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Maternal Health Outcomes in a Post-War

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Maternal Health Outcomes in a Post-War Maternal Health Outcomes in a Post-war Context: Analysis of Trends, Inequities in Social Determinants of Health and Progress Towards UHC in Somalia Jamila Aden PhD Candidacy Proposal Health Cluster 15072021 • Supervisors: AProf. Delia Hendrie • Co-supervisor: Dr. Judith Daire • Chairperson: AProf. Richard Norman Inequalities in Maternal Health Outcomes ▪ Globally, 295,000 women died in 2017 ➢ 94% of these deaths occur in LMICs o Two thirds of maternal deaths occur in Sub-Saharan Africa (SSA) ▪ Lifetime risk of maternal mortality Background ➢ 1 in 36 in SSA ➢ 1 in 4,900 in high income countries ▪ Somalia has third highest maternal mortality ratio in the world ➢ 733 maternal death per 100,000 live births International Calls for Reducing Maternal Health Inequalities 1948 1978 1987 1994 Universal Alma-Ata Safe Cairo International Declaration for Conference on Declaration of achieving “Health Motherhood Population and Human Rights for All” Conference Development (ICPD) SM conference marked the start of the Safe Motherhood Initiative (SMI) to reduce maternal mortality to 50% by the year 2000 International Calls for Reducing Maternal Health Inequalities 1995 2000 2005 2008 2015 th Fourth Beijing 58 World Health Commission Millennium Assembly on Social Sustainable International Developme Development Resolution on Determinant Conference nt Goals Goals (MDGs) Universal Health s of Health (SDGs) on Women Coverage ( UHC) (CSDH) SDGs: established a new and ambitious agenda for maternal health. SDG 3 specific to health CSDH: raised awareness of how the conditions in which people are targets include reducing born, grow, live, work, and age shape global health challenges. maternal mortality; and UHC: focus on universal access to needed healthcare services of UHC (greater access to good quality to the entire population without undue financial health services, financial hardship. protection and equitable outcomes) ▪ Studies in LMICs (e.g.Ethiopia, Mozambique, Ghana, and Zimbabwe) have explored social determinants shaping maternal health inequities ▪ My previous study with colleagues explored causes and contributing factors of maternal deaths In Somalia ➢Barriers to access and utilisation of maternal health care services included poverty, gender inequality, geographical terrain, political instability and health system challenges Aden JA, Ahmed HJ, Östergren P-O. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach. Global health action. 2019;12:1672314. https://doi.org/10.1080/16549716.2019.1672314 Rationale for the Study UHC is a catalyst for achieving SDG 3 : “Ensure healthy lives and promote wellbeing for all at all ages,” by promoting greater access to health services, financial protection and equitable outcomes (WHO and World Bank, 2015) Global and national platforms have been established to track the progress Existing studies show SDH determine inequitable distribution of maternal health outcomes. However, there is limited attention to localised evidence from in-depth case studies on mechanisms through which equity-oriented policies like UHC work to address SDH and lead to equitable distribution of maternal health outcomes. Significance Generating evidence for policy: current need for additional empirical studies to explore the mechanisms through which SDH shape inequities in maternal health outcomes in post-conflict context like Somalia. Research practice: contribute to the practice of evaluating the impact of policies on maternal health outcomes and developing context-specific pathways for monitoring progress towards achieving universal health coverage. Aim and Objectives Aim: Examine trends and inequities in maternal health outcomes (MHOs) in Somalia. 1: Analyse the policy context and progress towards achieving universal health coverage related to maternal health in Somalia. 2: Assess trends in maternal health outcomes and inequities in social determinants of maternal health. 3: Examine the mechanisms through which social determinants shape inequities in maternal health outcomes in Somalia. Underpinning Context and Trends in maternal Availability of maternal health policies, quality Theoretical Inputs, health programs and services, Outcomes Outputs outcomes and process interventions accessibility and impact inequalities in Framework towards and utilisation SDH achieving UHC Impact Evaluation Model Mechanisms through which inequalities in SDH determine the distribution of maternal health outcomes ▪Realist evaluation approach – guide steps adopted in the evaluation process Other ▪UHC action framework– help with theoretical mapping maternal health policies insights and indicators for assessing UHC ▪SDH action framework – help with developing themes on mechanisms through which UHC policies work to improve MHOs Study Design Adopt a mixed methods case study design, which allows for an in- depth analysis of a complex phenomenon within a ‘bounded system’ using both qualitative and quantitative research methods Phenomenon to be studied is ‘social determinants of maternal health inequities’, and the ‘bounded system’ or case study site is Somalia. Scoping review Document analysis Quantitative data Data Collection Key informant Focus group Data triangulation interviews (KI) discussions (FGDs) Scoping ▪ Understand overall context, policies, and review programs for achieving UHC for maternal health in LMICs Scoping Document literature analysis review ▪ Examine progress towards achieving UHC for maternal health in LMICs Quantitative Key informant data interviews (KI) ▪ Scoping review will follow the Joanna Briggs Focus group Institute (JBI) guidelines Data discussions triangulation (FGDs) ▪ Findings will inform document analysis Document ▪ Purpose is to establish the initial theory of change of UHC for maternal health in Somalia as a basis for analysis evaluating progress in maternal health outcomes ▪ Relevant country-specific documents will be retrieved Scoping Document from the government websites in Somalia and literature analysis review international organizations ▪ Document analysis will follow a systematic procedure Quantitative Key informant and an iterative process combining content, thematic data interviews (KI) and interpretive analysis to generate key themes ▪ NVivo software for analysing the extracted data Focus group Data discussions triangulation ▪ Findings will confirm variables for quantitative (FGDs) analysis of trends in maternal health outcomes and inequalities in SDH Quantitative ▪ Aim: analyze trends in maternal health outcomes and data inequities in Somalia using IBM SPSS Statistical Software ▪ Quantitative data will be retrieved from existing Scoping household and other national surveys from 1990 Document literature analysis (post-conflict period) onwards review ➢ Analysis will include descriptive statistics and Quantitative Key informant preparing time sequential plots of maternal health data collection interviews (KI) indicators ➢ Appropriate regression methods will be determined Focus group Data discussions by nature of data and time series patterns with triangulation (FGDs) segmented linear regression a possible approach Key informant interviews ▪ Aim is to understand the policy implementation challenges (KI) for policies related to UHC of maternal healthcare in Somalia ▪ KIs will be selected using purposive sampling from the Scoping Document literature national, zonal, regional and district levels of the health analysis review system ➢ Cross-section of policy makers and health services Quantitative Key informant managers with roles and responsibilities related to data interviews (KI) maternal health and UHC Focus group ▪ Interviews to be conducted face to face or by telephone, Data discussions triangulation will be recorded and take 40-60 minutes (FGDs) ▪ Recorded KI interviews will be transcribed and thematically analysed using NVivo Potential Key informants Health System Levels Position and Roles of Key Informants Total # National level • MoH Director General 1 • MoH Departmental and service directors, 12 coordinators, managers Representative from INGOs • UNICEF 1 • UNFPA 1 • WHO 1 Zonal, regional and district level • Zonal health officers 3 • Regional health officers 3 • District health offers 3 Total number of potential 25 participants ▪ The aim of the FGDs is to gain insight from FOCUS GROUP participants about their experiences and perceptions DISCUSSIONS of specific maternal health policy processes and (FGDS) outcomes. ▪ FGDs to be conducted in ONE Zone: Northeast Zone due to time and resource constraints Scoping Document literature analysis ▪ Participants for FGDs to be: review ➢ Purposively selected from district hospitals and health facilities Quantitative Key informant data interviews (KI) ➢ Conveniently selected from three regions in Northeast Zone. Focus group ➢ Each FGD (6-8 participants) to take 40 to 60 minutes Data discussions triangulation (FGDs) ➢ Eligible participants to include health workers, community representatives, women of childbearing age Number of districts and PHC facilities for FGDs Regions District hospitals Urban Maternal and Child Rural Maternal and Child Total selected Health/Health Center Health/Health Center Total Selected Total Selected Total Selected Total (n) (n) (n) (n) (n) (n) selected (n) Bari 1 1 9 1 5 1 3 Nugal 2 1 9 1 9 1 3 Mudug 3 1 16 1 8 1 3 Total 6 3 34 3 22 3 9 Total 3 DHMTs 3 Groups of HWs, women attending 3 Groups of HWs, women attending 21 FGDs Groups ANC/PNC, health
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