1. A. Maternal Mortality Reduction in Honduras, 1990-1997 B. Maternal Health Indicators Jerker Liljestrand The World Bank

2. A. Maternal Mortality Reduction in Honduras, 1990-1997 A Case Study

3. Methods n One year retrospective studies (1990 and 1997). “Entire country”. n Identified all deaths to women of reproductive age (WRA), using multiple sources of information. n Determined if death occurred during pregnancy or within 42 days of end of pregnancy. n Determined if it was a maternal death.

4. n Vital statistics (60% of deaths are registered) n Key community informants (TBAs, voluntary health workers, nurses in CESARs, leaders) n Hospital death records (including private hospitals) n Cemeteries n Autopsy records, forensic records Sources of Information Data collection instruments were the same in both studies.

5. Findings n 1,757 deaths of WRA n 381 deaths during pregnancy or within 42 days of pregnancy (21.7%) n 314 maternal deaths (17.9%) 1990 n 2,175 deaths of WRA n 258 deaths during pregnancy or within 42 days of pregnancy (11.9%) n 194 maternal deaths (8.9%) 1997

6. Comparison of Mortality Rates and Ratios: Honduras, 1990 and 1997 1990 1997 WRA mortality rate per 1000 WRA 1.43 1.50 Deaths within 42 days of pregnancy per 100,000 LB 221147 Maternal mortality ratio182108 Maternal mortality rate (per 1000 WRA)0.260.13

7. General Objective of studying process in Honduras: What reasons for the reported reduction in maternal mortality?

8. n Improved access to treatment of obstetric emergencies n Improved referral of high risk women for hospital delivery n Improved access to and utilization of skilled attendants during delivery n Improvement in the quality of care n Vitamin A fortification Specific Objectives To assess hypotheses:

9. Improved access to treatment of obstetric emergencies n Availability of obstetric emergency services n Referral of women with obstetric emergencies

10. Improved access to treatment of obstetric emergencies n Availability of obstetric emergency services 3 Construction and equipping of health facilities 3 Adequate staffing 3 Focus on areas with higher mortality

11. Health facilities attending pregnant women, 1990 and 1997 19901997% change CESAR 516782+51 CESAMO 177213+20 CMI 013 Area Hosp. 1017+70 Reg. Hosp. 660 Nat'l Hosp. 220 TOTAL 7111033+45

12. Human resources, MOH, 1990 and 1997 19901997% change Doctors 12611507+20 Prof. nurses 422702+66 Aux. nurses 35194993+42 Dentists 109127+14 Hlth. prom. 420404- 4 Other 59645067-15 TOTAL 11,67212,800+10

13. Pregnancy-associated mortality ratios (PAMR) by region of residence Region1990 PAMR1997 PAMR% change 1 + Teguc.158123-22% 2360194-46%* 3 + Sn Pedro170125-26% 4161111-31% 5348190-45%* 6250169-32% 7172141-18% 8NA MetroNA TOTAL221147-33%* * statistically significant

14. Improved access to treatment of obstetric emergencies n Referral of women with obstetric emergencies 4 TBA training 4 Integration of TBA into formal health system 4 Improved relations between community and health service sector --> improved acceptance and demand 4 Birthing centers 4 Improved transportation / roads / communication

15. Percent Cesarean Deliveries by Area of Residence* 19871990/19911996 TOTAL5.66.46.3 Teg. / SPS12.812.610.6 Other urban8.19.28.7 Rural2.83.23.9 * based on last live birth in 5 year period prior to survey

16. Improved referral of high risk women for birth with skilled attendant n Policy of 'Focus on reproductive risk' n TBA training n Prenatal care n Maternity waiting homes

17. Data from maternity waiting home at San Marcos Ocotepeque (Region 5) Time period # women admitted # high risk women% high risk % of deliveries at hosp. July-Dec. '94463883%46/852 = 5% 199515310669%153/952 = 16% 199619415479%194/1155 = 17% Jan.-Nov. '9730522674%305/1247 = 24%

18. Increase in deliveries with skilled attendants n Birthing centers in communities with higher risks n Increased acceptance / demand

19. Percent of Women with Birth in Health Facility by Area of Residence* 19871991/19921996 TOTAL414654 Teg. / SPS898792 Other urban646677 Rural212432 * based on last live birth in 5 year period prior to survey

20. Distribution of maternal deaths by cause and place of death, 1990 and 1997 15 19901997

21. n Decentralization of decision-making, promotion of local initiative to solve problems n Community involvement in maintenance, sustainability of community health services n Training of community health providers/ TBAs n Changes in hospital culture --> acceptance, integration of community health providers/ TBAs n Community health education activities n Community health councils Community Participation

22. n 1990 study revealed magnitude of problem --> changes in health policy at the national level n Commitment to reaching areas most in need --> resources redistributed n Emphasis on access to health services ("Project Access") 4 improved community health services 4 training of human resources 4 community participation n Foreign aid channeled to promote these strategies n 7.2% of GDP spent on health and social services National Health Policy, 1990-1997

23. n Relatively stable political situation n End of "cold war" in late 1980s n Cadre of well trained, experienced, highly committed people working in public health Other considerations

24. n Multiple interventions n National leadership n Focus on higher risk / mortality areas Summary Causes for the reduction in maternal mortality

25. n Targets for maternal mortality cannot be achieved n Maternal mortality cannot be measured Summary The Hondurans have challenged the idea that:

26. B. Maternal Health Indicators

27. Measuring Maternal Health n Reduced maternal mortality n Reduced maternal morbidity n Improved maternal well-being The Target Outcomes:

28. Measuring Maternal Health n Can be difficult to measure n May not be useful for short-term programmatic evaluations However, outcome indicators have limitations:

29. Measuring Maternal Health n Proportion of deliveries with skilled attendance (who, where) n Number and distribution of EOC services n Cesarean delivery rate n Institutional case fatality rates Process indicators recommended by WHO/UNFPA/UNICEF/World Bank

30. Measuring Maternal Health n Prenatal care n Quality of care 4tetanus toxoid, VDRL or RPR during ANC 4use of partogram during labor 4client satisfaction n Knowledge about complications Examples of other process indicators:

31. Measuring Maternal Health n Definitions n Even these may not be useful for short-term programmatic evaluations n Are not necessarily associated with desired outcomes These process indicators too have limitations:

32. Measuring Maternal Health n What is the program trying to accomplish? n How can progress to this goal be measured? n Develop indicators at the beginning! Bottom line for programs: