Service delivery strategies to improvematernal health

Mar 2010

Dr. Marge Koblinsky PhD

Sr. Women’s Health Advisor

JSI

Talk outline

Reducing maternal mortality: what is effective?Lancet 2006: A new strategic focus

Bangladesh – Why is the MMR so low?-Matlab (E Chowdhury et al)-Khulna vs Sylhet

Indonesia — Why does the MMR remain so high?Human resourcesPublic private sectors

Work in progress:

Multi country analysis: pub/priv facility for birthConclusions

All women should be able to deliver in primary level health facilities (health centres) with midwives (SBAs) working in teams:

More efficient (achieving high coverage) than skilled attendants in the home or hospital

Most effective (impact on mortality) because skilled attendants can provide proven single interventions

Lancet 2006: A new strategic focus…..

Area 144 thou sq km

Population 140 million.

GDP Per Capita US$ 388

GDP growth rate 5.26%

Population in

poverty 44.3%

MMR 322/100,000 LB

Use SBA 13%

Csection 3.5%

Source. HDR 2005; BMMS 2001, BDHS 2004

Dhaka320

Khulna351

Rajshahi223

Barisa387l

Sylhet471

KM

806040200

Bangladesh: Why MMR declined?

GIS unit, ICDDR,B

India

India

Myanmar

India

N

Chittagong325

Per

1,0

00 l

ive

bir

ths

Projection of MMR in Bangladesh 1976-2015Projection of MMR in Bangladesh 1976-2015

Current declining rate = 3.2% annually (1999-2015)

Required declining rate = 5.1% annually (to achieve MDG target)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

1976

1979

1982

1985

1988

1991

1994

1997

2000

2003

2006

2009

2012

2015

Projection National Sisterhood National Verbal Autopsy

1.43 /1000 LB

75% of MDG

Courtesy: Mahbub Elahi ChowdhuryBMMS 2001

Govt. Service Area

ICDDR,B Service Area

SylhetRajshahi

KhulnaChittagong

Barisal

Legend

ICDDR,B Hospital

ICDDR,B Subcenter

KM

43210

BANGLADESH

Dhaka

Matlab

@

Bay of Bengal

Divisional boundaries

Main rivers

GIS unit, ICDDR,B

Govt. Service Area

N

Map of Matlab Study Area

Matlab Home-Based Strategy, 1987-1995

In each block (20,000) 2 midwives were posted 24 hours on call

- Conduct home deliveries

- Refer complicated deliveries

- Provide ANC & PNC Other duties included:

- Organize community meetings, train

health workers, TBAs, organize

referrals, FP

Support systems

- Rickshaw/boat, porter

- Matlab clinic,

- Comm serv--immuniz, ORS

• No charges

Matlab Facility-Based Strategy, 1996 to date

In each block, 2 midwives posted in an upgraded Basic EOC facility

Services were better organizedconsistent suppliesseparate labor roomimproved links with Matlab

Hospitaltreat children’s problems

No charges

Matlab Clinic– BEOC Centre

Lady medical officers

Assisted vaginal deliveries

possible

No charges

• Backed up by transportation Speed boat/rickshaws/boatsAmbulance in Matlab

• Referrals linkages District hospital EmOC facility at

Matlab

0

100

200

300

400

500

76-80 81-85 86-90 91-95 96-00 01-05 76-80 81-85 86-90 91-95 96-00 01-05

Mat

ern

al d

eath

s p

er 1

00,0

00 p

reg

nan

cies Mortality fell by 68%

Mortality fell by 54%

ICDDR,B area Government area

Bangladesh national

Trends in maternal mortality over time

0

100

200

300

400

500

600

76-80 81-85 86-90 91-95 96-00 01-05 76-80 81-85 86-90 91-95 96-00 01-05

Ma

tern

al d

ea

ths

pe

r 1

00

,00

0 p

reg

na

nc

ies

0

10

20

30

40

50

60

70

80

90

100

% o

f b

irth

s w

ith

he

alt

h p

rofe

ss

ion

al

Maternal deaths % of births with health professional

Maternal mortality and use of skilled care at birth over time by areas

ICDDR,B area Government area

02000400060008000

100001200014000160001800020000

CE

mO

C

BO

C &

refe

rra

l

No

car

e

CE

mO

C

BO

C &

refe

rra

l

No

car

e

CE

mO

C

BO

C &

refe

rral

No

ca

re

1987-1993 1994-1999 2000-2005

Mor

tali

ty p

er 1

00,0

00 p

reg

nan

cies

0.0

10.0

20.0

30.0

40.0

50.0

% u

sed

sk

ille

d c

are

% of used skilled care

Reduction of mortality

For CEmOC - 26% per year

BEOC & referral - 8% per year

No care - 8% per year

p value for interaction between time and type of care <0.01

Pregnancy-related mortality and use of skilled care at birth, over time in the ICDDR,B service area

n =19

n =16 n =31

n =10

n =17 n =26 n =9 n =29

Total deaths = 173

n =16

At individual level

At low level of skilled attendance (about 10%):

Selection of high risk women in EmOC

Midwives/hospitals cannot save these women (women may have more severe complications; may have poor quality of care)

At the highest level of use of skilled care (about 40%):

Maternal mortality among those using care remains high (150 at BEOC; 720 at EmOC)

Maternal mortality among those not using skilled attendance is much lower (60/100,000)

Similar patterns are observed for perinatal mortality but selection effects are less strong

Place of birth in the Matlab surveillance area2007-2008 (n= 4817 births)

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Home ICDDR,Bhealth centre

ICDDR,Bclinic

Thana healthcomplex

PublicHospital

Chandpur

Privatehospital

Chandpur

Hospitalbeyond

Chandpur

No referral Referral via ICDDR,B

62% births in facility; 44% ICDDRB facilities (BEOC level); 19% other hospitals (20% pub, 57% private, 23% beyond Chandpur)

C section—7.5% overall; 22% pub, 70% priv Huda, F et al 2009

Dhaka320

Khulna351

17% doc8% csec

Rajshahi223

Barisa387l

Sylhet471

8% doc4% csec

KM

806040200

GIS unit, ICDDR,B

India

Myanmar

India

N

Chittagong325

Bangladesh

MMR by division 2003

India

 Divisions

CEmOC facilities/ 500,000

population

Dhaka 9.5Chittagong 5.6Rajshahi 6.3Khulna 12.7Barisal 5.1Sylhet 4.7Total Public NGO Priv

7.8 1.1 0.4 6.3

Geographic distribution of CEmOC

facilities in Bangladesh

1

2

3

5

6

CEmOC Facilities with CSection and Blood by type and division (%)

Cs and BT available in 60, 80 and 90% of public, NGO and private facilities respectively In 1/3 of public facilities, Cs not available mostly due to unavailability of ob/anesthetists

Among divisions Cs and BT most available in Khulna and least in Sylhet division

Professional assistance during birth and MMR: Indonesia

Why is the MMR so high?

Bangladesh vs Indonesia

Bangladesh IndonesiaPopulation (mil) 150 225Income low medRural % 74 48Density (pop/Km2) 920 119 (17000 is)TFR 2.7 2.8Midwives 5000 80,000

Obs 900 2100

Anes 860 750

Maternal Mortality Ratio Indonesia 1990-2015

390

334307

228

102

-

100

200

300

400

500

1990-1994 1993-1997 1998-2002 2003-2007 2015

Year

Mat

erna

l Dea

th p

er 1

00.0

00 L

ive

Birt

h

Estimated by Unicef, WHO, UNFPA, The WorldbankYear 2005 : 420

Target MDG 5 by 2015

IDHS 2007: Preliminary result

Village midwife program Decentralization

Financial crisis

 

IDHS 1987 & 2002: Increase in SBA from 35% to 66%, especially among the two poorest quartile (2007-73%)

Gap between rich and poor narrowing, but access of the poor still very low

0

10

20

30

40

50

60

70

80

90

100

Poor Lowmiddle

Middle Uppermiddle

Rich%

de

liv

eri

es

wit

h a

sk

ille

d a

tte

nd

an

t

SBA among 60% of the poorest is very low

Assistance during delivery

 

Trend of Cesarean Section 1986 – 2002 by wealth quartile

Access to Emergency care: C-Section

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

Lower 80% Rich

% C

ae

sa

rea

n s

ec

tio

ns

Among the poorest 80% CS is less than 1% compared to 3.6% in the richest quartile (2007 overall-6.8%)

Catastrophic effect in the ‘almost poor’ group

MMR by presence/absence of health professional and wealth quartile, and proportion of births with HP by quartile, Serang, Pandeglang, Indonesia, 2004-6

0

500

1000

1500

2000

2500

Den

gan

NA

KE

S

Tan

pa

NA

KE

SPoorestt Lower middle Upper Middle Least Poor

Mat

erna

l de

aths

per

100

,,000

live

bi

rths

0

10

20

30

40

50

60

70

80

90

100

% b

irths

with

HP

am

ong

wom

en w

ith r

ecen

t birt

h

Kematian Ibu per 100,000 live births % kelahiran dg Nakes

Den

gan

NA

KE

S

Tan

pa

NA

KE

S

Tan

pa

NA

KE

S

Tan

pa

NA

KE

S

Den

gan

NA

KE

S

Den

gan

NA

KE

SMMR 1.9 times higher with SBA; only amongst richest is MMR same

with/without SBA but still over 200 Ronsmans et al 2009

In-patient costs at different types of facilities ($US)

Public

Hospital

Military Hospital

IND-DRG (class C-A)

Normal Delivery

82-89 163 70-154

C section

340-435 494 128-282

Indonesia: Why is MMR high? Most women use midwife for birth, little access to

emergency care due to lack of availability of skilled providers, costs and insurance issues

Costs of birthing Variability and lack of transparency of fees for hospitals Many private facilities/providers will not accept insurance for poor Public hospitals may not treat until they receive card Midwife is not reimbursed for woman’s care if she refers to hospital

Quality of care Regulations govern who can treat patient; no control over private sector, No coordination between midwives and hospitals; between District

Health Office (FH) and Governor’s office (where hospitals/doctors report) Low availability of obs in facilities (not clear re anes)

Private sector and its role in delivery care among countries, Asia and Middle East

Amanda Pomeroy

Marge Koblinsky

Soumya Alva

Growth in the private sector, Asia

Total Facility Births, by Facility Type, Asia

0

10

20

30

40

50

60

70

80

90

100

India *

Indonesia

Philippines

Bangla

desh

Cambodia

Nepal

% o

f all

birt

hs (b

ar h

eigh

t ind

icat

es to

tal f

acili

ty b

irth

s) Private Govt NGO

*India facility rates are for three years preceding the survey, because the 1998 data do not have information on births five years preceding survey. For all other countries, these rates are for all births five years preceding survey.

All DHS data; first time point was chosen to be from the fourth round of DHS survey collection (1997-2003) while the second time point was chosen to be in the fifth phase (2003-Present).

Second Year

First Year

Growth in the private sector, Middle East

All DHS data except Yemen 2nd year (PAPFAM 2003); first time point was chosen to be from the fourth round of DHS survey collection (1997-2003) while the second time point was chosen to be in the fifth phase (2003-Present). The first year of Yemen (1997) data is not split by facility type. Jordan: 2002-2007, Egypt: 2000-2008.

Total Facility Births, by Facility Type, Middle East

0

10

20

30

40

50

60

70

80

90

100

Yemen -First Yr*

Yemen -Second Yr

Jordan -First Yr

Jordan -Second Yr

Egypt -First Yr

Egypt -Second Yr

% o

f all

birt

hs (b

ar h

eigh

t ind

icat

es to

tal f

acili

ty b

irths

) Private Public NGO

By Facility Type, Breakdown of Births by Type of Delivery, by Year, Bangladesh

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Public- 1

st Yea

r

Public- 2

nd Year

Privat

e- 1

st Y

ear

Privat

e- 2

nd Yea

r

Natural Delivery

C-section

Percent Change in Private C-sections:

51%

Percent Change in Public C-sections: 54%

Shift from normal to csection in both pub and private

By Facility Type, Breakdown of Births by Type of Delivery, by Year, Indonesia

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Natural Delivery

C-section

Percent Change in Public C-sections: 41%

Percent Change in Private C-sections:

43%

Increase in csections in public and private sectors but as 78% of fac births are private, hence most of csec are in priv sector

Conclusions Bangladesh

Access to EmOC is a must! SBAs bypassed in densely pop areas where EmOC available;

may not be skilled to manage cx Specialists (or those trained in surgery/anes) not available in rural

public facilities Increase in EmOC private facilities and use Expenditure for birthing care high

Asia Private sector use is growing Dualism allowed (Bangladesh, Indonesia, Nepal, some

states/India); FTEs in Govt few; Doctors have large debts from med school

Csection use high in private sector, depends on access (distance, costs, insurance coverage)