A bold endgame:Ending preventable maternal

deaths worldwide by 2035CORE MeetingBaltimore, MDApril 26, 2013

1

Sub-Saharan Africa Eastern Asia(excluding China)

Southern Asia(excluding India)

LAC World -

100

200

300

400

500

600

700

800

900

850

53

590

140

400

500

45

240

80

210

While maternal mortality has declined globally between 1990 & 2010, there has been considerable regional variation

1990 2010

MM

R: m

ater

nal d

eath

s pe

r 100

,000

live

birt

hs

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

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0

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, 7.3On

Track

Insufficient Progress

5.4% (on target)

Little/No Progress

Source: Trends in Maternal Mortality 1990-2010

Ending preventable maternal deaths worldwide by 2035-reaching MMR = 50

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

50

100

150

200

250

300

350

400

450

Ma

tern

al M

ort

alit

y R

ati

o (

pe

r 1

00

,00

0 li

ve

bir

ths

)

Source: UN Estimates for Trends in Maternal Mortality 1990-2010

543,000 deaths annually

287,000 deaths annually

4.1% Annual Rate of MMR Re-duction 2000-

2010

5.6% Annual Rate of MMR

Reduction 2010-2035

Accelerated Trend

4.1% Annual Rate of MMR

Reduction 2010-2035

Current trend

Global MMR

OECD Upper Limit MMR

Countries require different rates of reduction to end preventable maternal deaths by 2035 –

reaching MMR = 50

5

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

100

200

300

400

500

600

700

800

900

1000

Mat

erna

l Mor

talit

y Ra

tion

(per

100

,000

live

birt

hs)

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, YemenAfrica: 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

0.0 2.0 4.0 6.0 8.0 10.00.0

2.0

4.0

6.0

8.0

10.0

12.0

Kenya

Malawi

Mozambique Nigeria

Rwanda

Sudan

Tanzania

Uganda

Zambia

Ghana

Liberia

Mali

DR Congo

Ethiopia

Bangladesh

Senegal

Afghanistan

MadagascarIndonesia Nepal

Pakistan

Yemen

India

Haiti

Observed Rate of MMR Reduction between 2000 and 2010

Requ

ired

Ann

ual R

ate

of R

educ

tion

betw

een

2010

and

203

5 to

Re

ach

MM

R =

50 in

203

5

Bubble size = Number of Maternal Deaths in 2010

SSA with High HIV PrevalenceSSA with Low HIV Prevalence

AsiaHaiti

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 emphasize1. Family planning 2. Quality respectful intrapartum and immediate

postnatal care with effective referral3. 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 12,0004%

* 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 Quintile 1 Quintile 5

Per

cen

t Co

vera

ge

Child Health Indicators Maternal Health Indicators

Barros, Ronsmans, Axelson et al. 2012

High Burden Population

Family planning can ensure an intended birth

Africa South, Southeast and West Asia

Other Asia LAC0

100

200

300

400

500

600

700

800

20%

35%66%

49%

22%

18%5%

14%

58%

47%

29%

37%

Modern Contraceptive Use Unmet need for modern methods Not at risk*

Wo

me

n o

f R

ep

rod

uc

tiv

e A

ge

(1

5-4

9),

in m

illio

ns

Percent unmet need highest in Africa...

...but absolute number w/unmet need highest in S/SE/W Asia

Fertility plays a major role in MMR Reduction:

Unmet need of 222 million women for modern contraception leads to 79,000 pregnancy-related and 572,000 newborn deaths annually

Singh S and Darroch JE, Guttmacher Institute and United Nations Population Fund (UNFPA), 2012.

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 COUNTRIESESTIMATED HIV PREVALENCE AMONG TOTAL POPULATION 2011

The boundaries and names used on thismap do not imply official endorsementor acceptance by the U.S. Government.

ESTIMATED HIV PREVALENCE AMONGTOTAL POPULATION 2011

Data Source: UNAIDS, 2011 Map Source: OST/ GeoCenter, J anuary 2013

*Natural Breaks (J enks)

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 2010WHO, 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

Mali

Ghana

Seneg

al

DR Congo

Tanzan

ia

Madag

ascar

Malawi

Uganda

Ethiopia

Rwanda

IndiaNep

alHaiti

0

10

20

30

40

50

60

70

8076

70

6260

53

38 38

31

2220

59

4850

Prevalence of Anemia in Pregnant Women

USAID Priority Countries with Natoinal Data by Region

%

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