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									Choice for women:
wanted pregnancies,
safe births

Public consultation
on reproductive, maternal and
newborn health in the developing
world to inform the UK
Government’s forthcoming
Business Plan

                                   Picture: Robert Yates / Department for International

Slide 1
Our mission
 • Improving reproductive, maternal and newborn health
   in the developing world is a major priority for the UK

 • DFID is developing a new Business Plan, which will
   determine our contribution towards achieving
   Millennium Development Goal (MDG) 5 to improve
   reproductive and maternal health as well as reducing
   newborn deaths (thereby contributing to MDG 4 to
   reduce child mortality).

 • The views and opinions expressed during this
   consultation exercise will be used by DFID to give us
   a greater understanding of where we should target
   our aid interventions.

 • The new business plan will be published to

                                                            Picture: Storyline / Storyline / Safe Motherhood Programme /
                                                            Department for International Development

Slide 2
Get involved
• How to use this presentation: please use this presentation to inform your thinking and structure your
  discussions - and then send us your responses either online where others can view them or downloading
  the template provided and emailing a completed version to us.

• Duration: the consultation runs until 20 October 2010.

• Enquiries: for enquiries about the consultation - please email: choiceforwomen@dfid.gov.uk

• How to respond: for more information on the issues and questions, please submit your responses online
  on DFID’s website http://www.dfid.gov.uk/choiceforwomen. If you have difficulty accessing the internet
  or a low bandwidth connection, please download and complete the template response document and
  email it to choiceforwomen@dfid.gov.uk. Alternatively you can post your response to:
  AIDS and Reproductive Health Team, DFID, 1 Palace Street, London, SW1E 5HE, UK

Slide 3
Choice for women – wanted pregnancies
• Investing in family planning is one of the most effective development interventions and the most cost
  effective way to reduce maternal mortality.

• 215 million women in the developing world would like to delay or avoid a pregnancy (see map 1 on the
  next slide), but do not have access to modern family planning methods. Each year there are up to 75
  million unintended pregnancies.

• Young women’s unmet need for family planning is double that of older women. Adolescent birth rates are
  high, particularly in Africa (see map 2 on next slide). The youth population of the world is rising, so
  demand will increase.

• Failing to prevent unintended pregnancy leads some women and girls to seek an abortion. Globally, 20
  million of these abortions are in unsafe circumstances and result in up to 70,000 maternal deaths each

Slide 4
          Map 1: Unable to choose: Unmet need for family planning              source: White Ribbon
                                   Alliance, Atlas of Birth, 2010

                                                              Uganda (40%)
                                                              Rwanda (38%)
                                                              Ethiopia (34%)
                                                              Ghana (34%)

Slide 5
    Map 2: Mothers too soon: Adolescent pregnancies                 source: White Ribbon             In Bangladesh, 65 percent
                         Alliance, Atlas of Birth, 2010                                              of 20- to 24-year-old
                                                                                                     women were married
                                                                                                     before the age of 18.
                                                                                                     (source UNICEF).

                                                      Adolescent girls and young women
                                                      are at high risk of contracting sexually
                                                      transmitted diseases or HIV. In Malawi
                                                      and Ghana, around one third of girls
                                                      reported that they were “not willing at all”
                                                      at their first sexual experience.

Slide 6
Choice for women – safe births
• More than a third of a million women die due to complications in pregnancy or childbirth each year.

• Women and girls in Afghanistan and Sierra Leone have a 1 in 8 chance of dying in childbirth. Se map 3
  on the next slide.

• The few minutes and hours around childbirth is the time when the risk of death is greatest for both
  mothers and babies.

• More than 3.5 million newborn deaths (more than 40% of deaths in children under 5 years of age) occur
  in the first month of life – up to 45% of these in the first 24 hours. See map 4 for newborn death rates.

• Pregnant girls aged 15-19 are twice as likely to die in pregnancy and childbirth than women in their
  twenties. Those under 15 are 5 times more likely to die.

Slide 7
11 countries account for      Map 3
65% of maternal deaths –
                                                      source: White Ribbon Alliance, Atlas of
including India, Nigeria,                             Birth, 2010
Ethiopia, DRC, Afghanistan,
Bangladesh, Pakistan, and

                                      The 15 least developed
                                      countries that have been
                                      affected by conflict
                                      during the years 2000 to
                                      2006 have worse
                                      indicators than non-
                                      conflict affected countries

Slide 8
Map 4

          source: White Ribbon Alliance, Atlas of
          Birth, 2010

Slide 9
 The importance of the continuum of care
 Most maternal and newborn deaths are preventable if women and babies have access to a functioning
 “continuum of care” (see below) - quality reproductive and maternal health services before and during
 pregnancy, during labour and after the birth. Women and girls fail to access the systems at critical points for
 ensuring that every pregnancy is wanted and that every birth is safe and baby healthy (see figure 1 on
 following slide).
                  Reproductive, Maternal and Newborn Health

            Pre pregnancy                 Pregnancy &         Birth           Newborn                 Child
(adolescent girls and women – and men                                      Birth to 28 days   Up to 5 years (infant 1
        – of reproductive age)                                                                  month to 1 year)

                                        CONTINUUM OF CARE
        Family Planning        Safe        Ante natal   Safe          Post-birth    Newborn        Child
        Within wider SRH       abortion    care         delivery      care          care           Health

   The continuum of care through to child health is important. DFID invests significantly in child health
   in a number of ways – please go to the Consultation website for more information.

 Slide 10
                      Figure 1: Important gaps in coverage of key services for women and
                                        girls – the example of Tanzania
                            Source: Wendy J Graham & Ann E Fitzmaurice, Immpact, University of Aberdeen
                               Data sources: Countdown to 2015 (2008) Report; Tanzania DHS 2004-05
                                                                                                All women: 68 Priority countries
           % uptake                                                              x
                                         x                                       x
                  80                     x
                  60                                         x
                                                             x              Tanzania:
                                                                            all women
                  40                                                                                            x
                                                             x                                                  x
                  20                                                                 poorest women

                      0               X                  X                       X                     X
                                     ANC        Skilled birth attendant         DTP3 (child)        Contraception

Slide 11
Question 1. What should we aim to achieve?
    We want to improve women’s control of their
    reproductive lives and to save mothers’ and
    newborn lives. What should we be trying to

    Things you might like to consider include:

•   Reduce the unmet need for family planning
•   Reduce the number of unsafe abortions
•   Reduce the adolescent fertility rate
•   Increase the number of births attended by skilled
    birth attendants
•   Increasing newborn survival
•   Increase the availability of prevention of mother-
    to-child transmission (PMTCT) services
•   Improve maternal nutrition
•   Reduce the prevalence of malaria in pregnancy
•   Do you have any other ideas to share with us?
                                                         Picture: ALAFA / Franco Esposito

Slide 12
  Question 2. Which interventions, or combination of
  interventions, should we prioritise to have the
  most impact?
                                                                   Things you might like to consider include:

                                                               • Comprehensive family planning
                                                               • Better safe abortion services
                                                               • Antenatal and post natal care services
                                                               • Skilled birth attendance
                                                               • Maternal nutrition interventions before and during pregnancy
                                                               • Emergency obstetric care
                                                               • Newborn care
                                                               • Exclusive breastfeeding
                                                               • Prevention and treatment of malaria for pregnant women
                                                               • PMTCT services, at and after birth
                                                               • HIV prevention with sexual and reproductive health services
                                                               • Stronger health services to deliver quality services along the
                                                                 continuum of care
                                                               • Do you have any other ideas to share with us?

Picture: Storyline / Storyline / Safe Motherhood Programme /
Department for International Development

  Slide 13
Question 3. Where should we work?
• Although family planning is a cost-effective intervention and provides good value for money, progress in
  meeting the unmet need for modern and effective family planning methods has been slow, especially in
  Africa and Asia where the unmet need is greatest.

• The difference in the lifetime risk of maternal mortality between developed and developing nations is the
  largest of any health indicator. The chances of dying from maternal causes over a woman’s lifetime is 1 in
  7 in Niger compared to 1 in 8,200 in the UK.

• There are also substantial differences between and within developing countries in the ability of women to
  access quality care at the time of birth. The poorest women in all countries are those least likely to have
  skilled attendance at delivery.

    Should we prioritise where we work on the basis of:
•   The countries with lowest contraceptive prevalence rates? The countries with the highest unmet need for
    family planning?
•   Those with the highest absolute numbers of maternal deaths? Or those where the lifetime risk of maternal
    death is greatest?
•   Those with the greatest inequity in access to services between rich and poor?
•   Those countries classified as fragile states?
•   A combination of all of the above? By some other criteria?

Slide 14
Question 4: What are the most important approaches
we should consider to tackle inequalities in
reproductive, maternal and
newborn health?
    There are huge and persistent inequalities in
    reproductive, maternal and newborn health outcomes
    between different socio-economic groups, different
    geographical areas, different ages and marginalised
    groups such as those living with HIV.
    What inequalities are most important to tackle, and how?

    You might want to consider:
•   Cash transfers and other mechanisms (like vouchers) to
    remove financial barriers faced by the poorest and offer
    choice where relevant.
•   Innovative and community based solutions, like transport for
    women in need of referral.
•   Making services women and girl friendly.
•   Better and more transparent data to track if results benefit the
•   Other suggestions?
                                                (source: Countdown, 2010)

    Slide 15
Question 5. How can we improve the realisation of
women’s rights and women’s and girls’
• Women’s lack of control over their own sexuality and fertility and their poor access to
  reproductive, maternal and newborn health services is closely linked to a general lack of respect
  for women’s rights, including their right to health. Which actions should we prioritise to address

    Options you might like to consider include:

• Political commitment to girls’ and women’s health at all levels
• Girls’ education, including post-primary
• Women’s economic empowerment (income and employment opportunities)
• Legal frameworks for girls’ and women’s rights
• Reducing violence against girls and women
• Girls’ and women’s participation and organisation for their own and their babies’ health
• Social change (social norms, attitudes and practices that drive girls’ and women’s control over resources
  and own body)
• Other suggestions

Slide 16
 Question 6: Which neglected and sensitive issues
 should we prioritise in our work?
• Pregnancy among adolescents aged 15-19 years of age has fallen since 1990 in all developing
  regions, but progress is slow.
• About 19% of pregnancies globally end in induced abortion; unsafe abortion accounts for 13% of all
  maternal deaths. 70,000 women die as a result of unsafe abortion every year; many more are
  permanently injured. Lowering abortion-related maternal death is a key way to reduce maternal mortality
  given that nearly all maternal deaths from unsafe abortion are preventable.
• In some societies, a strong preference for sons leads to sex-selected abortions and infanticides.
  In 2005, UNFPA estimated some 60 million missing girls in Asia.
• Violence against women by a partner is a global public health problem and a human rights violation
  directly linked to women’s lack of status and power.
• Female genital mutilation/cutting (FGM/C) is a human rights and a health issue for both mothers and
  babies. Complications in deliveries are significantly more likely among women with female genital
• Obstetric fistula is a hole that occurs as a result of prolonged and obstructed labour. It is an injury that
  leaves women and girls leaking urine or faeces from the vagina, usually uncontrollably. WHO estimates
  that more than two million women are living with fistula in developing countries.

Slide 17
   Which neglected and sensitive issues should
   we prioritise in our work?                      Source: Atlas of Birth, 2010
  Options you might want to consider include:

• Improving adolescents’ sexual and reproductive
  health and rights
• Delaying age at first pregnancy
• Improving access to safe abortion services
• Infanticide of girl children
• Reducing violence against girls and women
• Addressing female genital mutilation/cutting
• Addressing obstetric fistula
• Any others?

 Slide 18
Question 7. How can we deliver better results
through multilateral aid?
    DFID currently supports work to improve
    reproductive, maternal and newborn heath in the
    developing world through the following multilateral

•   European Commission (EC)
•   United Nations Population Fund (UNFPA)
•   United Nations Children’s Fund (UNICEF)
•   The Joint United Nations Programme on HIV/AIDS
•   World Bank
•   World Health Organization (WHO)
•   Global Fund to fight AIDS, Tuberculosis and
    Malaria (GFATM)

    How can we deliver better results through
    multilateral aid? Who should we work with to
    improve reproductive, maternal and newborn            Picture: Robert Yates / Department for International Development

Slide 19
 Question 8. How should we work with private and
 other non-state actors more to deliver successful
 reproductive, maternal and newborn health
• The vast majority of DFID funding for health is currently channelled to public sector health services. The
  case for the public sector role in health is clear: the state needs to be involved in order to protect the
  public, avoid excessive costs and reach the poor.

• Non-state actors include private for-profit companies and a wider range of informal for-profit healthcare
  providers, such as non-governmental, faith-based and community-based organisations.

• We recognise the role of the private sector in health, for example in the provision of commodities and

• Civil society organisations play an important role in increasing equity, empowerment and accountability in

Slide 20
Question 9. What are optimal models of service
delivery for delivering reproductive, maternal and
newborn health outcomes?

  • What can we learn from experience in delivering reproductive, maternal and
    newborn health outcomes around the world?

Slide 21
  Question 10. How should we work in fragile and
  conflict affected states and humanitarian
  Should reproductive, maternal and newborn health
  be included as part of the response to rapid onset

• You might like to consider

• Working bilaterally to strengthen national health systems
  if possible and as appropriate in fragile states
• Working through non-state actors to deliver reproductive,
  maternal and newborn health services, information and
• Work through multilateral channels to deliver improved
  reproductive, maternal and newborn health outcomes
• Strengthening the humanitarian cluster system to deliver
  coordinated reproductive, maternal and newborn health
• Include reproductive, maternal and newborn health as
  part of a response to rapid onset emergencies               Picture: Russell Watkins / Department for International Development
• Are there other ways in which we could be working?

 Slide 22
Question 11: What should we support in terms of
knowledge, research and innovation?

  What are the key gaps in the global knowledge about how to improve reproductive, maternal and
  newborn health, and which should we seek to fill? How can we ensure existing research is used?

  You might want to consider:

• Continue to provide funding for high quality research to improve reproductive, maternal and newborn
  health programmes, along with implementation or operational research to ensure findings are effectively
  translated into front-line programmes
• Invest in data and information systems for registering births and deaths and for tracking results in
  developing countries
• Support innovation and development of reproductive health commodities, including family planning
• Improve the way that research findings are used and translated into policy and practice
• Other suggestions?

Slide 23
Question 12. If we could do only one thing to
improve reproductive, maternal and newborn
health outcomes, what should it be and why?

Slide 24
           Thank you for contributing

Slide 25
Leading the UK government’s fight against world poverty

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Slide 26

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