1. Understanding and responding to the determinants of maternal deaths Photo by Renee Bourque, Bright Star Consultants, www.brightstargrants.com

2. Learning objectives By the end of this session, participants will be able to: Explain the difference between causes and determinants of maternal death Classify determinants using the “3 delays” Identify how community-level action links to MDSR

3. Brainstorming Exercise In the next 5 minutes: 1)List 3-5 main causes of death during or immediately after childbirth in Ethiopia 2)For each of these, note down what social factors you think contribute to them

4. Follow up Discussion 1)Sharing different determinants identified by the group 2)Grouping similar ones together 3)Discuss how many may be outside the health system!

5. Review of Terms Causes The immediate clinical or medical reason for the woman’s death, classified as a direct or indirect maternal death Determinants The “causes of the causes” or factors that increased the woman’s risk of dying from a specific cause

6. Common Determinants of Maternal Deaths 1)Poor access to family planning and safe abortion services 2)Insufficient use of antenatal services 3)No skilled attendance at delivery 4)Difficulties in obtaining transport 5)Insufficient supplies or staff 6)Low status of women These are very different factors, operating at different levels of social influence

7. The “3 Delays” Model Generally refers to events following an obstetric emergency, so very specific Related to seeking and obtaining clinical care Divides the process of accessing care into 3 phases: – Recognising an emergency & need for treatment – Reaching a health facility where care is available – Receiving the care that is needed

8. Delay 1 Delay in deciding to seek care: Rapid recognition of a problem can be critical to saving a mother’s life (esp. for excessive bleeding) Delay 1 measured as length of time from onset of a complication to decision to seek care Determinants include: – Inadequate knowledge – Reliance on family members who are not present – Lack of familiarity with or trust in services Education, socio-economic status and women’s autonomy also affect Phase 1 in seeking care

9. Delay 2 Delay in reaching care: Once decision to seek care is made, there can be delays in reaching it Determinants include: – Unavailable or expensive transport – Long distances to facilities – Costs related to accompanying woman or paying fees/ expenses related to services – Inadequate referral systems between facilities Inequitable or insufficient distribution of CemOnc services increase type 2 delays

10. Delay 3 Delay in receiving care: Delays 1 & 2 can lead to a women never reaching a facility or arriving in critical condition Delays within a facility also contribute to maternal deaths or “near misses” Determinants relate to Quality of Care: – Shortages of staff, equipment or blood products – Time lag between arrival and initiation of treatment/ surgery – Poor technical competence

11. Addressing Community Level Determinants Delay 1 relates mainly to Individual & Family determinants Delay 2 relates to Community determinants Delay 3 relates to Health System determinants All delays reflect background factors, such as: – Women’s autonomy & education – General reproductive health – Laws, policies and cultural norms

12. GROUP WORK Divide into small groups of 5-6 people Group will be assigned one of the 3 delays Discuss what factors in Ethiopia are most likely to lead to that delay Identify at least 3 strategies or activities that targets the factors you identified and might help reduce the delay

13. Summary Points Social determinants are the “causes of the causes” of maternal deaths, and depend on many social levels Addressing maternal deaths thus requires action at every level, not just medical or health services Because many women die at home, in transit or soon after arrival at a facility, understanding the delays in receiving care helps analyse patterns of deaths MDSR identifies determinants related to the 3-delays from the onset of obstetric complications At higher levels (RHB, national) social determinants beyond the 3 delays should be considered (culture, gender)