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 7 th , 2010
Maternal Mortality Ratio (MMR)* • Between 1990 and 2005, global 1000 decline in MMR of 900 800 2.5 700 1990 600 • Despite this 500 2005 (actual) progress, all 400 2005 (target) 300 regions are behind 200 to meet the MDG5 100 0 goal by 2015— East Asia Europe & Latin Middle South Sub- & Pacific Central America & Easat & Asia Saharan reduce MMR by Asia Carribean North Africa 75% since 1990. Africa World Bank. 2009. *modeled estimate, deaths per 100,000 live births
Achieving MDG 5 entails all women having access to and using health services. • Poorest women in the poorest regions have lowest access and use of 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 Delivery Attended by Medically Trained Person by income quintile deaths increased with 100 90 greater poverty 80 70 60 • Indonesia: risk of 50 40 maternal death 3-4X 30 20 greater among poorest 10 0 a c n a c a i a c f i i s than richest groups i e r i c r f b A A f a A b P h Lowest h i n r & t t a u r a o C o r a a N S i & h s d a A a n S Highest c • 5 regions: less than ½ t a s - i b r a t e s u E m a S E A e Population n l i d t a d women in lowest wealth L i Average M World Bank, 2004. quintile deliver w/trained attendant.
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 At Least One Antenatal Visit to a Skilled Health Personnel Africa and South Asia, less 120 than 50% of women in the 100 lowest income quintile see a 80 skilled health professional P e rc e n t 60 for an antenatal visit. 40 20 0 East Asia Europe & Latin Middle South Sub- Low est & Pacific Central America & East & Asia Saharan Highest Asia Caribbean North Africa Africa Population Average
Gender inequality is a critical and neglected factor • Women are disproportionately poor, low education, lack of 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 100.0 • In Burkina Faso and Mali 90.0 more than 80% of 80.0 70.0 currently married women 60.0 Percentage cannot decide to use 50.0 health care on their own; 40.0 30.0 Nigeria—76.5% 20.0 Malawi—72% 10.0 0.0 Benin—65% n a n a a i e a a a a e i w l o n a u i d d w i n y r i n b o a q e n i a n M n b e k m r l a h e a i g a a B r b e u G K M i w g a b m m N B U Z m R a a i z C Z o M Kishor S, and Subaiya L. 2008.
Women’s education and employment impact on utilization and maternal mortality Births attended by skilled health personnel by • Large differences in education level of mother attended deliveries 100 90 between women with 80 highest and lowest 70 Percentage education levels (figure) 60 50 40 30 • Indonesia: MM 4X higher 20 among unemployed 10 0 women than employed SSA LAC MENA SA EAP women 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 on poor women – Cash transfers or vouchers may be needed to offset 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
Recommend
More recommend
