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A bold endgame:
Ending preventable maternal
deaths worldwide by 2035
CORE Meeting
Baltimore, MD
April 26, 2013
1
850
53
590
140
400
500
45
240
80
210
-
100
200
300
400
500
600
700
800
900
Sub-Saharan Africa Eastern Asia
(excluding China)
Southern Asia
(excluding India)
LAC World
MMR:maternaldeathsper100,000livebirths
While maternal mortality has declined globally between 1990 &
2010, there has been considerable regional variation
1990 2010
41%
AAR: 2.6%
59%
AAR = 4.4%
41%
AAR: 2.6%
41%
AAR: 2.6%
47%
AAR: 3.1%
Source: WHO/UNICEF/UNFPA/World Bank. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva, World Health Organization, 2012.
MDG 5 Assessment of Progress for 24 priority
countries: Maternal Mortality Ratio Average Annual
Rate of Reduction (%) 1990-2010
Zambia, 0.4
Kenya, 0.5
Sudan, 1.6
Liberia, 2.4
Ghana, 2.6
Nigeria, 2.6
DR Congo, 2.7
Haiti, 2.7
Pakistan, 3.0
Senegal, 3.0
Mozambique, 3.1
Tanzania, 3.2
Uganda, 3.2
Mali, 3.5
Malawi, 4.4
Madagascar, 4.7
Ethiopia, 4.9
Indonesia, 4.9
Rwanda, 4.9
Afghanistan, 5.1
India, 5.2
Yemen, 5.3
Bangladesh, 5.9
Nepal, 7.3
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0
On
Track
Insufficient
Progress
5.4% (on target)
Little/No
Progress
Source: Trends in Maternal Mortality 1990-2010
A Bold Endgame_Ending Preventable Maternal Deaths Worldwide by 2035_Mary Ellen Stanton_4.26.13
Countries require different rates of reduction to
end preventable maternal deaths by 2035 –
reaching MMR = 50
5
0
100
200
300
400
500
600
700
800
900
1000
1990 1995 2000 2005 2010 2015 2020 2025 2030 2035
MaternalMortalityRation(per100,000livebirths)
Asia, excl. India and
China
India
Sub-Saharan Africa
Global MMR
OECD Countries - Upper Limit
Asia: Afghanistan, Bhutan, Cambodia, Indonesia, Iran, Iraq, Kyrgyzstan, Lao, Morocco, Myanmar, Nepal, Pakistan, Papua
New Guinea, Philippines, Solomon Islands, Tajikistan, Turkmenistan, Uzbekistan, VietNam, Yemen
Africa: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Cote d'Ivoire,
Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau,
Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Sao Tome and
Principe, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Togo, Uganda, Tanzania, Zambia, Zimbabwe
225
50
Current
AAR 2000-
2010
AAR to
Reach
MMR = 50
Sub-Saharan
Africa -3.7% -8.9%
India -6.5% -5.4%
Asia, excluding
India and China -4.8% -5.1%
Global -4.1% -5.6%
6
Kenya
Malawi
Mozambique Nigeria
Rwanda
Sudan
Tanzania
Uganda
Zambia
Ghana
Liberia
Mali
DR Congo
Ethiopia
Bangladesh
Senegal
Afghanistan
MadagascarIndonesia
Nepal
Pakistan
Yemen
India
Haiti
0.0
2.0
4.0
6.0
8.0
10.0
12.0
0.0 2.0 4.0 6.0 8.0 10.0
RequiredAnnualRateofReductionbetween2010and2035to
ReachMMR=50in2035
Observed Rate of MMR Reduction between 2000 and 2010
Bubble size = Number of
Maternal Deaths in 2010
SSA with High HIV Prevalence
SSA with Low HIV Prevalence
Asia
Haiti
Countries above the diagonal line need to accelerate their
rate of MMR reduction to reach an MMR of 50 by 2035
Ending Preventable Maternal Mortality requires …
Geographic Focus
High Burden Populations
High Impact Practices
• Intensify programs where most maternal deaths occur
• Address barriers and scale up access towards equity and
respectful maternal and newborn care for those now
underserved
• Base the maternal health strategy on the local causes of
maternal and newborn death
• Strategy should emphasize
1. Family planning
2. Quality respectful intrapartum and immediate
postnatal care with effective referral
3. Provide prevention and treatment for obstetric
complications and co-morbidities that increase
maternal deaths—
HIV/AIDS, malaria, tuberculosis, and poor
nutrition—during the full spectrum of maternity
care.
• Build on and strengthen emerging health system changes
-- financing initiatives, decentralization, privatization
Mutual Accountability
• Promote transparency and shared accountability for
financing and results
• Monitor progress against a common set of metrics
• Ensure communications – electronic and mobile
technology – and improve documentation/surveillance and
mapping to improve the continuum of care and use of
knowledge in programming
Supportive Environment
• Educate girls and women—as well as men
• Empower women to demand quality services
• Enact smart policy for inclusive economic growth
• Leverage public, private and professional partnerships
Ending Preventable Maternal Mortality requires…
…
Over half of all maternal deaths
occur in just eight countries
India 56,000
20%
Nigeria 40,000
14%
DRC 15,000
5%
Sudan* 10,000
3%
Indonesia
9,600 3%
Ethiopia 9,000
3%
Tanzania 8,500
3%
Other 126,900
45%
Pakistan 12,000
* Sudan and South Sudan
Source: WHO, UNICEF, UNFPA and the World Bank estimates. Trends in Maternal Mortality: 1990-2010
Geographic Focus
Maternal coverage indicators
show widest gap in equity
0
10
20
30
40
50
60
70
80
90
100
Early start
of
breastfeeding
DPT
immunization
Fully
immunized
Vitamin A Oral
rehydration
therapy
Family
planning
needs
satisfied
Antenatal
care with a
skilled
provider
Antenatal
care (≥ 4
visits)
Skilled birth
attendant
PercentCoverage
Quintile 1 Quintile 5
Child Health Indicators Maternal Health Indicators
Barros, Ronsmans, Axelson et al. 2012
High Burden Population
A Bold Endgame_Ending Preventable Maternal Deaths Worldwide by 2035_Mary Ellen Stanton_4.26.13
Proven interventions can address
the leading causes of maternal
death, both direct and indirect
Preeclampsia
Eclampsia
18% Hemorrhage
35%
Unsafe Abortion 9%
Sepsis
8% Indirect and Other
Direct
30%
Source for Causes: Countdown to 2015
• Active management of the
third stage of labor
• Uterotonics: oxytocin &
misoprostol
•Blood transfusion
• Family Planning
• Diet, supplementation
and fortification
• Prevention and
treatment of infections
• Iron folate supplements
• De-worming
• Malaria intermittent treatment
• Anti-retrovirals
• Tetanus toxoid
• Clean delivery
• Antibiotics
• Family planning
• Post-abortion care
• Calcium
• Magnesium Sulfate
• Aspirin
• Anti-hypertensives
• Cesarean section
Underlying causes:
• Unintended pregnancy
• Under-nutrition
• Co-infections
High Impact Practices
HIVAIDS programs need to be tailored to diverse epidemics and
integrated into maternal newborn programs
Indirect Causes of Maternal Mortality
are growing
HIDN/MCH AFRICA PRIORITY COUNTRIES
ESTIMATED HIV PREVALENCE AMONG TOTAL POPULATION 2011
The boundaries and names used on this
map do not imply official endorsement
or acceptance by the U.S. Government.
ESTIMATED HIV PREVALENCE AMONG
TOTAL POPULATION 2011
Data Source: UNAIDS, 2011
Map Source: OST/GeoCenter, January 2013
*Natural Breaks (Jenks)
1% - 2%
3% - 4%
5% - 7%
8% - 13%
No Data
Country HIV burden MMR
Mozambique 490
Zambia 440
Malawi 460
Kenya 360
Uganda 310
Tanzania 460
Nigeria 630
DRCongo 540
Rwanda 340
Senegal 370
Ethiopia 350
Rwanda 340
Mali 540
Ghana 350
Source: MMRs: Trends in Maternal Mortality: 1990 to 2010
WHO, UNICEF, UNFPA and The World Bank Estimates, WHO 2012
In SSA, the proportion of indirect vs. obstetric causes is greater
than in South Asia – reflecting the important contribution of
infectious diseases to maternal mortality in Africa
Country MMR
Mozambique 490
Zambia 440
Malawi 460
Kenya 360
Uganda 310
Tanzania 460
Nigeria 630
DRCongo 540
Rwanda 340
Senegal 370
Ethiopia 350
Rwanda 340
Mali 540
Ghana 350
Liberia 770
Senegal 370
Madagascar 240
Maternal mortality is also high in areas
of epidemic and endemic malaria
Source: 2010 Malaria Atlas Project, available under the
Creative Commons Attribution 3.0 Unported License.
Clinical burden of Plasmodium falciparum,
2007
76
70
62
60
53
38 38
31
22
20
59
48
50
0
10
20
30
40
50
60
70
80
%
USAID Priority Countries with Natoinal Data by Region
Prevalence of Anemia in Pregnant Women
22% of maternal deaths are associated with iron deficiency anemia
Source: Stolfus et al, Iron deficiency anemia, “Comparative quantification of health risks,” WHO, 2002.
Integrated care during
pregnancy, childbirth and beyond
Care for Mothers with TB and other
infectious diseases
Care for Mothers and Newborn in
Areas With Malaria
Care for HIV Positive Mothers and
Newborns
Emergency Care for Mothers and
Newborns
Standard Care for Maternal and
Newborn Health
Family Planning
•TB screening and treatment
•STI screening and treatment
•Screening and treatment for other infections like Hepatitis
•Use of ITNs
•Intermittent Preventative Treatment
•Case management for malaria illness and anemia
• ART initiation or continuation
• Couples counseling and testing
• Prevention of opportunistic infections
• Extra monitoring and treatment for HTN, pre-eclampsia/eclampsia and anemia
• On-going case management for mother and newborn
•Referral networks
•Surgery and Medical care
•Availability of Blood
•Focused Antenatal Care and improved nutrition
•Intrapartum Care
•Postnatal Care
•Voluntary access to modern contraceptive methods
•Healthy Timing and Spacing of Pregnancies
•Post-abortion care
• Weak health systems –
especially inadequate
number of midwives and
surgeons, poor quality
drugs, poor quality of
care, financial
barriers, measurement
challenges, and so forth
• Urbanization
• Privatization
• Decentralization
Contextual Challenges
Innovations– mHealth has potential to be a
powerful accelerator of progress
Communications to improve referral systems, and so forth
Quality of care is critical:
an important part is respect
• A “veil of silence” has obscured
widespread humiliation and abuse
of women in facilities during
childbirth, a time of intense
vulnerability for women.
• In many settings, disrespect of
women in childbirth has been
“normalized” and is sometimes
accepted by women themselves.
• Institutional disrespect and abuse
of women can significantly deter
women’s use of facility skilled
care for normal and emergency
birth care.
USAID promotes
In summary….
1. Target setting— a work in progress
2. Reaching the target – Strategies based on local causes of maternal
death and contextual factors
3. More data needed — including reporting death, including
cause, time and place of death
4. Implementation research on untested strategies and innovations
will guide more effective investment for better outcomes.
5. We have an unprecedented opportunity for accelerated progress -
- building on reduced fertility rates, increased rates of female
education, and economic growth
Many thanks

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A Bold Endgame_Ending Preventable Maternal Deaths Worldwide by 2035_Mary Ellen Stanton_4.26.13

  • 1. A bold endgame: Ending preventable maternal deaths worldwide by 2035 CORE Meeting Baltimore, MD April 26, 2013 1
  • 2. 850 53 590 140 400 500 45 240 80 210 - 100 200 300 400 500 600 700 800 900 Sub-Saharan Africa Eastern Asia (excluding China) Southern Asia (excluding India) LAC World MMR:maternaldeathsper100,000livebirths While maternal mortality has declined globally between 1990 & 2010, there has been considerable regional variation 1990 2010 41% AAR: 2.6% 59% AAR = 4.4% 41% AAR: 2.6% 41% AAR: 2.6% 47% AAR: 3.1% Source: WHO/UNICEF/UNFPA/World Bank. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva, World Health Organization, 2012.
  • 3. MDG 5 Assessment of Progress for 24 priority countries: Maternal Mortality Ratio Average Annual Rate of Reduction (%) 1990-2010 Zambia, 0.4 Kenya, 0.5 Sudan, 1.6 Liberia, 2.4 Ghana, 2.6 Nigeria, 2.6 DR Congo, 2.7 Haiti, 2.7 Pakistan, 3.0 Senegal, 3.0 Mozambique, 3.1 Tanzania, 3.2 Uganda, 3.2 Mali, 3.5 Malawi, 4.4 Madagascar, 4.7 Ethiopia, 4.9 Indonesia, 4.9 Rwanda, 4.9 Afghanistan, 5.1 India, 5.2 Yemen, 5.3 Bangladesh, 5.9 Nepal, 7.3 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 On Track Insufficient Progress 5.4% (on target) Little/No Progress Source: Trends in Maternal Mortality 1990-2010
  • 5. Countries require different rates of reduction to end preventable maternal deaths by 2035 – reaching MMR = 50 5 0 100 200 300 400 500 600 700 800 900 1000 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 MaternalMortalityRation(per100,000livebirths) Asia, excl. India and China India Sub-Saharan Africa Global MMR OECD Countries - Upper Limit Asia: Afghanistan, Bhutan, Cambodia, Indonesia, Iran, Iraq, Kyrgyzstan, Lao, Morocco, Myanmar, Nepal, Pakistan, Papua New Guinea, Philippines, Solomon Islands, Tajikistan, Turkmenistan, Uzbekistan, VietNam, Yemen Africa: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Cote d'Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Togo, Uganda, Tanzania, Zambia, Zimbabwe 225 50 Current AAR 2000- 2010 AAR to Reach MMR = 50 Sub-Saharan Africa -3.7% -8.9% India -6.5% -5.4% Asia, excluding India and China -4.8% -5.1% Global -4.1% -5.6%
  • 6. 6 Kenya Malawi Mozambique Nigeria Rwanda Sudan Tanzania Uganda Zambia Ghana Liberia Mali DR Congo Ethiopia Bangladesh Senegal Afghanistan MadagascarIndonesia Nepal Pakistan Yemen India Haiti 0.0 2.0 4.0 6.0 8.0 10.0 12.0 0.0 2.0 4.0 6.0 8.0 10.0 RequiredAnnualRateofReductionbetween2010and2035to ReachMMR=50in2035 Observed Rate of MMR Reduction between 2000 and 2010 Bubble size = Number of Maternal Deaths in 2010 SSA with High HIV Prevalence SSA with Low HIV Prevalence Asia Haiti Countries above the diagonal line need to accelerate their rate of MMR reduction to reach an MMR of 50 by 2035
  • 7. Ending Preventable Maternal Mortality requires … Geographic Focus High Burden Populations High Impact Practices • Intensify programs where most maternal deaths occur • Address barriers and scale up access towards equity and respectful maternal and newborn care for those now underserved • Base the maternal health strategy on the local causes of maternal and newborn death • Strategy should emphasize 1. Family planning 2. Quality respectful intrapartum and immediate postnatal care with effective referral 3. Provide prevention and treatment for obstetric complications and co-morbidities that increase maternal deaths— HIV/AIDS, malaria, tuberculosis, and poor nutrition—during the full spectrum of maternity care. • Build on and strengthen emerging health system changes -- financing initiatives, decentralization, privatization
  • 8. Mutual Accountability • Promote transparency and shared accountability for financing and results • Monitor progress against a common set of metrics • Ensure communications – electronic and mobile technology – and improve documentation/surveillance and mapping to improve the continuum of care and use of knowledge in programming Supportive Environment • Educate girls and women—as well as men • Empower women to demand quality services • Enact smart policy for inclusive economic growth • Leverage public, private and professional partnerships Ending Preventable Maternal Mortality requires… …
  • 9. Over half of all maternal deaths occur in just eight countries India 56,000 20% Nigeria 40,000 14% DRC 15,000 5% Sudan* 10,000 3% Indonesia 9,600 3% Ethiopia 9,000 3% Tanzania 8,500 3% Other 126,900 45% Pakistan 12,000 * Sudan and South Sudan Source: WHO, UNICEF, UNFPA and the World Bank estimates. Trends in Maternal Mortality: 1990-2010 Geographic Focus
  • 10. Maternal coverage indicators show widest gap in equity 0 10 20 30 40 50 60 70 80 90 100 Early start of breastfeeding DPT immunization Fully immunized Vitamin A Oral rehydration therapy Family planning needs satisfied Antenatal care with a skilled provider Antenatal care (≥ 4 visits) Skilled birth attendant PercentCoverage Quintile 1 Quintile 5 Child Health Indicators Maternal Health Indicators Barros, Ronsmans, Axelson et al. 2012 High Burden Population
  • 12. Proven interventions can address the leading causes of maternal death, both direct and indirect Preeclampsia Eclampsia 18% Hemorrhage 35% Unsafe Abortion 9% Sepsis 8% Indirect and Other Direct 30% Source for Causes: Countdown to 2015 • Active management of the third stage of labor • Uterotonics: oxytocin & misoprostol •Blood transfusion • Family Planning • Diet, supplementation and fortification • Prevention and treatment of infections • Iron folate supplements • De-worming • Malaria intermittent treatment • Anti-retrovirals • Tetanus toxoid • Clean delivery • Antibiotics • Family planning • Post-abortion care • Calcium • Magnesium Sulfate • Aspirin • Anti-hypertensives • Cesarean section Underlying causes: • Unintended pregnancy • Under-nutrition • Co-infections High Impact Practices
  • 13. HIVAIDS programs need to be tailored to diverse epidemics and integrated into maternal newborn programs Indirect Causes of Maternal Mortality are growing
  • 14. HIDN/MCH AFRICA PRIORITY COUNTRIES ESTIMATED HIV PREVALENCE AMONG TOTAL POPULATION 2011 The boundaries and names used on this map do not imply official endorsement or acceptance by the U.S. Government. ESTIMATED HIV PREVALENCE AMONG TOTAL POPULATION 2011 Data Source: UNAIDS, 2011 Map Source: OST/GeoCenter, January 2013 *Natural Breaks (Jenks) 1% - 2% 3% - 4% 5% - 7% 8% - 13% No Data Country HIV burden MMR Mozambique 490 Zambia 440 Malawi 460 Kenya 360 Uganda 310 Tanzania 460 Nigeria 630 DRCongo 540 Rwanda 340 Senegal 370 Ethiopia 350 Rwanda 340 Mali 540 Ghana 350 Source: MMRs: Trends in Maternal Mortality: 1990 to 2010 WHO, UNICEF, UNFPA and The World Bank Estimates, WHO 2012 In SSA, the proportion of indirect vs. obstetric causes is greater than in South Asia – reflecting the important contribution of infectious diseases to maternal mortality in Africa
  • 15. Country MMR Mozambique 490 Zambia 440 Malawi 460 Kenya 360 Uganda 310 Tanzania 460 Nigeria 630 DRCongo 540 Rwanda 340 Senegal 370 Ethiopia 350 Rwanda 340 Mali 540 Ghana 350 Liberia 770 Senegal 370 Madagascar 240 Maternal mortality is also high in areas of epidemic and endemic malaria Source: 2010 Malaria Atlas Project, available under the Creative Commons Attribution 3.0 Unported License. Clinical burden of Plasmodium falciparum, 2007
  • 16. 76 70 62 60 53 38 38 31 22 20 59 48 50 0 10 20 30 40 50 60 70 80 % USAID Priority Countries with Natoinal Data by Region Prevalence of Anemia in Pregnant Women 22% of maternal deaths are associated with iron deficiency anemia Source: Stolfus et al, Iron deficiency anemia, “Comparative quantification of health risks,” WHO, 2002.
  • 17. Integrated care during pregnancy, childbirth and beyond Care for Mothers with TB and other infectious diseases Care for Mothers and Newborn in Areas With Malaria Care for HIV Positive Mothers and Newborns Emergency Care for Mothers and Newborns Standard Care for Maternal and Newborn Health Family Planning •TB screening and treatment •STI screening and treatment •Screening and treatment for other infections like Hepatitis •Use of ITNs •Intermittent Preventative Treatment •Case management for malaria illness and anemia • ART initiation or continuation • Couples counseling and testing • Prevention of opportunistic infections • Extra monitoring and treatment for HTN, pre-eclampsia/eclampsia and anemia • On-going case management for mother and newborn •Referral networks •Surgery and Medical care •Availability of Blood •Focused Antenatal Care and improved nutrition •Intrapartum Care •Postnatal Care •Voluntary access to modern contraceptive methods •Healthy Timing and Spacing of Pregnancies •Post-abortion care
  • 18. • Weak health systems – especially inadequate number of midwives and surgeons, poor quality drugs, poor quality of care, financial barriers, measurement challenges, and so forth • Urbanization • Privatization • Decentralization Contextual Challenges
  • 19. Innovations– mHealth has potential to be a powerful accelerator of progress Communications to improve referral systems, and so forth
  • 20. Quality of care is critical: an important part is respect • A “veil of silence” has obscured widespread humiliation and abuse of women in facilities during childbirth, a time of intense vulnerability for women. • In many settings, disrespect of women in childbirth has been “normalized” and is sometimes accepted by women themselves. • Institutional disrespect and abuse of women can significantly deter women’s use of facility skilled care for normal and emergency birth care. USAID promotes
  • 21. In summary…. 1. Target setting— a work in progress 2. Reaching the target – Strategies based on local causes of maternal death and contextual factors 3. More data needed — including reporting death, including cause, time and place of death 4. Implementation research on untested strategies and innovations will guide more effective investment for better outcomes. 5. We have an unprecedented opportunity for accelerated progress - - building on reduced fertility rates, increased rates of female education, and economic growth

Notes de l'éditeur

  1. Between 1990 and 2010, the maternal mortality ratio declined by nearly half—from 543,000 deaths to 287,000 deaths. While the first decade saw a rate of decline of approx 3.1% per year, the 2000-2010 decade rate increased to over 4% globally. But to reach a MMR of 50 by 2035—the upper limit of the MMR among OECD countries—the the ann rate of reduction worldwide must increase to 5.6%
  2. Given the variation in rates of decline in the reduction of preventable Mat mort by region to achieve any aggressive but plausible target set for the future, the question is just how do we achieve such a target. The draft strategies we have laid out follows the format of A Promise Renewed—as eventually we would like to see the maternal, newborn, child strategies better linked to ensure a continuum of care. -- Geog focus--…-- High burden pop speaks to ensuring that the vulnerable receive quality respectful care for both mothers/newborn—that barriers to access (such as cost, transport, cultural factors) are addressed and interventions are implemented at scale. -- High impact Care is provided based on the local causes of maternal and newborn death—and it starts with 1. family planning to ensure all women have a voluntary intended birth, That quality respectful intrapartum and immediate post natal care is available with effective referralThat prevention and treatment is available throughout the maternity period to address not only the ob complications (hem, PeE, sepsis, unsafe abortion and ob/prolonged labor) but also for co-infections, and poor nutrition. To do this policies and programs need to build on and strengthen if needed the various initiatives or situations that health systems find themselves in recently—financing initiatives (CCT, vouchers, fee exemptions, national or social insurance programs) , decentralization, privatization—and in Arusha we heard that nearly half of people in developing countries now live in urban areas
  3. A supportive enviroment is needed for both immediate an sustainabile resultsMutual accountability-- Needs to build on global and national commitments already publicly made as well as subnational efforts to set goals, fund programs and closely monitor progress with involvement of communities.
  4. Geographic focus: over half of all maternal deaths take place in just 8 countries –with 3 in Asia and 4 in SSA—with nearly equivalent numbers of maternal deaths-between 78-83,000 deaths/year. For USAID, the major focus is on 24 countries ( x in SSA, y Asia) that contribute to nearly 75% of the deaths annually.
  5. High burden population: While there have been increases in use of facility births and births with a skilled attendant over the decade between 1998-2008 in both SSA and Asian countries, the use of maternal health services –whether it be ANC 4 or use of a SBA for birth—shows the widest gap in equity as measured by the quintiles 1 and 5. The poor continue to use fewer services than the richest quintile by nearly a factor of 2??? Ck.When we look at maternal death, we know from national studies in both Ghana and Bangladesh and several smaller studies , that those women with higher education are far less likely to die than their counterparts without education. Empowering women with cash or with education is likely to contribute to improved use of services as well as reduce mortality.
  6. 2. High impact interventions: the direct causes of maternal death are well-known and have been for the 2 decades of the SMI. We often think there has been little progress in addressing them–but in effect there has been progress—in determining what works and in implementing such. Perhaps the biggest advance has been to address the major obstetric killer, postpartum hemorrhage. AMTSL using oxytocin has been widely accepted and recent research has led to the potential of a simplified regimen and guidelines have been promulgated to this effect (true?),; , the interest and excitement caused by misoprostol has led to… Even so, hemorrhage remains the largest contributor to maternal death.What has become increasingly obvious over the last decade is the escalating impact of co-infections on maternal health. The numbers of deaths due to these indirect causes of maternal death (HIV/AIDS, malaria, TB) has increased –but there are few data we can rely on…. Nutrition—specifically anemia—has continued to be recognized as a ….
  7. Malaria is also implicated in maternal deaths. And even in areas of endemic malaria, where it is anticipated that pregnant women will not die from malaria, reports are now available questioning this ….
  8. Given the varying contributing factors to maternal death, the care required must be adjusted to address the causes. For example, provision of basic and emergency obstetric care with family planning has contributed to the reduction of MMR , but in other sites where the causes of maternal death go beyond the direct obstetric complications, more care is needed to address the co-infections—HIV/AIDS, malaria, TB and more. IT is likely that in those areas with this higher morbidity burden, more providers per 1000 births will be needed as their workload will be higher. Yet according to the State of the World’s Midwives, it is in just those countries where the work force available is less. (think we should revers the services—with FP in circle at center