1. Overview: Maternal and Child Health in Resource Poor Settings or: The World is Not Flat HSERV/GH 544 Winter Term 2012

2. Session Objectives Define key terms used to describe MCH problems globally Provide an overview of where maternal and child deaths are occurring and trends over time Present an overview of underlying causes for limited improvements in maternal and child health Present an overview of direct medical causes of maternal and child deaths and introduce strategies to reduce mortality

3. Why focus on MCH?

4. MCH terms / indicators Definitions, Child: NMR = Neonatal mortality rate (deaths in 1 st 28 days of life/1000 live births) IMR = Infant mortality rate (deaths 0-11 months/1000 live births) U5MR = Under 5 mortality rate (aka CMR=child mortality rate) (deaths 0-4 years/1000 live births)

5. MCH terms / indicators Definitions, Maternal: Maternal death = Death of a woman while pregnant or up to 42 days after pregnancy from any cause except for accidental or incidental causes MMR = Maternal mortality ratio = pregnancy-related deaths per 100,000 births LTR = Lifetime risk of dying of a pregnancy-related cause (usually expressed in terms of odds, e.g. 1/74 = for every 74 women, 1 will die of maternal causes)

6. LTR Maternal Mortality, 2008 Source: Trends in Maternal Mortality 1990-2008. WHO, UNICEF, UNFPA and The World Bank.

7. MCH terms / indicators Definitions (continued): CBA = Child-bearing age = generally 15-49 years of age TFR=Total fertility rate (expected pregnancies per woman CBA) CPR=Contraceptive prevalence rate = proportion of married* women of CBA using contraception *entered into sexual union Interventions = “biologic agent or action intended to reduce morbidity or mortality” –Prevention or Treatment

8. MCH terms / indicators Common abbreviations ANC = Antenatal care (variously defined) HCW = Health care workers SBA = Skilled Birth Attendant (doctor, nurse or midwife) TBA = Traditional Birth Attendant CHW = Community Health Worker

9. MCH terms / indicators Terms related to economics and equity GNI PC=Per capita gross national income Ratio of richest 20% to poorest 20% -- Measure of equity/inequity in health indicators and intervention coverage Measure of equity/inequity in health indicators and intervention coverage using Wealth quintiles

10. Millennium Development Goals MDG4: Reduce U5MR by two thirds MDG5: Reduce MMR by three quarters Between 1990-2015

11. Trends in Child Mortality: Not on Track to Meet MDG4 Based on data from the Interagency Group for Child Mortality Estimates

12. Are MDG 4 & 5 realistic / attainable? Majority of maternal and child deaths are preventable with interventions that are already available and currently recommended for wide scale implementation. Despite worldwide failure to meet MDG 4 & 5 without massive acceleration, a few countries are demonstrating that it can be done.

13. Where do the maternal deaths occur?.

14. Where do the child deaths occur? Source: Levels & Trends in Child Mortality. UN Inter-agency Group for Child Mortality Estimation. 2011

15. Where do the child deaths occur? Source: Levels & Trends in Child Mortality. UN Inter-agency Group for Child Mortality Estimation. 2011

16. MMR# MaternalLTR Annual Deaths Maternal MMR Death Reduction Bolivia 180 470 150 -5.8 on track Peru 98 600 370-5.2 +progress Ghana 350 2600 66 -3.3 +progress Kenya 530 7900 38 1.8 no progress Sudan 750 9700 32 -0.5 insuff prog India23063000 140-4.9 +progress Timor-Leste 370 160 44 -3.2 +progress USA 24 1000 2100 3.7 Sweden 7 5 11,400 -1.6 Inequities Within Regions Source: Trends in Maternal Mortality: 1990 to 2008, WHO, UNICEF, UNFPA and The World Bank. 2010.

17. Inequities Within Countries Source: Skolink. Global Health 101.

18. Progress in Reducing Maternal and Child Deaths is also Unequal MMR (per 100,000 live births), 1990 to 2008

19. Reducing MMR: Much Variation Between Countries Source: Hogan et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–23

20. Source: Levels & Trends in Child Mortality. UN Inter-agency Group for Child Mortality Estimation. 2011 Reducing U5MR: Not all Countries are Equal

21. What Drives Inequities Across and Within Countries?

22. Determinants

23. Socio-political-economic factors and policies

24. MMRGNI PCAnnual MDG5 (USD) MMR Reduction Bolivia 180 4640 -5.8 on track Peru 98 8930-5.2 +progress Ghana 350 1660 -3.3 +progress Kenya 530 1680 1.8 no progress Sudan 750 2030 -0.5 insuff prog India230 3550-4.9 +progress Timor-Leste 370 3600 -3.2 +progress USA 24 47360 3.7 Sweden 7 39730 -1.6 GNI PC and MMR / MMR Reduction Source: Trends in Maternal Mortality: 1990 to 2008, WHO, UNICEF, UNFPA and The World Bank. 2010.

25. GNI PC and MMR Source: Markle. Understanding Global Health.

26. Economic growth and U5MR Source: Save the Children

27. Race / Ethnicity and Child Health Burden of low birth weight in US – highest among low income and populations of color

29. Child Mortality: ↑2x poverty, ↑2x rural, ↑3x lack maternal education

30. Poverty and Child Mortality In 18 of 26 developing countries with substantive declines in U5MR, inequality in U5MR between the poorest 20% and the richest 20% either stayed the same or increased.

31. Percent of women who have a final say in decision making regarding their own health Source: WHO Report on the Social Determinants of Health

32. Access to Care: SBA

33. Equity and Access to Care: SBA Source: 2005 World Health Report. WHO.

34. Equity and Access to Care: Malaria Interventions

35. Fall in the standardized death rate per 100,000 population for nine common infectious diseases in relation to specific medical measures for the United States, 1900-1973 (Source: McKinlay, J. B., & McKinlay, S. M. (1977). The questionable contribution of medical measures to the decline of mortality in the United States in the twentieth century. Milbank Memorial Fund Quarterly. Health and Society, 55 (3), 405-428.) But remember -- technology is not the only answer….

36. Maternal Health Problems ~200 million pregnancies / year ~75 million unwanted pregnancies ~20 million unsafe abortions ~350,000 maternal deaths 1 maternal death = 20 maternal morbidities

37. What are the medical causes of maternal deaths? Most causes can be prevented with treatment by SBA in facilities

38. Current approaches to reducing maternal mortality Antenatal care Improving skills of birth attendants –Traditional birth attendants (TBAs) –Skilled professional attendant at delivery (SBAs) Emergency Obstetric Care (EmOC) Postpartum care Family planning

39. Why do so many women lack skilled birth care? 1.Delay in decision to seek care –Lack of understanding of complications –Acceptance of maternal death –Low status of women –Socio-cultural barriers to seeking care 2.Delay in reaching care –Geography (mountains, islands, rivers) – no realistic access –Poor transport & organization 3.Delay in receiving quality care –Shortages of supplies, personnel, transport to higher facility –Poorly trained personnel with punitive attitude –Finances

40. Child Health Problems

41. 7.6 Million Child Deaths in 2008: Equivalent to a tsunami every few days Undernutrition = underlying cause >1/3 of deaths

42. Two-thirds of child deaths can be averted with interventions that are already available and recommended for wide scale coverage.

43. However… Poor progress in increasing coverage of many basic interventions Data from African countries. Reproduced from UNICEF ChildInfo website: http://www.childinfo.org/pneumonia_progress.phpand based on UNICEF global databases, 2009.

44. Summary Maternal health problems are often not predictable and may require facility based medical interventions Many common child health problems can be dealt with via community-based public health strategies Newborn health problems require a mixture of the two approaches Photo: WHO/C Black

45. Summary Aggregate statistics (e.g. national MMR or U5MR) are insufficient Strategies needed to reach most vulnerable populations with interventions Necessary to impact determinants and socio-political-economic policies that drive health in order to make deeper and long- lasting impact on MCH