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Maternal & Reproductive Health Services

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Definition

Maternal and Reproductive Health Services in health systems constitutes a large range of curative and preventative health services of particular importance to the health of women of reproductive age. It also refers to population-based services such as behavior change and health communication (e.g. promotion of antenatal care).

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Status  of Maternal and Repro. Health Services 

Improving maternal and reproductive health in developing countries is a significant global development challenge. The means with which services are delivered in a health system play a key role in the reduction of maternal deaths. One of the Millennium Development Goals is to reduce the maternal mortality ratio between 1990 and 2015 by three quarters.

Statistics show that approximately 600,000 women die worldwide every year from complications of pregnancy and childbirth. That is more than one woman dying every minute. For every woman that dies, approximately 20 women experience a debilitating injury, often with life-long consequences. Poorer women are disproportionately affected by maternal mortality and morbidity because they have significantly less access to health services compared to wealthier women. The maternal and reproductive health problems in developing countries are further discussed in World Bank: Population and Reproductive Health

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Issues in Maternal and Repro. Health Services 

Several systemic factors undermine the delivery of maternal and reproductive health services in developing countries. Problems include, but are not limited to, poor referral systems, weak facility infrastructure, and inadequate health service skills. 

  • Referral Pathways: Developing country health systems are often fragmented with poorly functioning referral pathways. Providers often don't know enough about upstream providers and don't know where or how to send their patients who require additional care. Further, they often don't receive information about patients they referred, hindering them from providing appropriate follow-up care or learning further information about the accuracy of they diagnosis. 
  • Infrastructure: If the facility infrastructure is inadequate or not hygienic, girls and women may not receive the quality care they need. 
  • Skills: If providers have poor skills in responding to maternal and reproductive health issues, girls and women risk low quality treatment and a higher disease burden. 

In addition to such issues, women's care-seeking characteristics in developing countries can also inhibit them from receiving appropriate services and improving their health. The low status of women in many developing countries reduces use of services, thus lowering their knowledge and access to family planning resources. Even in situations where women seek care, their tendency to seek it from informal providers, due to the social familiarity of these providers, can lead them to receive poor quality care.

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Trends in Maternal and Repro. Health  

In order to improve maternal and reproductive health services, policy makers have introduced several mechanisms to enhance the quality, efficiency, and equity of services. These strategies include training service providers, enhancing health facility infrastructure, and improving referral pathways. 

  • Training: This strategy focuses on improving the skills of health care providers so that they can appropriately respond to maternal health needs. 
  • Enhancing capacity: This strategy focuses on improving the supply and medical equipment in health facilities, as well as the administrative capacity to provide needed health services. It also aims at increasing the supply of certain health providers (ie. Midwives) 
  • Improving Referral Pathways: This strategy aims to develop reliable transportation and communication plans so that women can be referred to the district hospital or a first level referral center. 

Coordination of maternal/reproductive health service programs with other health service programs has also been promoted in order to reduce duplication of efforts and improve health outcomes. For instance, within the context of improving neonatal health, many initiatives promote the coordination of maternal health service programs with child health service programs. 

While the above strategies have tended to focus on publicly provided services, recently more attention has been given to improving the services received in the private sector via contracting, regulating, financing and social marketing. 

In Nicaragua, a voucher system has been used for sexual health services to target sex workers 

Rosen (2000) offers three case examples - from India, Haiti, and Columbia - that describe recent experiences in contracting for reproductive health

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Key References

World Bank

  • Patmanathan, I. et al. (2003). Investing in Maternal Health: Learning from Malaysia and Sri Lanka. Health Nutrition and Population Series, The World Bank.
    The main finding is that maternal mortality ratio reduction is feasible with modest public expenditures when appropriate policies are adopted and focuses are broad and flexible with the changing environment and systems capacity. The document describes in detail the policies and strategies used throughout the duration of the program. 
  • Rosen, J. (2000). Contracting for Reproductive Health Care: A Guide. Washington, World Bank.
    This document looks at the use of government contracting to meet the demand for quality reproductive care in developing nations. It is a guide that touches on some of the reasons why governments choose to contract out and provides an introduction to the range of contracting issues. Includes sample contracts for reproductive health in India and Columbia. Also includeses a sample contract for social marketing of condoms in Haiti. 
  • Tinker, A.., et al. (2000). Improving Women's Health: Issues & Interventions. Washington, World Bank.
    This paper identifies key determinants of women's health, discusses women's health needs in the developing world, and recommends cost-effective interventions that address the major causes of death and disability among women in developing countries. 
  • World Bank. (1999). Safe motherhood and the World Bank: Lessons from 10 years of experience. Washington, DC: The World Bank·
    The lessons reported here are based on a review of the World Bank's experience in providing support to borrowing countries for safe motherhood activities over the past decade. While the document is primarily intended for Bank staff, it also provides guidance to other entities in the implementation of programs to improve the maternal health.

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External

  • EngenderHealth, (2002) Emergency Obstetric Care: Leadership Manual for Improving the Quality of Services, Working Draft, in cooperation with Mailman School of Public Health, Columbia University. EngenderHealth, New York. 
    This manual is intended to aid emergency care providers and team leaders to improve service quality. The manual contains processes to improve service quality and tools to address challenges that providing emergency obstetric care can present. The manual is on the EngenderHealth website and can be accessed here. 
  • EngenderHealth (2002) Emergency Obstetric Care: Toolbook for Improving the Quality of Services, Working Draft, in cooperation with Mailman School of Public Health, Columbia University. EngenderHealth, New York. 
    This tool book provides tools and instructions for assessing quality of care in emergency obstetric care facilities. The tools allow for service providers and leaders to identify problems and implement solutions to improve the quality of care. The tool book is on the EngenderHealth website and can be accessed here. 
  • Levin A, et al. (2003) Costs of maternal health care services in three Anglophone African countries. International Journal of Health Planning and Management. 18(1): 3-22. 
    This document reviews three country case studies of provider and consumer costs for maternal health services provided at a variety of locations. The costs of providing the services in the facilities is examined to assess reasons behind cost differences, efficiency of service delivery and cost-effectiveness with quality care. 
  • Koblinsky, M., O. Campbell, et al. (1999). Organizing delivery of care: what works for safe motherhood. Bull World Health Organ 77(5): 399-406.
    This paper reviews four models of maternal health care delivery in developing countries. The four models vary in degree of health care accessibility and health system infrastructure, and are each assessed on their ability to decrease maternal mortality and morbidity. 
  • The International Perinatal Care Unit Institute of Child Health (2001) How to make maternal health services more women-friendly: A Practical Guide. University College London, United Kingdom. 
    This guide is intended for use be health service managers and health personnel who wish to improve the quality of maternal health services and make them more 'friendly' to women. This document can be accessed here. 
  • Ransom, EI, Yinger, NV. (2002) Making motherhood safer: overcoming obstacles on the pathway to care. Population Reference Bureau: MEASURE Communication, Washington, D.C.
    This document describes the current status of maternal health, giving an overview of the efforts made to address maternal health issues. It also suggests ways governments can reduce maternal mortality and morbidity by improving health systems, highlighting individual programs that have overcome obstacles to maternal survival.

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Resource People 

World Bank

  • Elizabeth Lule
  • GNV Ramana
  • James Rosen

External

To be added in the near future...

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Useful Websites

  • CDC Health Topic: Maternal Health 
    This site, organized by a US agency, provides links to other CDC sites related to maternal health, including information about the Safe Motherhood Prevention Program, Maternal and Child Health Epidemiology Program, and CDC's Reproductive Health information source. 
  • DFID: Health System Approach to Improving Maternal Health 
    This site, which is created by a UK agency, provides a brief background of information about health system needs to improve maternal health. The proposed program of work is also briefly summarized. 
  • EngenderHealth
    This non-for-profit organization created this website to provide information on prenatal/preconception healthca re services, postpartum care, post-abortion care and infertility. EngenderHealth works worldwide to improve the lives of individuals by making reproductive health services safe, available, and sustainable. We provide technical assistance, training, and information, with a focus on practical solutions that improve services where resources are scarce.
  • Family Care International (FCI) 
    This non-for-profit organization developed this website to provide guidelines, technical assistance, and other information tools that local partners can use to improve the services provided and strengthen their efforts when dealing with the wide range of reproductive and sexual health issues. 
  • International Federation of Gynecology and Obstetrics (FIGO)
    FIGO is a nonprofit organization and established The Save The Mothers Initiative in 1997 to expand its activities in the area of safe motherhood. The aim is to mobilize the obstetric and gynecological community in developed and developing countries to work in partnership to demonstrate the most cost-effective way to save mothers' lives. 
  • Ipas: Women's Health
    Ipas is a non-governmental organization dedicated to promoting safe motherhood and newborn health, especially among the most vulnerable populations. Their efforts to increase women's access to comprehensive abortion-related care encompass training, research, advocacy, distribution of reproductive-health technologies and information dissemination, with attention to services for induced abortion and post-abortion care. 
  • JHPIEGO 
    JHPIEGO is a non-for-profit organization that helps host-country policy-makers, educators, and trainers increase access and reduce barriers to quality health services, especially family planning and maternal and neonatal care, for all members of their society. JHPIEGO's work is carried out in an environment that recognizes individual contributions and encourages innovative and practical solutions to meet identified needs in low-resource settings throughout the world.
  • Millennium Development Goals: Maternal Health
    Organized by the World Bank, this site describes the 6th Millennium Development Goal, which calls for the reduction of maternal mortality by three quarters by 2015. This site provides information on what that goal means to different regions, what issues need to be addressed to attain this goal, and what areas are most likely to achieve the goal set forth.
  • Population Council: Safe motherhood and Postpartum Care 
    The Population Council, a non-for-profit organization, has actively participated in efforts to improve maternal health since the early 1980s. The Council's research agenda has sought to provide an evidence-based approach to improve obstetric, postpartum, and family planning services, including the prevention of unsafe abortions, in developing countries. 
  • Safe Motherhood Inter-Agency Group 
    The Safe Motherhood Initiative, an international partnership between various organizations, is a worldwide effort that aims to reduce the number of deaths and illnesses associated with pregnancy and childbirth. This site provides information about priorities for safe motherhood, as well as global commitments made to reduce the devastating affects of maternal mortality and morbidity.
  • UNICEF: Maternal Health 
    This site, created by an international agency, is a conglomerate of databases providing country-specific information and statistics on antenatal care, delivery care, fertility and family planning, and maternal mortality. 
  • United Nations Population Fund (UNFPA) 
    UNFPA is an international agency that aims to improve maternal and reproductive health by addressing a variety of issues. The website provides information about those issues and what resources and services are needed to be overcome the obstacles in the way of addressing those issues. 
  • USAID- Nutrition and Maternal Health 
    The United States Agency for International Development (USAID), an US government agency, works to improve the health and quality of life of millions of women and children worldwide. This site provides information about current request for proposals (RFP's), new programs underway by USAID, and other resources that may be of use to people in the area of maternal health. 
  • White Ribbon Alliance for Safe Motherhood
    The White Ribbon Alliance for Safe Motherhood, an international alliance between various organizations, develops new methods and techniques to raise awareness and promote safe motherhood within their own families, communities, governments, and countries. The website provides information on technical resources for field-based planners and managers of community-based activities. 
  • WHO: Maternal Health 
    This site, created by an international agency, provides links to various activities, reports, news and events, as well as contacts and cooperating partners in the various WHO programs and offices working on maternal health.

Additional References 

World Bank

Knowles, JC, Behrman, JR. (2003) Assessing the Economic Returns to Investing in Youth in Developing Countries. The World Bank, Health, Nutrition and Population, Washington DC. 

Koblinsky, MA. (2003). Reducing Maternal Mortality: Learning from Bolivia, China, Egypt, Honduras, Indonesia, Jamaica, and Zimbabwe. Health Nutrition and Population Series, The World Bank.

Ssengooba, F., McPake, B. World Bank Institute, Case Example: Financing Maternal Health Services in Uganda. For the World Bank Institute's Third Annual Adopting to Change Core Course. Can be accessed here. 

World Bank (1994). A New Agenda for Women's Health and Nutrition. Washington, World Bank.World Bank. (1993). Investing in health: World development report, 1993. New York: Oxford University Press.

World Bank. (2000). Population and the World Bank: Adapting to change (Rev. ed., Health, Nutrition and Population Series). Washington, DC: The World Bank, Human Development Network

External

AbouZahr, C. (1997) Improve Access to Quality Maternal Health Services. Presentation at Safe Motherhood Consultation in Sri Lanka, 18-23 October, 1997.

Askew, I., Maggwa, NB (2002). Integration of STI prevention and management with family planning and antenatal care in sub-Saharan Africa -- What more do we need to know? International Family Planning Perspectives. Jun; 28(2): 77-86. 

Berer, M. (2002) Health Sector Reforms: Implications for Sexual and Reproductive Health Services. Reproductive Health Matters; 10(20):6-15.

Besser M; Paruk F; Dinat N (2002) Changing obstetric practices in the context of HIV: An evaluation of service provision in the national PMTCT learning sites. Durban, South Africa, Health Systems Trust. Can be accessed here. 

Center for Health and Gender Equity (1999). Report of the meeting on The Implications of Health Sector Reform on Reproductive Health and Rights. Washington, Center for Health and GenderEquity.

Chapman RR (2003) Endangering safe motherhood in Mozambique: prenatal care as pregnancy risk. Social Science and Medicine. Jul; 57(2): 355-374. 

Chen CS; Liu TC; Chen LM (2003) National health insurance and the antenatal care use: a case in Taiwan. Health Policy. Apr; 64(1): 99-112. 

Claeys P; De Vuyst H; Mzenge G; Sande J; Dhondt V; Temmerman M (2003) Integration of cervical screening in family planning clinics. International Journal of Gynecology and Obstetrics. Apr; 81(1): 103-108. 

Curet LB; Foster-Rosales A; Hale R; Kestler E; Medina C (2003) Averting maternal death and disability. FIGO Save the Mothers Initiative: the Central America and USA collaboration. International Journal of Gynecology and Obstetrics. Feb; 80(2): 213-221. 

Hermida J; Robalino ME (2002) Increasing compliance with maternal and child care quality standards in Ecuador. International Journal for Quality in Health Care. Dec; 14 Suppl 1: 25-34. 

Kaufman, J. and F. Jing (2002). "Privatisation ofhealth services and the reproductive health of rural Chinese women." Reprod Health Matters 10(2): 108-116.

Lalonde AB; Okong P; Mugasa A; Perron L (2003) Averting maternal death and disability. The FIGO Save the Mothers Initiative: the Uganda-Canada collaboration. International Journal of Gynecology and Obstetrics. Feb; 80(2): 204-212.

Levin, A., R. Mangani, et al. (1999). Costs ofMaternal Health Care Services in Blantyre District, Malawi. Bethesda, Abt Associates.

Levin, A., M. McEuen, et al. (1999). Costs of Maternal Health Care Services in South Kwahu District, Ghana. Bethesda, Abt Associates.

Lush, L. (2002). Integrating HIV / STI and family planning services. Service integration: An overview of policy development. International Family Planning Perspectives. June 28(2): 71-6. 

McCord C; Chowdhury Q (2003) A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Averting maternal death and disability. International Journal of Gynecology and Obstetrics. Apr; 81(1): 83-92. 

Program for Appropriate Technology in Health (PATH) (2001). Reproductive Health, Gender and Human Rights: A Dialogue. Murphy, E and Ringheim, K., Eds. PATH, Washington, DC. 

Safe Motherhood Interagency Working Group and Family Care International. (1998) Good Quality Maternal Health Services Fact Sheet. 

World Health Organization (1998). Improve Access to Maternal Health Services. Presented at World Health Day, Safe Motherhood, Geneva Switzerland, 7 April, 1998.