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

1. A. Maternal Mortality Reduction inHonduras, 1990-1997B. Maternal Health IndicatorsJerker LiljestrandThe World Bank

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

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

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

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

6. 1990 1997 Comparison of Mortality Rates and Ratios: Honduras, 1990 and 1997 1.50 1.43 WRA mortality rate per 1000 WRA 221 147 Deaths within 42 days of pregnancy per 100,000 LB Maternal mortality ratio 182 108 Maternal mortality rate (per 1000 WRA) 0.26 0.13

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

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

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

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

11. Health facilities attending pregnant women, 1990 and 1997 1990 1997 % change CESAR 516 782 +51 CESAMO 177 213 +20 CMI 0 13 Area Hosp. 10 17 +70 Reg. Hosp. 6 6 0 Nat'l Hosp. 2 2 0 TOTAL 711 1033 +45

12. 1990 1997 % change Human resources, MOH, 1990 and 1997 Doctors 1261 1507 +20 Prof. nurses 422 702 +66 Aux. nurses 3519 4993 +42 Dentists 109 127 +14 Hlth. prom. 420 404 - 4 Other 5964 5067 -15 TOTAL 11,672 12,800 +10

13. Region 1990 PAMR 1997 PAMR % change Pregnancy-associated mortality ratios (PAMR) by region of residence 1 + Teguc. 158 123 -22% 2 360 194 -46%* 3 + Sn Pedro 170 125 -26% 4 161 111 -31% 5 348 190 -45%* 6 250 169 -32% 7 172 141 -18% 8 NA NA NA Metro NA NA NA TOTAL 221 147 -33%* * statistically significant

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

15. Percent Cesarean Deliveries by Area of Residence* 1987 1990/1991 1996 TOTAL 5.6 6.4 6.3 Teg. / SPS 12.8 12.6 10.6 Other urban 8.1 9.2 8.7 Rural 2.8 3.2 3.9 * based on last live birth in 5 year period prior to survey

16. Improved referral of high risk women for birth with skilled attendant • Policy of 'Focus on reproductive risk' • TBA training • Prenatal care • 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. '94 46 38 83% 46/852 = 5% 1995 153 106 69% 153/952 = 16% 1996 194 154 79% 194/1155 = 17% Jan.-Nov. '97 305 226 74% 305/1247 = 24%

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

19. Percent of Women with Birth in Health Facility by Area of Residence* 1987 1991/1992 1996 TOTAL 41 46 54 Teg. / SPS 89 87 92 Other urban 64 66 77 Rural 21 24 32 * based on last live birth in 5 year period prior to survey

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

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

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

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

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

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

26. B. Maternal Health Indicators

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

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

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

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

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

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