1. 23 May 2015 Delivering safer motherhood – sharing the evidence Vincent De Brouwere Institute of Tropical Medicine, Antwerp On behalf of all Immpact teams

2. 2 Acknowledgements The ITM Antwerp Immpact team -Hilde Buttiëns -Bruno Marchal -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 - Pascale Baraté - Anne Vriens - Dominique Dubourg

3. 3 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

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

5. 5 <100100-299300-499500-9991000+ Maternal deaths per 100,000 live births, 2000

6. 6 Have we made progress? MDG 5 Target

7. 7 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 2 New evidence of effective and cost-effective strategies OUTPUT 3 Stronger capacity for evidence-based decision- making and rigorous outcome evaluation OUTPUT 1 Enhanced methods and tools for measuring & attributing outcomes

8. 8 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

9. 9 OP1: Methods and Tools, focus on Measuring Maternal Mortality

10. 10 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) © Immpact

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

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

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

14. 14 Results from SSS-M compared to alternatives MM ratio (per 100,00 live birth) % maternal deaths among all deaths to women of reproductive age 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) WHO/UNICEF/UNFPA (National, modelled; 2000) 484 1000 (630 -1500) 22% 37%

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

16. 16 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

17. 17 Familial technique

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

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

20. 20 Evaluation questions in Ghana, Indonesia and Burkina OP2: New evidence on strategies

21. 21 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 ButBut: erratic funding is a threat to sustainability and credibility of the policy Other barriers still remain i.e. geographic, transportation and cultural

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

23. 23 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 Indonesia: Village midwifes

24. 24 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

25. 25 0,0% 2,0% 4,0% 6,0% 8,0% 10,0% 12,0% 14,0% richestpoorestRural area C-sections rate 19972003 Indonesia: contrasted improvement Better strategy can be to combine reduction of geographic and financial barriers to skilled care C-Sections Accouchements professionnels 0% 20% 40% 60% 80% 100% richestpoorest Rural area Proportion Of deliveries with health professionals 19972003 Institutional deliveries Caesarean sections

26. 26 Trends of institutional deliveries 30% Burkina: Community mobilisation

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

28. 28 OP2: 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

29. 29 OP3: 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

30. 30 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 long- term need of partner institutions for sustainability

31. 31 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

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