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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?
0
50
100
150
200
250
300
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
1980
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2015
0
5
10
15
20
25
30
35
40
45
50
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%
30%
40%
50%
60%
70%
80%
90%
100%
31% 26%
50%
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
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
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
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
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%
10%
20%
30%
40%
50%
60%
70%
80%
90%
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 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)
*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
10
20
30
40
50
60
3638
31
50
32 3333
28
23
48
2831
Unmet need among in-union
Before using the CCT platform After using the CCT platform
Unm
et n
eed
for m
oder
n FP
(in
%)
PQBLD Pangasinan Quezon City Batangas Leyte Davao Sur0
10
20
30
40
50
60
70
80
90
100
35
28
56
14
57
31
64
9285
57
79
42
FBD
Before using the CCT platform After using the CCT platforminterventions interventions interventions interventions
Unmet need for modern FP
32
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