3661122229
36385818
16269610
166911424
141811423
150771217
188921629
135611121
178901325
166771024
189921934
156771825
184861014
16973813
16176919
148691118
15780713
15483725
191881224
191981121
20499819
2161061826
216101824
166811121
206951127
18696921
Deliveries
Major obstetric complications
MOI/AMI (+eclampsia)
C-section
Month/Year
Number of admissions
Trends in hospital admissionsBanjar (Dec 96 - Nov 99)
282134
221745
201433
281942
13802
3227711
161221
231347
231634
191343
461133
391822
181422
302069
251643
221535
18902
181443
311732
161511
201311
231734
231634
241645
271023
322145
301832
311722
241700
14801
191302
261734
422621
352476
342042
281424
Deliveries
Major obstetric complications
MOI/AMI (+eclampsia)
C-section
Month/Year
Number of admissions
Trends in hospital admissionsBarito Kuala (Dec 96 - Nov 99)
1104555
564053
452741
522823
6144913
4738511
503235
543649
6135210
713427
902612
12428110
422944
9247315
433147
514016
544447
513937
4734210
353243
423333
292334
543921
442823
433201
432201
412904
231423
221501
473412
1338148
11874710
795204
483423
422223
603818
Deliveries
Major obstetric complications
MOI/AMI (+eclampsia)
C-section
Month/Year
Number of admissions
Trends in hospital admissionsHSS (Dec 96 - Nov 99)
137572499
1491761130
1459733128
146275096
128766096
1309650104
1312679104
1274666104
125562580
137771887
1771918107
145874496
All admissions
Major obstetric complications
Life threatening obstetric complications
Three-month period
Number of admissions
Figure 5: Trends in admissions in 7 hospitalsSouth Kalimantan (Dec 96 - Nov 99)
22831654
27745627
29053658
30446964
24134469
23039473
25942533
23636509
22527466
26930536
30634636
27231558
Major obstetric complications
Life threatening obstetric complications
All admissions
Three-month period
Number of admissions
Figure 6: Trends in admissions in 7 hospitals Banjar (Dec 96 - Nov 99)
000
000
000
000
000
000
000
000
000
000
000
000
Major obstetric complications
Life threatening obstetric complications
All admissions
Three-month period
Number of admissions
Figure 7: Trends in admissions in 7 hospitalsBatola (Dec 96 - Nov 99)
000
000
000
000
000
000
000
000
000
000
000
000
Major obstetric complications
Life threatening obstetric complications
All admissions
Three-month period
Number of admissions
Figure 8: Trends in admissions in 7 hospitalsHSS (Dec 96 - Nov 99)
74
77
54
70
59
62
56
52
62
77
69
76
59
60
44
73
48
42
63
68
54
63
87
74
69
59
78
82
86
67
114
90
96
Month/Year
Number of abortions
Abortion admissions in 7 hospitalsSouth Kalimantan (Dec 96 - Aug 99)
000
000
000
1997
1998
1999
District
Major obstetric complications in hospital as a proportion of all births
Figure 9: Trends in coverage of obstetric care for major obstetric complications (Dec 1996-Nov 1999)
000
000
000
1997
1998
1999
District
Life threatening obstetric complications in hospital as a % of all births
Figure 10: Trends in coverage of obstetric care for life threatening obstetric complications (Dec 1996-Nov 1999)
000
000
000
1997
1998
1999
District
Caesarean sections as a proportion of all births
Figure 11:Trends in proportion c-sections among all births
Skills Assessment: Village MidwifeIndonesia, 1999
Significant P
Indonesia: Challenges Ahead...Ensure strong policy guidanceto increase coverage --financial options? --partnering with traditional systems --improved communicationsto maintain quality --pre-service competency-based training --partnering with professional associations for continuing education (e.g. IBI, POGI, Perinasia)to increase accountability of professionals, andto ensure normal deliveries remain with BDD, BidansWhat is sustainability of BDD Program?
Cost of Model 2Indonesia: Village midwife training + 1 year service, 1998US$Initial training2000 - 3500Basic salary/year400__________2400-3900X 55,000 midwives=132 - 215 millionSource: Hull et al 1998; P Daly, pers comm.
MODEL 1 MODEL 3 & 4ZIMBABWE
Maternal Mortality Trends, Zimbabwe 1988-1989Sources: Mbizvo 1994; DHS 1994, 1999; Census Data 1992; NHIS 1988-1997
Chart1
77.11988
100.091989
81.53168
91.651991
66.74395
1401993
131.32283
105.421995
169.91996
145.231997
1999695
MMR
Year
MMR
Sheet1
19881989199019911992*19931994**1995199619971999
MMR77.1100.0981.5391.6566.74140131.32105.42169.9145.23
168395283695
Sheet2
Sheet3
Zimbabwe: Birth-related statistics, 1994 and 1999
Ref: DHS, 1994; DHS, 1999
_1057483463.xls
Chart1
69.172.2
68.472.5
66.7
1994
1999
% of births
Sheet1
Facility-based birthSBAC-Section
199469.168.46
199972.272.56.7
Sheet2
Sheet3
_1057483572.xls
Chart1
69.172.2
68.472.5
66.7
1994
1999
% of births
Sheet1
Facility-based birthSBAC-Section
199469.168.46
199972.272.56.7
Sheet2
Sheet3
_1057396722.xls
Chart1
69.172.2
68.472.5
66.7
1994
1999
% of births
Figure 2. Zimbabwe: Birth-related statistics, 1994 and 1999
Sheet1
Facility-based birthSBAC-Section
199469.168.46
199972.272.56.7
Sheet2
Sheet3
Zimbabwe: Impact of AIDS, 1999% Adults (15-49 years)25%% ANC clientsUrban30%31 sentinel sites30%% STD clients72%Source: UNAIDS, 2000
Zambia: Causes of Maternal Death, University Teaching Hospital, 1996-1997Causes%Direct42Indirect58Malaria30AIDS-relatedTuberculosis25Unspecific chronic respiratory infection221982- MMR 1181996-1997- MMR 921Source: Ahmed et al, 1999
Zimbabwe: Successful program elements, 1997Increased hospitals and clinics37% (1980-1997)1 clinic/10,000 popIncreased staffing (1997)1 midwife/1,500 popFP Program (1999)CPR54%Waiting Mothers Shelters1/50,000 popMaternal audits - district, provincial, national levelsTBA training - practical training with local midwifeSource: Feresu S. et al, 2000
Zimbabwe: Summary- MMR
- Indirect causes, especially AIDS, suspected.
- Maternity care alone is not the answer in such circumstances.
Here, you can see the baseline levels of awareness of danger signs in four countries.If you look at the green bars, you will notice that less than 30 percent of women in Bolivia, Indonesia, and Pakistan spontaneously mentioned danger signs of ante- and post-partum hemorrhage. In addition, in the same countries, the pattern of orange bars demonstrates that less than 5% of women spontaneously mentioned convulsions.High levels of awareness can be deceptive, as can be seen by the blue bar for sepsis in Bolivia and the green bar for hemorrhage in Nigeria. Even though awareness of the severity of sobreparto, a locally defined condition similar to puerperal sepsis is high in Bolivia, the cultural interpretation of its etiology makes women and families turn to the traditional system. Awareness of awareness of hemorrhage was also high in Nigeria, but cultural beliefs influenced the actions of families that turned to the traditional system for care.
You may ask . . .why is it challenging when we have been providing information to communities on danger signs for quite some time now. It is not as simple as that because:Pregnancy is considered a normal event in most countriesSome obstetric complications lack distinguishing characteristics along a continuum between normalcy and emergency that triggers alarm, andBeliefs associated with major obstetric complications in different settings affect the interpretation of their severity and the decisions to respond appropriately.
Therefore, recognizing of major obstetric complications at the time of occurrence does not easily translate into being aware of medically defined danger signs. Compounding this is the fact that complications are rare events, and messages facilitating diagnosis and action need to be retained and recalled.