Maternal Health & Maternal Health & Transport – a need for Transport – a need for

actionactionJeff TurnerJeff Turner

Independent Consultant, UKIndependent Consultant, UK& &

Margaret GriecoMargaret GriecoProfessor of Transport & Society, Napier Professor of Transport & Society, Napier

University, UKUniversity, UK

Maternal Mortality, Gender and TransportMaternal Mortality, Gender and Transport

There is a relationship between mobility, power and well There is a relationship between mobility, power and well being. being.

The differences between male and female travel patterns The differences between male and female travel patterns and the cultural rules and roles associated with these and the cultural rules and roles associated with these differences are under-charted in the policy environment. differences are under-charted in the policy environment.

The impact of constrained mobility on bargaining also The impact of constrained mobility on bargaining also has its impact on what comes to be available as has its impact on what comes to be available as resource and service within local constraints. resource and service within local constraints.

No better demonstration of these constraints can be No better demonstration of these constraints can be found than in Africa's portrait of maternal mortality: found than in Africa's portrait of maternal mortality: constraints on mobility and on the resources for mobility constraints on mobility and on the resources for mobility and accessibility have devastating consequences for and accessibility have devastating consequences for women's health on the African continent.women's health on the African continent.

Maternal MortalityMaternal Mortality

More than half of the 600,000 women who die More than half of the 600,000 women who die every year from pregnancy-related causes were every year from pregnancy-related causes were in the African region which constitutes only 12% in the African region which constitutes only 12% of the world's population and 17% of its births. of the world's population and 17% of its births.

Maternal mortality ratio in Africa remains the Maternal mortality ratio in Africa remains the highest in the world with the average actually highest in the world with the average actually increasing from 870 per 100,000 live births in increasing from 870 per 100,000 live births in 1990 to 1,000 per 100,000 live births in 2001. 1990 to 1,000 per 100,000 live births in 2001.

MDG Target 6:MDG Target 6:Reduce by three quarters, between 1990 and Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio.2015, the maternal mortality ratio.

Maternal MortalityMaternal Mortality Despite the various policy calls to action and Despite the various policy calls to action and

international networking amongst development agencies international networking amongst development agencies on the topic, in Africa the situation is worsening. on the topic, in Africa the situation is worsening.

In addition to displaying the scale of the gap there is a In addition to displaying the scale of the gap there is a need for a rapid identification of immediate operational need for a rapid identification of immediate operational measures which can be taken to redress this glaring measures which can be taken to redress this glaring inequity. inequity.

Though much has been learned during the past decade Though much has been learned during the past decade about the causes of maternal death, there is little about the causes of maternal death, there is little evidence of significant progress towards the ambitious evidence of significant progress towards the ambitious goal of halving maternal mortality. goal of halving maternal mortality.

Every year, over half a million women continue to lose Every year, over half a million women continue to lose their own lives to the hope of creating life. Women in their own lives to the hope of creating life. Women in Sub-Saharan Africa continue to face a 1 in 13 chance of Sub-Saharan Africa continue to face a 1 in 13 chance of dying from pregnancy and childbirth, when the risk for dying from pregnancy and childbirth, when the risk for women in the industrialized world is only 1 in 4,085.women in the industrialized world is only 1 in 4,085.

Medical ‘Model of Delay’ shows Medical ‘Model of Delay’ shows

transport’s role in Maternal Mortalitytransport’s role in Maternal Mortality

Three DelaysThree Delays Delay in decision making to seek helpDelay in decision making to seek help

Delay in transportation to health institutionDelay in transportation to health institution

Delay of care within health institutionDelay of care within health institution

Transport’s role in maternal healthTransport’s role in maternal health

The majority of poor rural women give birth at home partly in the The majority of poor rural women give birth at home partly in the absence of transport means to transport them to a health facilityabsence of transport means to transport them to a health facility

The financial and time cost of travelling to health facilities and their The financial and time cost of travelling to health facilities and their low status and negotiating power within the household may mean low status and negotiating power within the household may mean there is a trade-off for rural poor women which may delay the there is a trade-off for rural poor women which may delay the decision to seek care.decision to seek care.

If they seek care most women will walk (availability of bicycles and If they seek care most women will walk (availability of bicycles and improvised stretchers to be used in emergencies is often localised improvised stretchers to be used in emergencies is often localised and ad-hoc) – which delays arrival at the point of care.and ad-hoc) – which delays arrival at the point of care.

Rural health facilities often have large catchment areas and often Rural health facilities often have large catchment areas and often lack trained staff, drugs, equipment and effective transport and lack trained staff, drugs, equipment and effective transport and communication referral systems which delays the provision of communication referral systems which delays the provision of adequate careadequate care

It is becoming accepted that poor access may play a role in It is becoming accepted that poor access may play a role in maternal deaths and conditions such as Fistula, but little research maternal deaths and conditions such as Fistula, but little research available on how important this is and what may be effective available on how important this is and what may be effective interventionsinterventions

Localised Transport interventionsLocalised Transport interventions

Safe motherhood transport plans - MalawiSafe motherhood transport plans - Malawi 'A government-backed Safe Motherhood programme has 'A government-backed Safe Motherhood programme has

established village committees on safe motherhood, established village committees on safe motherhood, organized transportation plans and provided training to organized transportation plans and provided training to traditional birth attendants so that they can recognize traditional birth attendants so that they can recognize signs of obstructed labour and act efficiently to get a signs of obstructed labour and act efficiently to get a woman to a facility. woman to a facility.

Telephones and radios have been installed in some Telephones and radios have been installed in some health centres to communicate with the referral hospital health centres to communicate with the referral hospital and request ambulance transport for women in and request ambulance transport for women in distress...........distress...........

However, pervasive gender inequities sometimes prevent However, pervasive gender inequities sometimes prevent women’s access to transportation and emergency women’s access to transportation and emergency obstetric care. Decisions about when and where to seek obstetric care. Decisions about when and where to seek care are usually made by an uncle (or, occasionally, by care are usually made by an uncle (or, occasionally, by the husband); without their input, a woman would be the husband); without their input, a woman would be unlikely to seek care on her own.‘unlikely to seek care on her own.‘

Localised Transport interventionsLocalised Transport interventions Transport within Safe motherhood unions - Zegoua, MaliTransport within Safe motherhood unions - Zegoua, Mali The small Malian town of Zegoua - population 22,000 has The small Malian town of Zegoua - population 22,000 has

achieved something remarkable. Since January 2002, achieved something remarkable. Since January 2002, there's not been one case of neonatal or maternal there's not been one case of neonatal or maternal mortality in Zegoua or any other nearby village,mortality in Zegoua or any other nearby village,

The local health centre caters for nine villages, which are The local health centre caters for nine villages, which are divided into 16 zones. divided into 16 zones.

The secret of the area's success in reducing neonatal and The secret of the area's success in reducing neonatal and maternal mortality lies in the determination of its women to maternal mortality lies in the determination of its women to tackle these problems. tackle these problems.

They have organized themselves into teams for taking They have organized themselves into teams for taking charge of their health care and use micro-credit to finance.charge of their health care and use micro-credit to finance.

In the event that severe problems develop during a In the event that severe problems develop during a pregnancy, the coordinator of each village team must pregnancy, the coordinator of each village team must ensure that the woman concerned is transferred to a clinic ensure that the woman concerned is transferred to a clinic that is equipped to deal with such emergencies.‘that is equipped to deal with such emergencies.‘

Localised Transport interventionsLocalised Transport interventions Targeted approaches which integrate transport - Senegal and Targeted approaches which integrate transport - Senegal and

MaliMali 'In Mali, interagency collaboration has enabled the country to 'In Mali, interagency collaboration has enabled the country to

build and equip seven new community health centers in three build and equip seven new community health centers in three regions and a new maternity unit. regions and a new maternity unit.

The government of Mali, with support from various donors, The government of Mali, with support from various donors, developed a programme to bolster its referral system with a developed a programme to bolster its referral system with a rapid-response component. rapid-response component.

The country has invested in radio communication among The country has invested in radio communication among referral centers, and has procured vehicles to use for patient referral centers, and has procured vehicles to use for patient transport. District hospitals and local health centers are now transport. District hospitals and local health centers are now linked by a two-way system of radio communication and linked by a two-way system of radio communication and transportation. transportation.

A car, equipped with a stretcher, is available to transport women A car, equipped with a stretcher, is available to transport women from health centers to district hospitals. from health centers to district hospitals.

Under this system, the time required to transmit an urgent Under this system, the time required to transmit an urgent message and transport a patient is reduced from up to a day to message and transport a patient is reduced from up to a day to just a few hours just a few hours

Localised Transport interventionsLocalised Transport interventions

Walkie-talkies, transport strategies and a 40% reduction Walkie-talkies, transport strategies and a 40% reduction in maternal mortality: RESCUER, a Ugandan case studyin maternal mortality: RESCUER, a Ugandan case study

The project has three components: communications, The project has three components: communications, transport and provision of quality health services. transport and provision of quality health services.

The communications system uses VHF radios installed The communications system uses VHF radios installed in base stations and health units, in the referral hospital in base stations and health units, in the referral hospital ambulance and the District Medical Officer's vehicle, ambulance and the District Medical Officer's vehicle, while the birth attendants have walkie-talkies. while the birth attendants have walkie-talkies.

The midwives and birth attendants got additional training The midwives and birth attendants got additional training and now there is better quality care. and now there is better quality care.

But transport has been the biggest problem as the But transport has been the biggest problem as the ambulance sometimes breaks downambulance sometimes breaks down

Localised Transport interventionsLocalised Transport interventions

Using the existing fleet of vehicles and community Using the existing fleet of vehicles and community involvement: the yellow flag initiative in some parts of involvement: the yellow flag initiative in some parts of NigeriaNigeria

an initiative in which uses a local truck drivers union to an initiative in which uses a local truck drivers union to provide emergency transport for women. "If there is a provide emergency transport for women. "If there is a woman in difficulty in a village what her family will plant a woman in difficulty in a village what her family will plant a yellow flag on the main road.yellow flag on the main road.

When you can see a yellow flag truckers know there is a When you can see a yellow flag truckers know there is a woman in trouble and they can help by taking her. woman in trouble and they can help by taking her.

Reports suggest that the local truck drivers union were Reports suggest that the local truck drivers union were delighted to be able to help and maternal mortality was delighted to be able to help and maternal mortality was reduced quite significantly because of this initiative. reduced quite significantly because of this initiative.

Localised Transport interventionsLocalised Transport interventions

Emergency obstetric care motorised ambulances: the Emergency obstetric care motorised ambulances: the Ghanaian Matercare ProjectGhanaian Matercare Project

This service will provide the ability to resuscitate and to This service will provide the ability to resuscitate and to safely transfer mothers with severe childbirth safely transfer mothers with severe childbirth

complications from the villages to the district hospitalcomplications from the villages to the district hospital. .

Transport’s role in maternal healthTransport’s role in maternal health

The transport lessons around the The transport lessons around the reduction of maternal mortality in Africa reduction of maternal mortality in Africa clearly involve communication and clearly involve communication and organisation issues as well:organisation issues as well: fast information links can save lives, fast information links can save lives, rendering services locally can reduce the rendering services locally can reduce the

need for mobility, and need for mobility, and operating hostels for those at risk can operating hostels for those at risk can

temporarily reduce distance within critical temporarily reduce distance within critical windows of care. windows of care.

A space for actionA space for action

Within the policy discussion there is a need for:Within the policy discussion there is a need for: more accurate measurement, more accurate measurement, more focused solutions, more focused solutions, more sensitive social scientific analysis of the more sensitive social scientific analysis of the

relationship between mobility, gender and health. relationship between mobility, gender and health. There is now a policy goal of dramatically reducing There is now a policy goal of dramatically reducing

maternal mortality in Africa and there is a body of maternal mortality in Africa and there is a body of evidence which speaks to the scale of the problem evidence which speaks to the scale of the problem

However, the literature on concrete measures for However, the literature on concrete measures for bringing about this goal and the operational activities of bringing about this goal and the operational activities of development agencies in pursuit of this goal are thin on development agencies in pursuit of this goal are thin on the ground.the ground.

Particularly in respect of the transport and maternal Particularly in respect of the transport and maternal mortality link. mortality link.

A need for further investigationA need for further investigation

What is the nature of the interaction between physical access, What is the nature of the interaction between physical access, communication and maternal, neonatal and child health services communication and maternal, neonatal and child health services and their outcomes?and their outcomes?

How can we capture and measure the nature and scale of these How can we capture and measure the nature and scale of these complex interactions as part of a wider multi-dimensional picture of complex interactions as part of a wider multi-dimensional picture of maternal, neo-natal and child health services?maternal, neo-natal and child health services?

What can be learnt from a more systematic evaluation of the range What can be learnt from a more systematic evaluation of the range of localised access and communication solutions that have been of localised access and communication solutions that have been implemented to improve physical access to maternal health implemented to improve physical access to maternal health services?services?

How can greater community involvement be encouraged in tackling How can greater community involvement be encouraged in tackling barriers to access?barriers to access?

What are the institutional issues pertinent to maintaining the What are the institutional issues pertinent to maintaining the responsiveness of patient transport services?responsiveness of patient transport services?

What scope is there for new communication technologies and What scope is there for new communication technologies and 'telehealth' in overcoming access difficulties and interacting with 'telehealth' in overcoming access difficulties and interacting with access solutionsaccess solutions

A need for gender & transport actionA need for gender & transport action There is sufficient evidence that transport organisation and There is sufficient evidence that transport organisation and

provision is highly gendered in both the developing and provision is highly gendered in both the developing and developed context. Gender methodologies have not yet been developed context. Gender methodologies have not yet been sufficiently mainstreamed to tackle this existing pattern of sufficiently mainstreamed to tackle this existing pattern of equity. equity.

The reduction of maternal mortality in Africa - a Millennium The reduction of maternal mortality in Africa - a Millennium Development Goal - provides an operational ground in which Development Goal - provides an operational ground in which such methodologies are in need of urgent development.such methodologies are in need of urgent development.

There is evidence that more systematic approaches are There is evidence that more systematic approaches are beginning to be adopted but as of yet transport and gender beginning to be adopted but as of yet transport and gender statistics are of a limited character as evidenced by the World statistics are of a limited character as evidenced by the World Bank's own gender statistics site. Bank's own gender statistics site.

The development of a web site which provided consolidated The development of a web site which provided consolidated information on the relationship between gender, transport and information on the relationship between gender, transport and maternal mortality and carried detailed information on best maternal mortality and carried detailed information on best practice and how to effect it would be a useful addition to the practice and how to effect it would be a useful addition to the toolkit and process necessary to achieving the Millennium toolkit and process necessary to achieving the Millennium Development Goal of reduced maternal mortality in Africa.Development Goal of reduced maternal mortality in Africa.