Maternal & Newborn Health in the Pacific

1. Maternal & Newborn Health in the Pacific Pasifika Medical Association, Tonga September 2013

2. “ Children have a right to special care and assistance”

3. No mother should die giving life

5. PICT commonalities • Relative isolation • Resource poor • Collectivism • Service & obligation • Traditional social structures • Scattered populations • Geographical isolation • Resource poor • Cultural diversity • Traditional social structure • Gender inequity • Globalisation • Urbanisation • Erosion of traditional social structures

7. Available Medical Rx & technology

8. Pregnancy and better outcomes Pre-pregnancy health Antenatal care Health promoting behaviors Labour & delivery Postnatal care Supportive environment Mortality & Morbidity for mothers Mortality & morbidity for babies

9. MCH Policy & Strategy • “Regional Child Survival Strategy” 2005 • “Pacific Policy Framework for Universal access to Reproductive Health” 2008 • “Achieving MDG 4 & 5 : Scaling up programmes for Women and Childrens Health”. 9th Meeting Pacific MOH’s, 2011. • “Global Strategy for Women and Children’s Health” United Nations, 2010 • “Monitoring maternal newborn and child health: understanding key progress indicators”. UN Health Metrics, 2011

10. United Nations Commission on Information and Accountability, 2011

11. 11 Global MCH indicator Pacific data Data source: World Bank data Bank 2012, Cook Is Census 2011, World Health Statistics 2012, Division of Statistics FSM 2009, Marshall Is 2007, Nauru DHS 2007, Samoa DHS 2009, Global Aids Progress Reporting 2012

12. Health information & Vital statistics

13. DHS data complementing MOH dataTUVALU under 5 yr mortality

14. Maternal & Newborn healthChallenges & opportunities • Access to essential interventions • New technologies and medication • Lack of Investment in Maternal & infant health • Unclear policy and strategic direction • Not tracking results • ?? Accountability

15. Maternal & Newborn healthChallenges & opportunities • Maternal obesity • Maternal smoking • Non-communicable diseases • Maternal mental health • Family Planning access • Adolescent Mothers

16. Adapted from Black et al.2008.Cook I, FSM ,Fiji, Marshal Is, Nauru, Nuie, Palau, PNG, Samoa, Solomon Is, Tonga, Tuvalu, Vanuatu

17. Children’s lives saved if MDG target trajectory increased Adapted from : Asia Pacific MDG Report 2011/12 UNFPA, UNICEF, WHO

18. Oceania 31% 30% 23%

19. Country Neonatal Mortality, 2010per 1000 livebirths

20. Newborn survival • Maternal health & perinatal care • Neonatal resuscitation • Neonatal care – warmth, antibiotics, breastfed • Postnatal review <3 days

21. “Best Bets” Saving Newborn lives

22. “Neonatal Resuscitation in Low resource settings. What , who and How to overcome challenges to scale up” Wall et al. 2009

25. Change in Maternal Mortality Ratio by region 1990 – 2010Not all on track to Achieve MDG 5 WHO 2012 “MM Trends”

26. MDG 5 – Reduce Maternal mortality by 75%MMR (maternal deaths/100,000 births) MMR Source: ESCAP database

27. Maternal Deaths saved if “Off track” countries achieved MDG target Adapted from : Asia Pacific MDG Report 2011/12 UNFPA, UNICEF, WHO

28. Preventing Maternal Mortality • Maternal / women’s health • Prevent unintended pregnancies • Antenatal care • Skilled birth attendant • Access to emergency obstetric care • Postnatal care

29. Why women die Ronsmans et al. Maternal Survival. The Lancet, 2006

30. Giving Birth in the Pacific • Ideal = Delivery in a health facility with skilled birth attendant • Most continue to deliver at home with Skilled birth attendant access improving • Intervention needs to be “at the right time” >50% maternal & newborn deaths during the birth period (labour/delivery/postpartum)

31. Obstetric complications

32. Maternal & Newborn survivalStrategies for limited health facility setting Community based care • Education, access to Family Planning • Community Antenatal visits (nutrition, malaria, STI, birth preparedness) • Traditional Birth attendants / Village health workers • Delivery kits/hygiene/neonatal resuscitation/oral misoprostol • Postnatal care – temperature/hygiene/exclusive breast

33. Giving Birth in the Pacific - The “three delays” • Delay in decision to seek care • Delay in reaching care • Delay in receiving adequate care

34. The 1st delay – barriers & strategies • Female Education • Antenatal education • Antenatal care • Community promotion of Maternal & newborn care • Low status of women • Lack of understanding of pregnancy /labour complications • Lack of knowledge of interventions • Acceptance of maternal death

35. The “2nd delay” • Geography • Isolation & distance • Transport, roads • Seasonal barriers • Climate disasters • Cost • Transport infrastructure • Emergency transport • Anticipatory transfer • “waiting houses” • Patient subsidies

36. “third delay” - strategies • Infrastructure • Workforce • Skilled birth attendants • Emergency Obstetric care • Technology • Equipment & meds • Communication

37. MDG 5 - % of Births with Skilled birth attendant %

38. HIV +ve antenatal women receiving antiretroviral treatmentSource: Global Aids Progress Reporting 2012 for individual countries Pacific MCH Indicators

41. Essential equipment

42. “Stillbirth” weights TTM Hospital, Samoa, 2006-2009 Source: Pacific CHIP project PATIS & Delivery unit record data, Percival & Stowers 2012

43. Family Planning in the Pacific • 1 in 5 Adolescent girls (15-19yrs) already mothers • Increased health risk to mother & baby

44. Contraception Prevalence by region

45. Improving Maternal & newborn Health • Leadership (Country & Region) • Prioritize mothers and children • Prioritize Health • Infrastructure & workforce • Health Information, Vital statistics • Evidence based policy • Upscale “best bets”

46. Levels of Maternal & Newborn care Essential tools & skills • Village level (non-clinical workforce) • Core intervention/Rx • Expanded care & Rx • Comprehensive care & Rx

47. Maternal and newborn health included in other Policy