Implications for Maternal and Newborn Health Policies

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Implications for Maternal and Newborn Health
Policies

• Shahida Zaidi, FCPS
• Vice President, FIGO
• Director, Ultrasound Clinic and Institute of
  Ultrasonography
• 140 R/2, PECHS, Karachi. Pakistan
• ltzaidis_at_cyber.net.pkgt

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Focus on

• Medical causes, contributory factors of deaths
• What works Sri Lankan success
• Role of health professionals and professional
  bodies in policy-making

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• The medical causes of maternal deaths
• and perinatal deaths are well known,
• and overlap to a large extent

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High foetal deaths and early NNDs

• A reflection of
• ? poor nutritional and health status
• of mother
• ? little or no ANC, poor quality
• ? poor supervision of labour

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• Factors contributing to high foetal deaths are
  the same as those contributing to maternal deaths

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Causes of delay in 150 women brought dead to the
JPMC, Karachi

• First delay
• Family hesitancy 16.0 45.3
• Husband not present at home 12.7
• Lack of awareness of severity of problem 5.3
  
• Financial constraints 11.3
• Second delay
• Transport not available 24.7
• Third delay
• Transfer from one facility to another 10.7 20.7
• Delayed referral by health facility 10.0
• Undetermined 9.3
• Jafarey and Korejo, 1990

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• What works is also known
• Success story of Sri Lanka

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Sri LankaJN RodrigoLow maternal mortality in
Sri Lanka how has this been achieved?

• . . . midwifery training for nurses and
  registration of midwives started in 1897 probably
  caused the extinction of this species (the
  traditional birth attendant).

In Maternal and Perinatal Health. Ed. S Zaidi,
1991
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DGH de Silva Perinatal Care in Sri Lanka
Secrets of Success in a Developing Country

• In 1999
• 54 paediatricians, 77 obstetricians in the
  health department
• Less than half this number in the 1950s when
  the perinatal mortality rate was about 50/1000
  total births

In perinatal and newborn care in south asia.
Priorities for action. Ed. ZA Bhutta. Oxford
University Press, 2006
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• de Silva
• Specialised neonatal care services a myth in
  perinatal care (first neonatal ICU established in
  mid-1980s in Colombo)
• Good primary health care infrastructure reaching
  grassroot level
• Skilled birth attendants (family health midwife)
• High literacy rate 10 of GNP spent on
  education

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Investments needed

• Long term
• Skilled birth attendants recognised
• by many governments (Bangladesh,
• Pakistan)
• Good infrastructure, education
• Short term
• Many initiatives e.g. training available
• HCPs in recognising dangers signs, creating
  community awareness

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Role of health professionals and professional
organisations

• ? Assume leadership
• ? Help train and provide support to birth
  attendants
• Audit services, maternal and perinatal
• deaths

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• Assume leadership
• ? influence governments to increase
• budget for health and education
• ? seek help of the media in bringing this
  about, and to enhance public awareness
• about measures to improve maternal health
• ? help introduce community interventions
• ? help plan and implement cost-effective
  interventions carry out pilot projects

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Korangi Safe Motherhood Project,Karachi, 1999
2001

• Society of Obstetricians and Gynaecologists of
  Pakistan,
• Aga Khan Community Health Sciences,
• with support from JSI, MotherCare, USA

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• ? Training of 4 categories of HCPs in EmONC
• in Korangi (industrial) area
• - recognition of complications and referral
• ? Linkage to a tertiary care hospital
• ? Bringing all HCPs together for a
• discussion every month
• ? Community education about danger signs

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FIGO Saving Mothers and Newborns Projects with
NS of O G in 12 countries
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• Community-based Interventions to reduce maternal
  and perinatal mortality and morbidity in rural
  Sindh, Pakistan
• 2006-2009

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Interventions2 facilities upgraded 1
district hospital (C section), 1 rural health
centre (RHC)Obstetrician 2 medical officers in
district hospital2 medical officers in
RHCTraining of community midwives
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• Community level
• members raise awareness of
• - danger signs in pregnancy
• - need for birth preparedness (setting finances
  aside, arrangements re transport)
• - newborn care
• - breastfeeding
• HCPs
• - ANC iron and folic acid, TT, BP,
  identification of high risk pregnancies and
  referral,
• - clean, safe delivery
• - use of partogram
• - early referral in case of complications
• - neonatal resuscitation, care
• - early breastfeeding

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Impact

• Increased utilisation of services
• C sections and instrumental deliveries performed
  at the referral centre

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Hala project, in rural Sindh, Pakistan

• Aga Khan University

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Impact

• Over a period of two years, care-seeking for
  delivery increased from 13.9 to 33.6
• Delivery in the government health facility
  increased from 17.9 to 34

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Impact on indicators in intervention clusters
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Linkage to a functioning health facility
very importantJokhio, Winter, Cheng (2005) An
Intervention Involving Traditional Birth
Attendants and Perinatal and Maternal Mortality
in Pakistan. N Engl J Med, May 19,2005,
35220,2091-2099
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• Interventions
• 3-day training for TBAs in antepartum,
  intrapartum and postpartum care
• care of newborn
• obstetricians provided outreach services
• referral of complications to a health
• facility
• provision of disposable delivery kit

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• 10,114 women in intervention group,
• 9443 women in control group
• Impact
• Lower PNMR in intervention group 84.8 vs 120
• Lower maternal mortality 268 vs 360 (NS)
• Lower p. sepsis and PPH rates
• Obstructed labour diagnosed in greater no.

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Janani Suraksha Yojani (JSY), government
programme in India to promote facility deliveries
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Promoting institutional deliveries

• Cash incentive
• Family
• Rs. 1400 (35)
• ASHA / mobilizer
• Rs. 600 (15)

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JSY impact 28 times increase in institutional
deliveries in one year (in govt sector)
Million beneficiaries
Projected
VK Paul, UNFPA personal communication
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• REDUCING MATERNAL AND PERINATAL MORTALITY IS NOT
  NECESSARILY EXPENSIVE
• WHEN 3 GOES A LONG WAY
• . . . . to provide the essential services needed
  to tackle the problem that would cover a skilled
  health worker to assist every delivery, access to
  essential obstetric care for mothers and their
  infants when complications arise, and family
  planning information and services so that
  unwanted pregnancies and unsafe abortions can be
  avoided.

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• We have the skills, the science, the resources.
  And certainly the political will.
• Minister Douglas Alexander
• We need some passion, some collective,
• to galvanise political action.
• Mary Robinson

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• Thank you!

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