November 22, 2014

Ryerson University

Inequalities in Access to Maternal Health

Care and Role of Transport Intervention:

Mom’s Van as an Example.

Nazmul Alam, MPH, DrPH

Université de MontréalQuebec, Canada

Outline of the Presentation

• Maternal mortality: causes and consequences

• Maternal care services: persistent inequality

• Interventions to address inequality

• Role of transport intervention: The walk

• Mom’s van intervention

Maternal Mortality: A Global Tragedy

• In 2013, 289 000

women died from

complications of

pregnancy or

childbirth.

– 99% in developing

world

– >50% of them in

Africa

• http://gamapserver.who.int/gho/interactive_charts/mdg5_mm/atlas.html

99

0

55

0

20

0

14

0

17

0

65

94

0

43

0

12

38

0

68

0

280

14

0

93

10

0

36

61

0

30

0

11

27

0

51

0

19

0

11

0

85

74 27

44

0

23

0

15

21

0

0

200

400

600

800

1000

1200

1990 2005 2013

Trends in Maternal Mortality Ratio

Source: Trends in Maternal Mortality: 1990-2013 (WHO, UNICEF, UNFPA, World Bank)

5

Progress towards Millennium

Development Goal 5

Countdown of 75 countries, account for 95% of all deaths.

Nine countries are on track; 25 made insufficient or no progress.

Count down to 2015: briefing note

Causes of Maternal Mortality

Source: Countdown to 2015, 2010.

*Malaria, HIV, accident etc..

**Obstructed labor, ambolism etc..

• 1st delay: delay in decision to seek care

• Lack of understanding of complications

• Acceptance of maternal death

• Low status of women

• Socio-cultural barriers to seeking care

• 2nd delay: delay in reaching care

• Mountains, islands, rivers

• Distance to health centres and hospitals

• Availability of and cost of transportation

• 3rd delay: delay in receiving care

• Supplies, personnel

• Poorly trained personnel with punitive attitude

Three Delays Model

* 3 delay model, Thaddeus 1994

8

Maternal Health Care

Prenatal care

Antenatal care

Skilled attendent at Birth

Emergency obstetric care

Postnatal care

EmOC is fundamental

Emergency Obstetric Care

Skilled

Attendant Referral

Risk

Screening

Social

Mobilization

Waiting

Homes

TBA

Training

Antenatal

Care

Coverage of care

• Good quality maternal health

services are not universally

available and accessible

– > 35% receive no antenatal

care

– ~ 50% of deliveries

unattended by skilled

provider

– ~ 70% receive no

postpartum care during 1st 6

weeks following delivery

R2 = 0.74

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0 10 20 30 40 50 60 70 80 90 100

Y Log. (Y)

Maternal care services and MMR

% skilled attendant at delivery

Mate

rnal death

s p

er

1000000 liv

e b

irth

s

Praveen et. al., PLoS One. 2010 Oct 27;5(10):e13593.

Prenatal care, skilled birth attendance and MMR

in India.

13

Contraceptive prevalence rate and maternal

mortality

Ahmed et al, Lancet 2012: 380:111-25

14

Count down to 2015: briefing note

Inequalities in access to Care

Inequalities in facility birth by residence and wealth

15

Channon et. al, 2012, Maternal health inequalities overtime: is there a pattern?

16

Wilunda et al. International Journal for Equity in Health 2013, 12:27

Inequality in utilization of in Oromiya, Ethiopia

Caesarean section by wealth

WHO, 2013

18

Trends in the percentage of skilled birth attendance by (A) woman’s education, (B) partner’s

education, (C) wealth index, 1993–2008. BMJ Open 2013 3:

Mothers education and SBA

Interventions to reduce maternal

mortality

Health systems improvements

• Antenatal care

• Skilled attendant at delivery

• Functional EmOC

• Referral

Structural interventions

- Girls education

- Infrastructure

- Health care financing

Maternal Mortality Reduction

Sri Lanka 1940–1985

0

200

400

600

800

1000

1200

1400

1600

1800

1940–45 1950–55 1960–65 1970–75 1980–85Mate

rna

l D

eath

s p

er

100 0

00 liv

eb

irth

s

85% births attended

by trained personnel

Maternal Mortality: UK 1840–1960

0

50

100

150

200

250

300

350

400

450

500

1840

1850

1860

1870

1880

1890

1900

1910

1920

1930

1940

1950

1960

MaternalDeaths

Improvements in

nutrition, sanitation

Antibiotics, blood bank,

CSAntenatal care

Education

23

Health Voucher scheme

Demand side financing: maternal health voucher scheme in Bangladesh, Ahmed, Soc. Sci & Med, 2011

24

In Burkina Faso, household costs related to maternal care has been

progressively reduced: i. abolition of ANC user fees, 2002; ii. subsidy for

C-sections, 2006; iii. subsidy for all deliveries, 2007. (De Allegri, Valerie, 2012)

User fee abolitions

Poor transport specially in rural areas in LMIC is one

of the avoidable factors.

• scarcity of transportation

• distance

• cost of transport

• poor road conditions

Referral and transport intervention

The Walk video:

http://youtu.be/8HZuMmU778I

Every Mother Counts

Referral and transport intervention

Three wheeler motor van (Mom’s van)

for transportation of women with

obstetric emergency

Mostly in Africa, where it needs more….

- RESCUER project in Uganda

- Yellow flag initiative in Nigeria

- Safe motherhood transport plan- Malawi

But existing transport intervention are either inadequate,

urban focused, facing management or sustainability

problem

Existing transport intervention:

Objectives

• to understand availability transportation and

referral network during obstetric emergencies in

rural areas

• to assess acceptability, feasibility and utilization

of ‘Mom’s van’ intervention

Goal: Contribute in reduction of maternal mortality to

achieve MDG targets

30

Implementation Framework

Methodology

The study has two phases:

31

Bangladesh, Mymensingh District, Nandail Upazila: approximately

328,847 population

Study Area

Kaya district in Burkina Faso: approximately 66,851 population

Formative research

Qualitative and quantitative methods have

been used:

Those methods included:

• Literature review,

• Survey with a semi structured

questionnaire,

• In-depth interviews with key informants,

• Focus group discussions (FGDs),

32

33

34

Recruitment of mothers

Burkina Faso: n= 340 Bangladesh: n= 300

35

Place of delivery and experience to travel

BangladeshBurkina Faso

36

Characteristics Number, N=300 %

Complications during last

pregnancy/delivery 137 45.7

Sought care for complications 128 42.7

Mode of transportation to go health

centres

Ambulance/micro-bus

CNG/Auto

Rickshaw/ Rickshaw van

Boat

On foot

(n=187)

26

80

71

3

7

13.9

42.8

38.0

1.6

3.7

Time needed to go a health facility

(range) 1h24m (30m-3h30m)

Cost for one visit (range) 752.7 (1500-3500)

Care seeking during pregnancy and delivery,

Bangladesh

37

Characteristics Number (N=340) %

Complications during last

preg./delivery247 73.2

Sought care for complications 229/247 92.7

Available transportation

Motor cycle

On foot

Moto ambulance

208

69

2

75.0

20.3

0.6

Ave. time to reach health facility (range) 1h:30m (10m-10h)

Cost (FCFA*) for each visit (range) 750 (0-3750)

Care seeking during pregnancy and delivery, Burkina

Faso

Van modeling

38

Allwells Marketing company and Rasendic

motors Inc..

• A three wheeler, suitable for rural roads, safer than two

wheeler.

• Cell phone connectivity to help rapid communication

with families and service providers.

• Manage by community support group to promote sense

of ownership, included women in committee

• Adopted a business model for limited income generation

for sustainability.

• Will carry women from poor families for free to promote

equity.

Key features/innovations:

How it helps:

•Availability of Mom’s van in the community will help

reduce 1st delay (decision making)

•Women with complications can reach facilities in

less 60 minutes (2nd delay).

• Mobile connectivity will help reduce delay at the

facility (3rd delay).

Major outcomes:

• Acceptability: acceptability will be assessed by

interviewing women who received services and their

family head .

• Feasibility: feasibility will be assessed by measuring cost,

management and administrative issues

• Effectiveness: measuring distal outcome like met need,

travel time, referral rate, etc..

42

Launching of Mom’s van

43

Promotion of Services

44

Service utilizations

45

Process data collection:

- Sustainability vs. affordability

- Creating demand

- Risk of accident

- Monitoring and supervision

Major challenges:

47

Singh A, Mavalankar DV, Bhat R, Desai A, Patel SR, et al. (2009) Providing skilled birth attendants and emergency obstetric

care to the poor through partnership with private sector obstetricians in Gujarat, India. Bulletin of World

Health Organization 87: 960–964.

Houweling TAJ, Ronsmans C, Campbell OMR, Kunst AE (2007) Huge poorrich inequalities in maternity and child care in

developing countries. Bulletin of the World Health Organization 85(10): 745–754.

Freedman LP, Graham WJ, Brazier E, Smith JM, Ensor T, et al. (2007) Practical lessons from global safe motherhood

initiatives: time for a new focus on implementation. Lancet 370: 1383–91.

Pathak PK, Singh A, Subramanian SV. Economic inequalities in maternal health care: prenatal care and skilled birth

attendance in India, 1992-2006.PLoS One. 2010 Oct 27;5(10):e13593.

McIntyre D, Thiede M, Birch S: Access as a policy-relevant concept in low- and middle-income countries. Health Economics,

Policy and Law 2009, 4:179–193.

MATERNAL HEALTH INEQUALITIES OVER TIME: IS THERE A COMMON PATHWAY? Andrew Amos Channon, Sarah

Neal, Zoe Matthews and Jane Falkingham University of Southampton, UK October, 2012

Målqist M, Lincetto O, Du NH, Burgess C, Hoa DT. Maternal health care utilization in Viet Nam: increasing ethnic inequity.

Bull World Health Organ. 2013 Apr 1;91(4):254-61.

The World Health Organization, Department of Reproductive Health and Research (2007) Maternal mortality in 2005:

estimates developed by WHO, UNICEF and UNFPA. Geneva: World Health Organization.

United Nations. 2012b. The Millennium Development Goals Report. New York.

Barros AJ, Ronsmans C, Axelson H, et.al. Equity in maternal, newborn, and child health interventions in Countdown to 2015:

a retrospective review of survey data from 54 countries.Lancet. 2012 Mar 31;379(9822):1225-33.

Maternal health inequalities over time: is there a common pathway? Andrew Amos Channon, Sarah Neal, Zoe Matthews and

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Pub Health 2012, 12(252):1–10.

Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994 Apr;38(8):1091-110.

De Allegri M, Ridde V, et al. The impact of targeted subsidies for facility-based delivery on access to care and equity -

evidence from a population-based study in rural Burkina Faso.J Public Health Policy. 2012 Nov;33(4):439-53.

Arsenault C, Fournier P, Philibert A. et. al. Emergency obstetric care in Mali: catastrophic spending and its impoverishing

effects on households. Bull World Health Organ. 2013 Mar

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References

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Funded by:

Implemented by:

Acknowledgement

Thank you

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http://www.mofa.go.jp/policy/oda/white/2011/html/honbun/b2/s3_2.ht

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