Delivering safer motherhood sharing the evidence Vincent

Delivering safer motherhood – sharing the evidence Vincent De Brouwere Institute of Tropical Medicine, Antwerp On behalf of all Immpact teams 19 March 2018

Acknowledgements • The ITM Antwerp Immpact team - Hilde Buttiëns - Dominique Dubourg - Bruno Marchal - Pascale Baraté - Anne Vriens - Yvette Jacob • Wendy Graham, PI, and Aberdeen team • The Centre Muraz (Burkina Faso), Centre for Family Welfare (Indonesia), Nogutchi (Ghana) teams who produced the results in collaboration with teams from north institutions (University of Aberdeen, London School of Hygiene and Tropical Medicine, Johns Hopkins, Institute of Tropical Medicine Antwerp) • Carine Ronsmans (especially for the slides of the Lancet series presentation graciously provided) • Donors: Bill & Melinda Gates Foundation, DFID, USAID, EU 2

The problem of maternal death is large • A woman dies each minute -- day in, day out • Maternal mortality is the public health indicator with the greatest gap between rich and poor countries 3

1 in 30, 000 die in Sweden compared to 1 in 16 in sub-Saharan Africa Maternal deaths Maternal death in Sweden in sub-Saharan Africa 4 Women who survive Maternal deaths in sub-Saharan Africa Maternal death in Sweden

Maternal deaths per 100, 000 live births, 2000 5 <100 100 -299 300 -499 500 -999 1000+

Have we made progress? MDG 5 Target 6

Immpact Framework Of Objectives SUPERGOAL Maternal mortality and morbidity reduced GOAL Women receive timely care which is appropriate, effective and acceptable to their needs arising from pregnancy, childbirth and the puerperium PURPOSE Policy makers and programme managers practise evidence-based decision-making for safe motherhood OUTPUT 1 Enhanced methods and tools for measuring & attributing outcomes 7 OUTPUT 2 New evidence of effective and cost-effective strategies OUTPUT 3 Stronger capacity for evidence-based decisionmaking and rigorous outcome evaluation

Output 1: Methods and Tools • About 30 different tools generated to measure: - Maternal outcomes - Perinatal outcomes - Process - Factors influencing health systems - Outcomes after pregnancy - Economic outcomes - Policy making process - Functionality of health centres 8

OP 1: Methods and Tools, focus on Measuring Maternal Mortality 9

Guiding principles for maternal mortality work programme 1. Promote multiple measurement approaches (to increase the armoury of tools) 2. Increase efficiency of data capture (to address in-country capacity constraints & large sample sizes needed) 3. Improve reliability of data (to promote awareness that quality matters) 4. Focus research and development effort (to build on promising existing tools & innovate) 10 © Immpact

Work programme innovations in phase I POPULATION BASED ESTIMATES INSTITUTIONAL ESTIMATES 1. Sampling at service sites (SSShealth facilities; SSSmarkets) Secondary research: 2. MADE-IN/ MADE-FOR Meta-analytic methods 11 Familial Technique; Profiles; CAUSE OF DEATH Rapid Ascertainment Process for Institutional Deaths (RAPID) CAPACITY STRENGTHENING Barriers and facilitators to reporting facility and community deaths Computer algorithm for causes (Inter. VAM) E. g. CAL packages Census workshop

Innovation in sampling, hence called Sampling at Service Sites (SSS) © Immpact 12

Exploring alternative sampling sites – Burkina Faso “Sampling at shopping sites”- market places © Immpact Proof of principle trial of SSS-M compared to household survey Market survey was quicker and also cheaper (3 US$ compared to 11 US$) 13

Results from SSS-M compared to alternatives MM ratio (per 100, 00 live birth) SSS-M (Ouargaye; 2003/04) 397 (254 - 540) 26. 9% Immpact census: deaths in household (Ouargaye; 2003/04) 400 (343 – 457) 26. 4% Immpact census: direct sisterhood method (Ouargaye part; 2003/04) 332 (246 - 418) 18. 0% DHS (National; 1999) 484 22% WHO/UNICEF/UNFPA (National, modelled; 2000) 14 % maternal deaths among all deaths to women of reproductive age 1000 (630 -1500) 37%

Work programme innovations in phase I POPULATION BASED ESTIMATES 1. Sampling at service sites (SSShealth facilities, SSSmarkets); 2. MADE-IN/ MADE-FOR 15 INSTITUTIONAL ESTIMATES Secondary research: Familial Technique; Profiles; Meta-analytic methods CAUSE OF DEATH Rapid Ascertainment Process for Institutional Deaths (RAPID) CAPACITY STRENGTHENING Barriers and facilitators to reporting facility and community deaths Computer algorithm for causes (Inter. VAM) E. g. CAL packages Census workshop

What is MADE-IN/MADE-FOR? Maternal Death from Informant (MADE-IN) Village-based informants identify maternal deaths among women of reproductive age Maternal Death Follow On Review (MADE-FOR) Follow-up interviews with families confirm cause of death 16

Familial technique 17

Work programme innovations in phase I POPULATION BASED ESTIMATES INSTITUTIONAL ESTIMATES 1. Sampling at service sites (SSShealth facilities, SSSmarkets); Secondary research: 2. MADE-IN/ MADE-FOR Meta-analytic methods 18 Familial Technique; Profiles; CAUSE OF DEATH Rapid Ascertainment Process for Institutional Deaths (RAPID) CAPACITY STRENGTHENING Barriers and facilitators to reporting facility and community deaths Computer algorithm for causes (Inter. VAM) E. g. CAL packages Census workshop

Computer algorithm for causes (Inter. VAM) Inter. VAM a model for determining pregnancy-related causes of death from verbal autopsies 19

OP 2: New evidence on strategies Evaluation questions in Ghana, Indonesia and Burkina 20

Ghana: Delivery Fee Exemption policy • 2003: pilot trial in four regions • 2005: extension to the whole country in public, private-for profit and private not for profit sectors • Results: - 11% increase of skilled care utilisation - Better access of poor women • But: erratic funding is a threat to sustainability and But credibility of the policy • Other barriers still remain i. e. geographic, transportation and cultural 21

Ghana Quality of care before and after the introduction of the free delivery policy (average score in 2003 and 2005) Maximum score: 44 22 Before fee exemptions After fee exemptions

Indonesia: Village midwifes • Reduction of geographic barriers: - By 1996: 54. 000 village midwives posted in each village - Immpact 2005: • Urban area well covered • Only 29% of villages covered • Where there is a village midwife, this halves MMR 23

Village midwifes efficacious, but… • Identify on time obstetric complications • Facilitate the decision to refer early • Help the family to organise the transfer • But knowledge, skills and quality of care still insufficient 24

Proportion Of deliveries with health professionals Indonesia: contrasted improvement Accouchements Institutional deliveries professionnels 100% 80% 60% 40% 20% 0% Rural area richest Better strategy can be to combine reduction of geographic and financial barriers to skilled care poorest 1997 2003 Caesarean sections 14, 0% C-sections rate 12, 0% 10, 0% 8, 0% 6, 0% 4, 0% 2, 0% 0, 0% richest 25 poorest 1997 2003 Rural area

Burkina: Community mobilisation Trends of institutional deliveries 30% 26

Access to life saving interventions Caesarean rates per 100 births in the two districts under study 27

OP 2: Summary findings Ghana • Removing financial barriers increased institutional deliveries but financing must be sustained • Accompanying measures required Indonesia • Addressing geographic barriers increased skilled attendance at delivery • Financial barriers remain Burkina Faso • Community mobilisation increased institutional deliveries • Geographic and financial barriers remain for hospital care In all settings, quality of care is an issue 28

OP 3: Capacity strengthening • Involvement of country technical partners has improved national research capacities • Key policymakers and stakeholders must be involved in setting health and research priorities and translating results 29

Capacity-Strengthening Challenges • Balancing international research and national interests • Managing the tension between the need for fast results and the need to establish new competencies. • Balancing short-term need of research with longterm need of partner institutions for sustainability 30

Conclusion • Direct causes of maternal deaths are avoidable provided there is a functioning health care system and a comprehensive approach of maternal health • Main challenge is the human resources: competent, available in an appropriate working environment • This health care system depends on the societal development - Pressure to get quality care - Functioning logistics - Women’s empowerment - Equity 31

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