Presenter: Valentina Zendejas, Instituto de Liderazgo Simone de Beauvoir
While disseminating the TGN with the government, the local Officer of the High Commission on Human Rights collaborated with members of the civil society platform CPMSM (Comité Promotor por una Maternidad Segura en Mexico), facilitating a meeting with the federal Minister of Health. The Ministry of Health in Mexico is responsible only for making public policies and surveillance, none of the implementation of the fragmented health system (Private insurance, EIMSS, ISSSTE and Seguro Popular) is under the Ministry of Health. However it was hoped that high-level interaction would faciliate implementation of the TGN within the provinces. When 18 maternal deaths occurred between January – May 2014 in the prosperous province of Jalisco, the CPMSM planned to apply the TGN while conducting verbal autopsies to establish causes of death, analyze health system gaps and bring out the perspective of families, towards articulating recommendations for improving service quality. However, the provincial health officials and providers were somewhat threatened by the notion of human rights especially for the poor or indigenous communities. They associated it with court cases, compensation claims or punitive action; and despite repeated efforts over six months, refused to provide any contact information of the deceased women. The members of CPMSM modified their original strategy and leveraged contact with an influential parliamentarian to obtain access to the Director of the Jalisco Civil Hospital. A space has been negotiated to discuss ways of operationalizing the TGN through formation of a Working Group among hospital staff who will be facilitated by CPMSM to study the TGN. The sensitive nature of maternal deaths led to health managers’ reluctance to disclose information and resistance to rights-based approaches. It is important to build providers’ understanding of human rights based approaches for accountability, that incorporate redress, remedy and guarantee of non-repetition to prevent similar deaths in future.
Presenter: Jashodhara Dasgupta, SAHAYOG
While the earlier Indian government had provided considerable recognition to civil society especially around the realization of social-economic rights, the regime change following 2014 General Elections has led to shrinking spaces. Adapting to this changed context, the civil society organization (CSO) SAHAYOG working in partnership with the National Alliance for Maternal Health and Human Rights (NAMHHR) decided to promote implementation of the budget components of the TGN, working with parliamentarians to strengthen legislative oversight of departmental budgets and implementation. However as human rights based approaches in the TGN would need considerable simplification and adaptation, three key elements were taken up for advocacy: the use of budget quotas for promoting health of socially marginalized groups such as indigenous tribes with high maternal mortality, the protection of women’s reproductive rights, and the notion of ‘maximum available resources.’ Political attention was generated by focusing on frequent maternal deaths reported among indigenous tribal women over two years, a tragic incident of deaths among thirteen young women following sterilization operations (November 2014), and the widely criticized federal budget cuts to social sectors. A key strategy centred around the annual oversight of departmental budgets by the Parliamentary Standing Committee (PSC) on Health and Family Welfare, with representatives from all major political parties. The director of the Secretariat, Chairperson and key Parliamentarians of the PSC were briefed using the TGN, fact-finding reports, data and suggested budget queries. Presentations were also made to the Special Economic Advisor to the Finance Minister. The recommendations of the PSC (82nd Report on Demand for Grants, 2015) and the Finance Ministry’s Economic Survey of India 2014-15 both carry a noticeable mention of the issues around rights-based budgeting for maternal mortality prevention. The responsiveness of the PSC has indicated the potential to advocate for implementation of the TGN through this national accountability mechanism.
Presenter: Ariel Frisancho, Catholic Medical Mission Board / ForoSalud
Building on the citizen monitoring model in Puno, political advocacy led to launching of National Policy Guidelines for the Promotion of Citizen Monitoring of Health. However, following elections, the current National government (mid-2011 onwards) is not facilitating citizen monitoring, and the Peruvian Ministry of Health has initiated a health sector reform process focusing more on extension of public and private health insurance to cover as much as population as possible, than on quality or rights-respecting mechanisms. A prolonged strike by protesting medical doctors has led to shrinking of spaces to dialogue for other civil society organizations as well. ForoSalud as a national movement has decided to implement strategies for institutionalizing social accountability through citizen monitoring of maternal health services, especially by the marginalized women who are reporting to the Ombudsman’s office. The purpose is to inform ways in which the OHCHR TGN could be implemented at the sub-national and local level through monitoring of availability, accessibility, acceptability and quality of health services, especially for indigenous women. ForoSalud organized a regional workshop with decision makers to disseminate a “people friendly” leaflet on health services users’ rights and entitlements. A training programme was planned for health personnel in collaboration with the office of the Ombudsman to build knowledge on health services users’ rights and disseminate the “people friendly” version of the TGN. However the standoff between the Ministry of Health and the medical doctors impeded interventions at the national level. Nonetheless, it was possible to strengthen the linkages with the regional authorities and rural indigenous women engaged in citizen monitoring and reporting to the Ombudsman’s office. This has led to the promoting of human rights based approaches using the lessons brought in from this social accountability process.
Presenter: Busisiwe Kunene, Society of Midwives South Africa
South Africa is making some gains towards reducing neonatal deaths but is less likely to achieve reduction of maternal mortality and realise the MGD goal. While HIV has undermined most of the contribution towards achieving this, the Society of Midwives, South Africa (SOMSA) have raised concerns that unless the country plans accurately on human resources and competency skill for midwifery cadre that is responsible for 72% of all MNH care service in the country, it cannot achieve goals for maternal and newborn health. SOMSA has developed a manual on most relevant principles of HRBA selected from the TGN, and conducted a workshop with selected educators who then conduct workshops with their students. The advanced course requires that the students go back into clinical work and take up a community project in an obstetrics unit, to apply what they have learned during their course. The students during their community work assignment in the Midwifery Obstetric Unit used their training in HRBA. They attempted concrete actions, such as encouraging women to choose their most preferred position during labour, ensuring privacy for antenatal examinations and labour rooms, allowing disposal of the placenta in accordance with women’s own customs and practices, and ensuring a basket of contraceptive choices were offered to postpartum women during counselling with no coercion to accept contraception. For any grievances, a notice in the reception area prominently displayed a number where patients could call with complaints. Students acknowledged that implementing HRBA in their work made them feel more responsible to the women they cared for. As one of them said, ‘I am taking accountability to bring change, to do good to the women” and yet another felt that HRBA helped her to “Speak up and do the right thing.”
Presenter: Manuela Garza, IIMMHR
The United Nations Human Rights Council recognized that preventable maternal mortality and morbidity are serious human rights issues (A/HRC/11/L.16 of 2009), and requested the Office of the High Commissioner for Human Rights (OHCHR), to prepare concise technical guidance on applying human rights-based approaches to policies and programmes to reduce preventable maternal mortality and morbidity. This technical guidance note (TGN) was launched in 2012 (A/HRC/21/22); welcomed by all UN bodies, and countries were expected to take up its implementation. Using the policy planning cycle, the TGN aims to assist policymakers in reducing maternal mortality and morbidity in accordance with human rights standards and essential principles. Beyond health decision-makers, the guidance is relevant to other sectors, including finance, parliamentarians, judiciaries, human rights institutions and donors. The report of two years’ implementation of the TGN by countries and UN agencies has been published in 2014. The TGN recognizes women’s human rights to health and promotes women’s active agency to claim their rights, especially women suffering multiple forms of discrimination. It requires States to fulfil women’s sexual and reproductive health rights, to use “maximum available resources” for the progressive realization of rights, and to enforce appropriate laws, policies, regulations and guidelines. The TGN stresses the importance of accountability, including effective redress and remedies. It holds that engagement of civil society is necessary for the effective implementation of rights-based approaches, and to hold Governments to account. The International Initiative on Maternal Mortality and Human Rights is a civil society platform that is promoting the implementation of the TGN at national and sub-national levels across South Africa, Mexico, Peru and India, with a wide range of stakeholders. Using a rigorous documentation framework that tracks stakeholder interventions and contextual shifts, the two years’ experience from civil society strategies brings out challenges and learning in applying rights-based approaches.
Presenter: Sarah Moxon, London School of Hygiene and Tropical
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Background: To achieve the Every Newborn Action Plan (ENAP) national targets of <12 neonatal deaths and stillbirths per 1000 births by 2030, ambitious plans are needed to improve data on coverage of perinatal and newborn interventions, especially for newborns at risk or with complications requiring specific treatment. ENAP metrics group prioritised indicators and developed a systematic measurement improvement roadmap.
Methodology: A matrix of more than 100 indicators were graded in a multi-stage process based on importance for ENAP and data availability. Of the resultant 10 indicators, 4 coverage indicators were mapped by task teams, linking to existing technical workings groups, and priorities identified to improve measurement at scale. Consultations were held throughout.
Results: Five of the ENAP core indicators are for measurement of the coverage of specific high impact treatment interventions for newborns at risk or with complications: antenatal corticosteroids, neonatal resuscitation, treatment of severe neonatal infections, kangaroo mother care and an additional indicator, chlorhexidine cord cleansing. All of these interventions have major data gaps and lack standard indicator definitions. Measuring the population in need (for the denominator) is especially challenging. Apart from KMC and CHX, data are unlike to be feasible to collect through maternal recall in household surveys. Process indicators are presented to use now, with coverage indicator definitions proposed for testing. Facility-based validation will be undertaken in three countries (Bangladesh, Ghana and Tanzania).
Conclusion: The ENAP Measurement Improvement Roadmap (2015-2020) outlines actions needed to test, validate and institutionalise the proposed coverage indicators. The facility-based nature of these high-impact interventions for newborns presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys, and linking to centres of excellence in Africa and Asia.
Presenter: Agbessi Amouzou, UNICEF
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Background: To track maternal and newborn health care, population-based estimates rely on household surveys which focus on coverage of antenatal (ANC), skilled birth attendance (SBA) and postnatal care (PNC), as prioritized by the Commission for Information and Accountability. Yet these metrics only assess contact, not content or quality of care. We approximate quality of services by assessing mothers’ report of selected interventions during these periods in Demographic and Health Surveys (DHS).
Methodology: We used DHS data for antenatal, intrapartum and postnatal care, 2010-2014 in 21 countries. We analysed the proportion of pregnant women with at >ANC and those with >4 visits, who received seven interventions. For PNC, we analysed women delivering with a skilled birth attendant (SBA) whose newborn received seven interventions. We carried out random effect logistic regression to assess factors associated with receiving all interventions.
Results: Although 61% to 99% of women received at least one ANC visit with a SBA across the 21 countries, only 2% to 41% received all seven ANC interventions. Women who had four or more ANC visits were more likely to receive all seven interventions, but the proportions remained low, ranging from 3% to 46%. For PNC, between 1% and 13% of newborns received all seven interventions, despite their mothers having SBA. Characteristics associated with receipt of seven ANC interventions included urban residence, wealth, low parity, age 30-39, education, at least 4 ANC visits, and ANC with a doctor. For PNC; wealth, marriage and education were significantly associated with receipt of all seven interventions.
Conclusion: The coverage-quality gap is large in all these countries, with less than half receiving the interventions assessed, lower for poorer families. More action is needed to strengthen the quality of care, as well as coverage; improved indicators and data will be integral to inform and monitor this programmatic shift.
Presenter: Kate Kerber, Saving Newborn Lives, Save the Children
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Background: Previous meta-analysis suggests that small-scale perinatal audit programmes linked to action may reduce perinatal mortality rates by 30%. The Commission for Information and Accountability recommended scale up of maternal and perinatal mortality audit, yet whilst there has been major policy traction on the former, tools are lacking and progress limited for the latter. In the light of this, one of the Every Newborn Action Plan (ENAP) milestones is to develop perinatal mortality audit tools and promote use at scale.
Methodology: We assessed the status of policy and implementation for maternal and perinatal audit in low- and middle-income countries, reviewing evidence of effectiveness. Key challenges to completing the audit cycle and affecting change were identified along with solutions.
Results: Only 17 out of the 60 priority countries reporting maternal death notification in 2014 have a specific policy for auditing stillbirths and neonatal deaths. Maternal death surveillance is moving rapidly with many countries enacting policies and accountability mechanisms. Current evidence demonstrates that audit can improve birth outcomes when the whole cycle is completed. Lack of leadership and health information systems were found to be primary challenges and should be addressed to achieve effective audit systems. Functional audit requires a no-blame environment. Concurrent development and the use of clear guidelines and protocols also contributed to ensuring that the audit cycle is completed.
Conclusion: Health workers have the power to change what is in front of them, but wider change requires action at other health system levels, e.g., for human resources or commodity supply chains. Linking to wider change also requires a data management system including consistent cause of death classification, guidelines and especially leaders to champion the process, and to access change agents at other levels to address larger, systemic challenges. WHO perinatal audit tools are being developed based on these findings.
Presenter: Peter Waiswa, INDEPTH Network and Makarere School of Public Health
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Background: National tracking for targets of <12 neonatal deaths and stillbirths per 1000 births is essential. Yet mortality capture relies on 5-yearly household surveys, with statistical modeling. Urgent action is required to improve quality, quantity and frequency of impact data.
Methodology: We undertook a systematic assessment for 195 countries regarding data for stillbirth rates (SBR), intrapartum stillbirths, neonatal mortality rates (NMR), cause-of-death, plus gestational age and birthweight. We generated ENAP metrics scorecards for each impact level ENAP indicator. We considered research questions and improvement strategies through routine health systems.
Results: Since 2000, child mortality data have increased four-fold, with more countries now categorized “complete” Civil & Vital registration Systems (CVRS). However, 33% births are not registered by their first birthday, with <5% of 2.8 million neonatal deaths and fewer of the 2.6 million stillbirths worldwide being registered. For neonatal cause-of-death, 65 of 195 countries have high-quality vital registration data (4% deaths). For high-mortality countries, data remain dependent on various verbal autopsy (VA) tools which are expensive and often apply inconsistent attribution approaches. Stillbirth rate data have increased especially in national registries, but survey data remain low quality. Intrapartum stillbirth data are lacking from >150 countries and SBR/NMR misclassification requires systematic evaluation. Data for neonatal morbidity are even rarer, and key risk factors such as birthweight and gestational age require specific focus.
Conclusion: To improve mortality data, a critical question involves comparison of prospective surveillance data with maternal recall in surveys, using either live birth or pregnancy history modules. Improved, more consistent, lower cost tools are needed for VA. Strengthening coverage and quality of CVRS, including more relevant and useable coding in ICD11, is critical and we propose development of a minimum perinatal dataset, linking facility birth registries, CRVS, improved birthweight and GA data.
Presenter: Joy Lawn, London School of Hygiene and Tropical Medicine
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Background: Every Newborn Action Plan (ENAP) developed national targets, for less than 12 neonatal deaths and stillbirths per 1000 births by 2030, with a resolution at World Health Assembly 2014. To track progress, urgent data improvements are required, with milestones by 2010 including validated coverage indicators and institutionalisation of data collection, impact data collection through civil registration and vital statistics (CVRS), minimum perinatal dataset and perinatal mortality audit tools. This paper describes the work of ENAP’s metrics group and multiple stakeholders to prioritise and select indicators and develop a systematic measurement improvement roadmap.
Methodology: In 2014, ENAP listed 10 core (plus additional) indicators prioritised from a list of 120 through systematic grading according to relevance to ENAP and data availability. Since then the indicators have been mapped, with identification of measurement gaps, research questions set. Through multi-partner planning processes including a WHO Technical meeting, December 2014, the measurement improvement roadmap was refined.
Results: Core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) are well-defined, focus is needed to improve data quantity and quality. Indicators for newborns at risk or with complications or disability mainly lack indicator definitions or data. Coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content of care provided at these contact points and quality of care. The most major gap is for coverage for specific treatment indicators, related to some of the highest impact interventions.
Conclusion: The measurement improvement roadmap outlines actions to improve data quantity, quality and use working with existing global networks, such as INDEPTH and All India Institute of Medical Science (AIIMS), and centres of excellence in three high burden countries. Real change requires intentional transfer of leadership to countries with the greatest disease burden.