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					  UNFPA strategy for increasing
access to skilled birth attendants in
 institutions (with special focus on
        rural/isolated areas)
            Dr Vincent Fauveau,
 Maternal Health Adviser, TSD, UNFPA-GVA

 Regional Workshop on skilled birth attendants
            in South and West Asia,
         Islamabad, 19-21 April 2004
             The new paradigm
• All pregnancies are at risk: Most obstetrical
  complications are neither predictable, nor
  avoidable, but can be treated if assisted by a SBA
• Shift of focus from pregnancy to delivery,
• Therefore, from the viewpoint of providers,
  readiness becomes the key word, accompanied
  by quality of obstetric care,
• Provided parturients can access and use these
            ready and quality institutions
The UNFPA Vision and Strategy
 for the Reduction of Maternal
   Mortality and Morbidity
           is based on 3 pillars:
• 1.Family Planning,
• 2.Skilled attendance at (all) births,
• 3.Emergency Obstetric Care
           2. Skilled Attendance
             during Childbirth
• « skilled »: Need a coordinated definition,
  universally accepted, evidence based
• « attendance or attendants »? Focus on the human
  resources, on quality and commitment, in an
  enabling environment, therefore on « care »
• « during childbirth »: because evidence shows that
  most complications, and deaths, occur during
  childbirth (25%), or immediately thereafter (60%,
  the rest before labour)
      Attendance at birth according to
         community-based surveys
            6%   6%




26%                                      Doctor
                                         Other SkAt
                                         TBA
                                         Relative
                             40%
                                         No-one




      22%
           The 3 Delays Model


       DELAY#1                 DELAY#2                  DELAY #3
       Deciding               Reaching               Receiving
       To seek                 An EmOC               EmOC
        EmOC                    Facility              At Facility




Onset of            Time                                 Recovery
Complication                               Program       or  death



                  EmOC = Emergency Obstetric Care
       The Three Delays approach
• First: delay in deciding to seek care for a
  perceived obstetrical complication (community)
• Second: delay in reaching the appropriate
  facility (transport)
• Third: delay in receiving appropriate care at the
  facility (skilled care)
• Put emphasis on the third delay, which should
  come first. Useless to address the other two if
  quality care is not ensured in health facilities.
  Barriers to availability of SBAs
 Lack of human resources strategy – planning
  and budgeting, long-term vision of needs
 Posting and retention – low quality of life
 Initial training – professional schools
 No continuous education and on the job training
 Lack of positive supervision/support
 Low status, income, promotion
 Gender and rights issues
       Barriers to access to SBA
Availability and geographic distribution of facilities –
  availability of equipments and supplies – of means of
  communication – 24/24 h
 Economic: cost of care (even where services are
  supposed to be free: out of pocket expenditures)
 Technical capacity for ensuring quality of procedures –
  flow of patients – water & sanitation – infection control
  – standards of care
 No delegation of authority, fear of consequences
 Transport – availability, cost, no roads, radio
        Strategies for first delay:
          Empowering women
Ensuring access to information (Malaysia,
 Philippines, Indonesia, India, Bangladesh)
     Seeking care, institutional deliveries
     If home delivery- calling SBA, preparations
      including for referral
     Knowledge of danger signs, when and where to
      seek care
     Client rights (consumer protection act)
           Strategies for first delay:
           Empowering women (2)
Promoting access to money/funds
Encouraging women to save for pregnancy and
 delivery (Sewa, India-maternal protection scheme)
Economic empowerment (evidence that women who
 have savings are in a better position to negotiate their
 rights) (Bangladesh)
  Most insurance limited to services, does not cover
 transportation
Focus on poor women
Enabling women to exercise their rights and seek
 accountability from the providers
Safe and timely referral- Sharing
responsibility – Husbands and Families
Provide information on importance of care during
  pregnancy, dangers signs, when and where to seek care
  (involve in Birth Preparedness plan, e.g.Indonesia,
  birth preparedness)
Developing a birth preparedness plan:Designated birth
  attendant, transport, emergency funds, location of
  EmOC facility ( CARE, Bangladesh uses a card)
 Domestic budgeting, contingency plannning
 Safe and timely referral-
 Community mobilization
 Education and mobilisation about the need for
  special care during pregnancy and childbirth---
  the goal is to ensure that appropriate health
  seeking behaviour becomes part of social norm
Women representatives of local governments
  take lead
 Safe and timely referral-
 Community mobilization
Community insurance
      Insurance (demand side financing)
      Indonesia – safety net (midwives paid for care and
       referrals)
      Bangladesh- micro-health insurance schemes by micro-
       credit institutions
      India – for women below poverty line
Community auditing of maternal deaths
Community emergency plan (transport, funds, care of
 children)
Safe and timely referral- Transport
 Identification of transport – negotiation with transport
  companies, community transport, (boats, mules, group
  of people on duty to carry in makeshift strechers)
 Calling of transport (radio system, mobile phones)
 Payment--- revolving funds operated by
  women/community, insurance scheme including tr.
 Who accompanies? Skilled Birth Attendant?
 How to manage IV drips, medications on the way
         Maternity waiting homes

 Several types, not well evaluated
 They decrease the distance, the time and the
  stress
 Problems: cannot predict time of delivery, away
  from home for long, need to have someone full
  time to provide care and arrange transport
 MWH must be built on or close to the hospital
  compound, and operated by community (NGO)
But the main argument for institutional
delivery remains Quality of care
Good experience with providers encourages use of care
  – cost is not a major concern in such situations
Women’s perspectives about quality of care
 Respect by health service providers- not to be abused
  or scolded- talk and smile…particularly at night…
 Sensitivity to needs, including respect for dignity
 Care and support, explanations, choices
 Costs
           Program Activities:
Start by improving existing EmOC services (Third
  Delay), or upgrade existing facilities into BEmOC
• Renovation of facilities (Humanization)
• Purchase/distribution of equipment (maintenance)
• Training of staff, providers and managers
• Organize 24 hours readiness (night duty, bells)
• Improving quality of care (norms & standards
• Infection control
• Supportive supervision
  UNFPA Purpose: To guide national
 MMR programmes in integrating SkAB
   &EmOC into their health systems
Four Expected Outputs:
1. Increased knowledge of all parties (Government
   and partners) concerning the effectiveness of
   SkAB and EmOC
2. Strengthened collaboration with all parties to
   integrate EmOC into national health system
3. Improved availability, accessibility and quality of
   EmOC services, according to standards
4. M & E: Improved understanding and use
             of EmOC Process Indicators & %SBA
      Human Resources strategies
• The most crucial constraint, or factor of success,
• The challenge is to post (and keep) skilled and
  committed providers in basic EmOC facilities
• Formulate/review national HR policies and
  strategies (addressing « brain drain »)
• Laws & regulations: delegation of authority
• To be included in the reform of health system,
• Need multi-partner coordination, not only health
  Gender & Human Rights in MMR
• MM reduction is a matter of gender, sexual and
  reproductive rights, and social justice,
• Links must be established and analyzed, at the
  individual level, family level, community level,
  and institutional level,
• Too often, maternal death or disability are the
  result of gender-based violence
• Socio-economic inequities - MNH & Poverty

				
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