Targeting Poverty and Gender Inequality to Improve Maternal Health - - PowerPoint PPT Presentation

Targeting Poverty and Gender Inequality to Improve Maternal Health

presented by Rekha Mehra, Ph.D.

Based on paper by: Silvia Paruzzolo, Rekha Mehra, Aslihan Kes, Charles Ashbaugh

Expert Panel on Fertility, Reproductive Health, and Development United Nations Population Division December 7th, 2010

Maternal Mortality Ratio (MMR)*

• Between 1990 and

2005, global decline in MMR of 2.5

• Despite this

progress, all regions are behind to meet the MDG5 goal by 2015— reduce MMR by 75% since 1990.

100 200 300 400 500 600 700 800 900 1000 East Asia & Pacific Europe & Central Asia Latin America & Carribean Middle Easat & North Africa South Asia Sub- Saharan Africa 1990 2005 (actual) 2005 (target)

*modeled estimate, deaths per 100,000 live births

World Bank. 2009.

Achieving MDG 5 entails all women having access to and using health services.

• Poorest women in the

poorest regions have lowest access and use

• f MHC
• Poverty and gender

inequality closely linked—affect demand for and supply of MHC

(c) D. Mhala

Key Questions

• How do poverty and gender inequality impede

maternal healthcare access and utilization— specifically ANC, attended delivery and postnatal care?

• Which strategies address poverty and gender

inequality and are successful in increasing utilization?

Poverty key determinant of maternal mortality and service utilization

• 10-country analysis:
• prop. of maternal

deaths increased with greater poverty

• Indonesia: risk of

maternal death 3-4X greater among poorest than richest groups

• 5 regions: less than ½

women in lowest wealth quintile deliver w/trained attendant.

Delivery Attended by Medically Trained Person by income quintile

10 20 30 40 50 60 70 80 90 100 E a s t A s i a & P a c i f i c L a t i n A m e r i c a & C a r i b b e a n M i d d l e E a s t a n d N

• r

t h A f r i c a S

• u

t h A s i a S u b

• S

a h a r a n A f r i c a

Lowest Highest Population Average

World Bank, 2004.

Costs are high, unpredictable and potentially catastrophic for the poor: disincentives to utilization

• Costs: formal and informal fees, drugs, equipment,

transport, lost time

• Bangladesh: Hidden costs in 4 govt hospitals –

US $32 normal delivery, $118 Caesarean (1995 data)

• Tanzania and Nepal: Transport >50%of total care

costs

• Indonesia: delivery costs for 68% of the poorest

households was 40% of annual disposal income.

• In Middle East and North

Africa and South Asia, less than 50% of women in the lowest income quintile see a skilled health professional for an antenatal visit.

At Least One Antenatal Visit to a Skilled Health Personnel

20 40 60 80 100 120 East Asia & Pacific Europe & Central Asia Latin America & Caribbean Middle East & North Africa South Asia Sub- Saharan Africa P e rc e n t Low est Highest Population Average

Gender inequality is a critical and neglected factor

• Women are disproportionately poor, low education, lack
• f autonomy and decision-making power; overall low

social status. Effects of gender unequal norms: – early marriage → early childbearing + high fertility = higher risk of maternal mortality and morbidity – norms restrict mobility → impedes utilization – limited education → less knowledge and tools for informed health decisions

Many women cannot make decisions about their own health care

• In Burkina Faso and Mali

more than 80% of currently married women cannot decide to use health care on their own; Nigeria—76.5% Malawi—72% Benin—65%

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 B e n i n B u r k i n a C a m e r

• n

G h a n a K e n y a M a l a w i M a l i M

• z

a m b i q u e N i g e r i a R w a n d a U g a n d a Z a m b i a Z i m b a b w e Percentage

Kishor S, and Subaiya L. 2008.

Women’s education and employment impact

• n utilization and maternal mortality
• Large differences in

attended deliveries between women with highest and lowest education levels (figure)

• Indonesia: MM 4X higher

among unemployed women than employed women

Births attended by skilled health personnel by education level of mother

10 20 30 40 50 60 70 80 90 100 SSA LAC MENA SA EAP Percentage highest education level lowest education level

World Health Organization. 2009.

Strategies to increase utilization

• Reduce the burden of

costs

• Improve and expand

services

• Reduce gender inequality

and empower women

(c) Robin Hayes

Reduce the burden of cost: Removing user

fees can increase demand by poor women

• Removing user fees increases demand for maternal

healthcare among the poor

– Ghana: delivery fees exempted—significant increase in facility-based care among poorest women – Niger: removing user fees doubled ANC visits; in Burundi hospital births were up 61% – Requires careful planning to handle increased demand in short-term – Long-term requires planning for financial sustainability

Reduce the burden of cost: Targeted subsidies

can increase service utilization by women

• Subsidies, e.g., vouchers (3 districts in Cambodia):

– # of facility deliveries increased (over 12 mths); no decline in self-paying deliveries; – additional poor women delivered in public health facilities – vouchers may work best when combined with social marketing to encourage use

Improve and expand services: Training &

posting skilled attendants can increase coverage among the poor

• Indonesia Village Midwife Program: ↑use of skilled

attendants during delivery among poorest and those in rural areas. – Access and use by poor not uniform; some midwives charged fees—disproportionate effect

• n poor women

– Cash transfers or vouchers may be needed to

• ffset costs

While it is critical to reduce the burden of costs and improve and expand services, these actions alone may not be sufficient. Empowering women and overcoming gender inequality requires explicit programmatic and policy approaches.

Conditional cash transfers can increase demand and empower women

• Mexico (Opportunidades): $ conditioned on

accessing care and health education sessions – Participants: More ANC visits and more procedures/visit (quality) – Women encouraged to be more active health consumers

Engaging women in participatory learning and networking can increase utilization

• Nepal: Local women trained to organize and facilitate

group meetings on maternal and neonatal health. – ↑ANC, institutional deliveries, attended births – Participation in women’s groups: ↑self-confidence, capabilities and collective action

Conclusions

• Poverty and gender inequality pose significant

barriers to utilization

• Need comprehensive strategies that:

– Lower costs, improve & expand services – Empower women through social support, networking, participatory learning & action – Reduce gender inequality through education and employment initiatives