The Evidence Towards MDG 5: A Working Paper Authors: Louise Hulton Susan Murray Deborah Thomas Commissioned by DFID and NORAD Presented by Options Consultancy Services Ltd. February 2010 *The contents of this review are the work of Options and do not necessarily reflect the views or policies of DFID or NORAD. Options Consultancy Services Ltd, 20–23 Greville Street, London EC1N 8SS. UK ● www.options.co.uk ● t: +44 (0)20 7430 1900 Acknowledgements Thanks to the many people and organisations who responded to our request for information on material and intelligence relevant to this review. We are very thankful for the valuable contributions of Barbara McPake, Chris Vickery, Katie Chapman, Sara Nam, Georgia Taylor, the Options Private Sector Team (Corinne Grainger and David Griffith), Zoë Matthews, Harriet Stanley, Sarah Bandali, Anne Nolan, and Reilly Dempsey for their contributions. Thanks to Alexis Palfreyman for her research support and help with the preparation of the final report. Particular thanks to Sophie Gallie who has provided such patient and efficient research support to the team. ii Contents Acknowledgements ................................................................................................................................... ii Abbreviations........................................................................................................................................... vi TTThehhee EEEvidencevviiddeennccee TT Towardsoowwaarrddss MMMDGDDGG 555::: AA WWWorkingoorrkkiinngg PPPaperaappeerr .........................................................................................1 Search strategy ......................................................................................................................................3 PPPartaarrtt OOOne:nnee:: MMMaternalaatteerrnnaall aaandnndd RRReproductiveeepprroodduuccttiivvee HHHealtheeaalltthh MMMatters:aatttteerrss:: RRRestatingeessttaattiinngg tt thehhee CCChallengehhaalllleennggee ............................................5 Section 1: Progress in meeting MDG 5 ....................................................................................................9 Current progress on tracking indicators for MDG 5a: Maternal mortality ratio and skilled birth attendants9 Current progress on indicators for MDG 5b: Unmet need for family planning, contraceptive prevalence, adolescent birth rate and antenatal care............................................................................................15 Current progress against indicators related to maternal and reproductive health...................................19 Section 2: Other dimensions of maternal health and well‐being..............................................................21 Maternal morbidity ...........................................................................................................................21 HIV/AIDS and maternal health............................................................................................................22 Morbidity from unsafe abortion .........................................................................................................22 Maternal under nutrition...................................................................................................................23 Violence against women....................................................................................................................23 Newborn health indicators.................................................................................................................23 Section 3: The funding challenge: Expenditure......................................................................................25 PPPartaarrtt TTTwo:wwoo:: MMMakingaakkiinngg aaa DD Difference:iiffffeerreennccee:: EEEffectiveffffeeccttiivvee PPPackagesaacckkaaggeess ooofff CCCareaarree .........................................................................35 Section 1: Effective packages of care.....................................................................................................39 Before pregnancy..............................................................................................................................39 Family planning.................................................................................................................................39 Pregnancy.........................................................................................................................................43 Birth.................................................................................................................................................48 Postnatal care: Care for mother and neonate .....................................................................................55 Section 2: Utilisation of new technologies .............................................................................................61 Magnesium sulphate: A case study ....................................................................................................61 New technologies for treating postpartum haemorrhage .....................................................................62 Innovation in medical abortion...........................................................................................................63 Section 3: Implementing effective packages of care ...............................................................................64 Strategies for implementing effective interventions.............................................................................65 PPPartaarrtt TTThree:hhrreeee:: MMMakingaakkiinngg aaa DDDifference:iiffffeerreennccee:: SSStrongttrroonngg HHHealtheeaalltthh SS Systemsyysstteemmss ...........................................................................69 Section 1: Health sector governance and political leadership..................................................................71 Section 2: Challenge: Human resources for health ................................................................................74 Section 3: Challenge: Referral..............................................................................................................78 Section 4: Challenge: Infrastructure .....................................................................................................79 Section 5: Challenge: Essential drugs, supplies and equipment...............................................................80 Section 6: Challenge: Health financing mechanisms for maternal health.................................................83 User fees ..........................................................................................................................................83 Social and community based health insurance.....................................................................................84 Community based emergency funds...................................................................................................86 Private health insurance ....................................................................................................................86 Cash transfer and Voucher schemes ...................................................................................................86 Cash transfers...................................................................................................................................88 Targeting..........................................................................................................................................88 Section 7: Challenge and opportunity: Making the most of the private sector .........................................90 Social marketing................................................................................................................................91 Social franchising ..............................................................................................................................92 Performance‐based Financing Approaches..........................................................................................93 PPPartaarrtt FFFour:oouurr:: TTThehhee DDDemandeemmaanndd SSSideiiddee ooofff MMMNH:NNHH:: EEEquity,qquuiittyy,, AAAccess,cccceessss,, AAdvocacyddvvooccaaccyy aaandnndd AAAccountabilityccccoouunnttaabbiilliittyy .....................................98 Section 1: Demand side barriers .........................................................................................................101 Challenge: Social exclusion..............................................................................................................101 Challenge: Women’s status, empowerment and education ...............................................................102 Challenge: Financial barriers............................................................................................................104 iii Challenge: Physical access to maternal health services......................................................................105 Challenge: Social and cultural barriers..............................................................................................106 Section 2: Increasing demand through community mobilisation and engagement..................................107 Impact on health outcomes .............................................................................................................107 Mobilisation as a vehicle for participation and empowerment............................................................108