House of Commons - International Development

Select Committee on International Development Written Evidence

Memorandum submitted by the Royal College of Obstetricians and Gynaecologists

GLOSSARY

SBA Skilled Birth Attendance

EOC Essential or Emergency Obstetric Care

BEOC Basic Essential or Emergency Obstetric Care

CEOC Comprehensive Essential or Emergency Obstetric Care

QA Quality of Care

DFID Department for International Development

SRH Sexual and Reproductive Health

MNH Maternal and Newborn Health

SSA Sub Saharan Africa

NGO Non Government Organisation

PAC Post Abortion Car

CAC Comprehensive Abortion Care

CBD Community Based Distribution

Reducing maternal and perinatal mortality and morbidity ...

  DAVID died. He was just a day old. This chubby baby, who weighed 5.5kg at birth, bled to death because his umbilical cord had been cut "badly".

  In fact, David was named after the shepherd boy in the Bible long after his little heart stopped beating. The Alur culture demanded that either way, he be named.

  Every two hours, a baby dies at the Hospital's maternity ward as a result of birth-related complications. Hospital records indicate that on average, nine babies die from birth-related complications every day, nine little souls like David. This means, about 270 babies die every month.

  "Some days, over 15 babies die", a hospital source, who spoke on condition of anonymity, says.

  David's only day in this world went terribly wrong. "We spent the whole day at the hospital but nobody cared", his father, Clinton, narrates. "The baby was bleeding. The baby really cried. Then a nurse helped us and put him on oxygen but she said we should pray because the machine was not working properly".

  Clinton will forever be haunted by the blank face of the doctor to whom he turned in desperation. "He just looked at me and walked away", he says as a slight tremor creeps into his deep voice.

  The Maternity ward of the hospital, Sunday 9.00 am: The air in the corridor of the labour ward seems to stand still. Over 20 women in labour are sitting or lying on the floor. "Musawo nyamba, nfaa!" (Doctor, help I am dying), one woman wails.

  She is kneeling on all fours. She jerks forward, then crawls rapidly back. Groaning in pain, she puts her elbows on the cold, stained marble floor, rising swiftly. The white blouse she is wearing slides over her shoulder, leaving her naked.

  "The baby is coming", another woman, swaying in pain next to her, shouts. A third expecting mother sits calmly next to them, a stream of waterish blood running from under her skirts towards the middle of the corridor. The woman opposite her tries to move away from the blood running towards her. She stands up, looks around, then slowly shakes her head and sits down again as her wrapper gets soaked. There is no other place to sit. The corridor is packed to capacity.

  According to the doctor in-charge of the gynaecology and obstetrics department, about 70 mothers are admitted and 60 deliver every day, yet the place was meant to cater for only 20. Some give birth in the corridors. "We are delivering three times the number we are supposed to handle", he says.

  "Most of these mothers are referred from other hospitals when their condition is already critical. In fact, many babies are born with the skin already peeling off, meaning that they died 24 hours earlier".

  On average, one third of the mothers received at the hospital need to deliver by caesarean section. The operation theatre, which has only one bed, handles an average of 18 mothers a day.
The doctors work day and night but hardly manage to cater for the influx. A proper operation, including preparations, takes two hours. Some have to wait for a day to find a slot.

  "Many times we have 21 emergency operations", says the nurse-midwife Rose. "Babies end up being born stressed or dead because the mothers waited too long for the caesarean operation. Imagine you have 15 patients waiting for an emergency operation, all of them in a critical condition. Whom do you operate and whom do you leave out?"

  Apart from lack of space and equipment, the maternity wing suffers from acute lack of staff. There are between eight and 12 staff members for the five wards at any one time, according to the doctor in charge. These include nurses, midwives and doctors.

  "In the labour suite, there are only three staff to cater for over 60 mothers a day, yet there should be 24", he says.

  The hospital serves as a referral hospital. It has become the only place where mothers around the city go to give birth. Most health centres around the city shun women who are about to give birth because they lack the operation facilities in case the delivery goes wrong.

  Many private clinics only give antenatal care and refer the mother to the hospital when the labour pain starts.

  "Some refer the women when it is too late", explains nurse-midwife Violet. "They don't tell the women what the problem is or even notify us of the condition of the patient and the reason for referral. Many times, the baby is already dead in the womb. And when they come when we have a lot of work, it is difficult to give them the attention they need. So the lives of the mothers are also at risk".

  Another problem, she says, is ignorance and poverty.

  "Some mothers arrive here after labouring at home for days". "Others don't have transport and are brought in by neighbours when it is very late. Many times we are just helpless".

Executive Summary

The International Office of the Royal College of Obstetricians and Gynaecologists (RCOGIO) received a great many responses from its Members, Fellows and partners working in resource poor countries. Their recommendations are:

1. There is great respect for what DFID is currently doing to catalyse progress towards achieving MDG5, although the priority given to this work should be greater.

2. A continued and sustained focus is needed to ensure all women have real access to Skilled Birth Attendance (SBA) and Essential Obstetric Care (EOC), independent of where they live.

3. The development of a functioning health service is needed for this which is of good quality ie provides evidence based and women friendly care. Providing a continuum of care including antenatal care, postnatal care, safe termination of pregnancy services together with family planning services form an integral part of this process.

4. The introduction of Quality assurance systems with an emphasis on audit processes, already developed in the UK, are vital.

5. Imaginative and innovative human resource strategies, to increase, maintain and sustain the medical and professional workforce, require development and financial support.

6. Evidence based medicine, which is sensitive to the needs of the local community needs encouragement with the introduction of new communication strategies.

7. Appropriate training and educational methodologies will underpin the whole process. The introduction of such processes should be undertaken with appropriate validation.

8. In line with the Crisp report, all such strategies must enjoy local support, accountability and ownership.

9. DFID should work to harmonise relationships and communication between interested and active participants.

10. It is anticipated that the current financial investment in this process is inadequate to realise these aspirations.

Q1 How can donors—especially DFID—catalyse progress towards MDG5?

"Women neglected in labour seem to be the most neglected of all categories of patient and need an emphasis of their own ..."

1.1 There is a clear recognition among health care providers that MDG5 is "not just a health issue"—it requires a multidisciplinary approach that includes improving roads and transport, sanitation, nutrition, poverty alleviation, changing socio- cultural norms and education. At the same time there is a strong concern that achieving MDG5 requires a functioning and complete health system and that this is very often not available and not accessible especially for women.

"A health system has many components such as the availability of quality health facility infrastructure, equipment, drugs and supplies, trained personnel, human resource management, free or affordable services, good monitoring systems and community participation."

1.2 The majority of respondents expressed the need to expand and strengthen the existing health facility infrastructure in resource poor countries to ensure Skilled Birth Attendance (SBA) can be provided at all births and Essential (or Emergency) Obstetric Care (EOC) can be provided for those women who need it. With regard to EOC there is a need to strengthen and expand in particular the infrastructure for Basic Essential Obstetric Care (BEOC),[165] but also to have functioning referral facilities higher up ie Comprehensive Essential Obstetric Care (CEOC) centres. In most countries access and availability are not ensured and/or there is non-equitable distribution of such health services. The need for strengthening and provision of blood transfusion services (One of the signal functions of a CEOC) in particular was noted by several respondents as a key issue (Egypt, Nigeria, Nigeria).

"I have no information from DFID nor from the Ministry of Health but I am aware that there are hospitals especially in the North West that have no doctor, no bed linen and few if any drugs. These hospitals are intended to be providing free healthcare for rural populations".

"Financial support for delivery and referral when needed helps to make hospital care available to the very poor. Usually money is only available at time of discharge from hospital and lack of funds to actually get to hospital and pay for what is needed for delivery still prevent access for many".

1.3 The Quality of Care (QA) is seen as absolutely crucial:

"Rural health facilities need to be made more credible places to have a baby. In many places rural health facilities are dirty, unreliable and not mother/women friendly at all".

Health care providers can be trained in QA systems and the use of benchmarking processes using structure, process and outcome criteria for example. Helping these countries to conduct audit of maternal (and perinatal) deaths in a non-blame atmosphere similar to the Confidential Enquiries into maternal deaths as in the UK or RSA will really help. Together with a process of setting standards and using criterion (standards) based audit this is a simple and effective mechanism for improving the quality of care. The Royal College of Obstetricians and Gynaecologists have a Guidelines and Audit Committee who have extensive experience in rolling this out and are able to assist with this. In addition, many Members and Fellows of the RCOG contribute to the UK Confidential Enquiry into Maternal Deaths.

1.4 Referral systems need to be in place and strengthened—this refers to both community to facility and facility to facility referral systems ... Examples cited include:

"The essential health care infrastructure is lacking in most places. The availability of mobile or hand phones is a major boost and needs to be exploited to the full".

"Maternity Waiting Homes are invaluable in rural areas and wherever travel is over long distances and difficult terrain".

1.5 Human Resources:

Human resource development (HRD) is a key area that still receives inadequate attention. Clearly for achieving MDG 5, HRD is critical and can best be addressed through sector wide approaches. DFID through its support to both the National Safe Motherhood Programmes and the Health Sector Reform Process is thought to be well placed to put human resources for MDG 5 at the centre of its development efforts.

1.6 Generally "manpower" is still severely lacking.

Adequate numbers of staff need to be trained and deployed. Different levels of skills and training are needed including:

— Skilled Birth Attendants—it is generally agreed these should be trained midwives—but there is recognition among the respondents that in some instances there is still a need to use and train "indigenous midwives" (eg "dais" in India) to play a vital role especially at community level.

— Doctors with general skills as well as specialist Obstetrician Gynaecologists with teaching and management abilities are needed. Respondents include Clinical Officers, Medical Assistants in this category of staff.

Midwives and doctors should work together on all programmes.

Countries where progress towards MDG5 has been achieved are those where midwifery as well as medicine is highly professionalised and well recognised (including at government level).

"The most challenging aspect of achieving MDG5 is the management of skilled human resources (HR)—doctors, nurses and midwives needed for provision of health care services to achieve MDG5".

"In some areas eg South Asia there are generally sufficient HRs overall but the available HRs are mal-distributed. This is a major rights issue requiring capacity building of rights holders increasing their accountability for correcting the mal-distribution, ensuring proper policies, posting, retention etc that are evidence based".

1.7 Interesting possible solutions for implementing this were given: eg in case of regional/in country disparities a well functioning supported medical school could "adopt" a community and it was noted that public-private partnerships can work well to improve staffing levels where private health care providers are available and are trained.

There is very clearly a need to look at the issue of motivation of staff and "make it lucrative for the health care provider to work for our women".

Among existing health care providers skills and knowledge regarding provision of SBA and EOC is often lacking and training in SBA and EOC should be supported better than it currently is.

"The major complaint of doctors and midwives working at district and provincial level in the developing world however is lack of access to appropriate, high quality training and coupled with that interaction with colleagues to reduce the sense of working in isolation".

1.8 A number of mechanisms are proposed:

— Send skilled obstetricians with teaching and management ability on short term attachments.

— Training should focus on training of available staff in SBA and EOC competencies, but also in QA systems.

— Linking with UK organisations (both professional and teaching) may guarantee investment is in a deliverable product and that expertise is shared more effectively.

— Training should have more funding allocated to it.

— Creating supernumerary positions for eg visiting clinicians from the UK who can both work and teach. Such supernumerary positions might be less threatening to the host institution staff than occupying a post that might be occupied by a national and could allow more time for training activities.

— Send skilled obstetricians (and midwives, gynaecologists, anaesthetists, paediatricians) with teaching and management ability on short term attachments.

— Support the inclusion of experience in rural areas (community medicine) in all medical (and midwifery) curriculae.

— Encourage consideration of training alternative non physician service providers eg non physician anaesthetists.

— Projects that reduce the "brain drain" must be prioritised (as above), licentiate type programs of training should be encouraged (for eg clinical officers).

— DFID should promote support and encourage professional schools of midwifery and nursing as well as professional organisations.

— Support to teaching hospitals (as when DFID was ODA) was discontinued but should have been sustained—"with better oversight though".

— Training at district level (as opposed to central level) in EOC is not being sufficiently supported by DFID.

— RCOG International Office working with DFID on initiatives to bring together doctors and midwives for the education and training of local health workers would be effective and encourage sustainability.

1.9 The recognition that there is a relationship between `the brain drain' and training is very strong:

"A positive approach to the problem of the "brain drain" or "skills drain" could be achieved by opening up funded exchange programmes at the Specialist Registrar level between the UK and selected developing world countries. Short term rotations from reasonably experienced UK graduates in training programmes (6 to 12 months) would offer them an opportunity to establish close personal contacts with doctors in the country in which they go to work which will allow collegial networks to be established. They will also have the opportunity to hone their diagnostic management and surgical skills under supervision".

"Doctors from the developing countries rotated into the UK should not be attending for basic or MRCOG Part 2 training but should already be holders of local specialist qualifications which enable them to practice in their country of origin at specialist level. They can come to the UK and occupy Senior Specialist Trainee posts particularly in subspecialties such as foeto-maternal medicine, gynaecological urology, gynaecological oncology and reproductive health. On return they will have up to date knowledge which can be applied as appropriate in their own country, but more importantly will have continuing relationships with one or more units in the UK where through medium of email etc they can continue to obtain advice and discuss cases of interest with named colleagues with whom they have previously worked".

"I would suggest that such schemes be initially launched on a small scale but with an appropriate budget to make sure that they are successful and such schemes rolled out to suitable hospitals across the developing world if the programme is seen to be successful".

1.10 The "brain drain" must be more effectively addressed.

DFID should fund projects that reduce the brain drain of doctors and midwives and facilitate doctors posted to work in rural areas to stay by financial, social and professional support. This should include mentoring to develop their clinical skills while freeing them from the distraction of excessive administration.

"One of the major threats to maternal health in the developing world is the loss of skilled medical and midwifery staff to better paid posts outside the country of training. Interventions by DFID need to be applied sensitively and whilst the option of salary boost for the trained specialists is superficially attractive it is unlikely to be acceptable to governments where this type of targeted action will disrupt Civil Service pay scales. A wiser approach would be to improve terms and conditions of service particularly in relation to subsidised accommodation, transport, school fees etc which would make such posts more attractive".

Support to "licentiate" type programmes eg as in Zambia—where clinical officers with many years of experience are upgraded to effectively function as doctors in their country and are expected to return to their local hospitals where they have worked and many have their families.

1.11 Evidence based care should be encouraged at all levels.

Funding research and formation of guidelines from meta analysis into simple interventions like—quality antenatal care, training birth attendants for safe home and hospital delivery, supply of drugs for prevention and treatment of PPH should be supported.

Support for research into the use of appropriate technology eg ketamine for CS, the safe use of the vacuum extractor, use of Symphysiotomy in some cases of obstructed labour, baby friendly policies that are relevant to local practice etc is needed at all levels.

Adaptation of best practice to local conditions (not taking away the validity of what is good evidence based practice) is still not happening in many areas.

"Kangaroo care and other clearly beneficial practices may be rejected on the basis that they are "not practised in the west".

"Please encourage funding for rolling out of best practices. It is clear what can and should be done but it is not (yet) happening".

How the health system can be improved as a whole is also not always clear. There is a need to more effectively share experience and lessons learnt in order not to "reinvent the wheel time and time again" and in order to ensure that the interventions being implemented are really those that work (ie evidence based).

"While DFID provides support to many areas for increasing availability of maternal health services, equity and access, affordability of maternal health services through removing user fees, providing demand side financing, supporting health sector reform etc, it is necessary to research how these various elements of support should be phased in to provide the most effective programe".

1.12 Accurate data collection and research that is locally relevant with local ownership should be encouraged. This will also ensure effective implementation of research into practice and implement change in practice.

Building national capacity and support for good quality research is needed especially in the area of maternal health. This should be done with the support of institutions such as the Liverpool School of Tropical Medicine, London School of Hygiene and Tropical Medicine, the Wellcome Trust etc.

"Local research into the causes of maternal and perinatal death (through maternal and perinatal audit) and into morbidity for both rural and urban areas is vital to determine the focus areas for implementation".

"Probably the most fundamental issue is the need for reliable demographic, social, economic and health statistics obtained bhy direct counts (not estimates) in a continuous rather than ad hoc basis. In places that lack them, a useful way to begin is the compulsory registration of all b irths and deaths. It is an action, which will open the eyes of every body in the society and teach the society to take responsibility for its actions. It is a way of stimulating people to work out for themselves what exactly they need".

Support for (ie funding) research programmes that address maternal and newborn health and sexual and reproductive health in general is essential and this is currently insufficient.

Dissemination of such research from developing (resource poor) countries is generally still poor and needs to be improved—the sharing of lessons learnt (including if the intervention did not work) is essential and should be much more actively supported and receive more attention.

"Examples of improvement in maternal and child health, reduction in poverty from areas of Bangladesh and India have stimulated the further investments in countries like Pakistan, Yemen, Nepal and Cambodia".

"Organisation of review meetings at regular intervals would result in sharing of lessons learnt by countries, organisations, and further raise the profile of maternal health".

1.13 The need for mainstreaming and continued support to raise awareness and advocate (lobby) for Sexual and Reproductive Health (SRH) and in particular Maternal and Newborn Health (MNH) was noted.

"International and global initiatives and conferences to keep the need for women's empowerment and health status at the forefront of investment in low resource coutnries must be regulary high profile events".

There is a need to more strongly involve both local government, legislators and senior politicians (President, Governors, Finance and Planning ministers):

"The burden of maternal mortality should be highlighted, lessons of success in other countries shared and the fact that most of the deaths are peventable (with use of simple technologies), but only if the leaders are TOTALLY committed to reversing the unacceptable trend".

1.14 Strong in-country Government commitment is seen as a key pre-requisite. Donors and DFID can support progress to MDG5 but

"only if the countries involved do their part by actively supporting the aid work `in word and deed'".

"Funding from Donors should be used through locally organised in-country initiatives in which benefits go to the disadvantaged who become stakeholders. Local involvement ensures sustainability and capacity development".

1.15 Where government corruption is high DFID is asked to continue to exert what pressure they have ... .

"Our government system is so corrupt that to get involved in that system we fear for our lives and hence we need the backing of a strong organisation".

1.16 The issue of "ownership" was also raised by the majority of respondents—it is important to involve local people who are committed and empowered to improve maternal health.

A priority to build on existing local resources and developing these to their full potential in liaison with the local community, giving them confidence and improving self-esteem.

"Look at local power relationships by clarifying roles and addressing structural and systems capacity in institutions as well as fostering accountability from, and engagement of, communities with social issues".

1.17 Accountability:

There is a need to make service providers more accountable for their actions/inactions.

"Catalysing progress should be both by carrot and stick. More of the carrot to those on the ground facing the harsh realities of rural and poor community resources. More of the stick to governments who ought to be responsible for local political participation".

For accountability it is important to ensure appropriate audit trails to ensure money is used appropriately, achieve planned outcomes and minimise misappropriation.

Systematic problems at government level are known to be a barrier to implementation of funded programmes in several countries from which reports were received.

Perhaps these issues are best summarised by one of the respondents from Sub Saharan Africa (SSA):

"These 11 questions for which answers are being sought from us, respondents, do not go into the heart of the problem of the persistence of high maternal mortality and morbidity rates. The fundamental operational factor is that the existing political, social, economic and financial arrangements in most societies in these countries are not meeting the needs of the vast majority of people in them. These are societies where haredly anythng works properly. So the need is to turn things round so that they work to the general benefit of society. It is not external donors with their myriads of projects that are important. Instead, the important thing is what the disadvantaged masses can do for themselves with donor support".

"In essence, across SSA, what we are seeing is a failure of the political elite and the consequences of this failure. There is no accountability to the people they claim to serve. The picture is depressing. However, all things considered and looking at the history of evolution of other countries and their societies, it will be correct to see the situation in SSA as part of a well trodden dynamic process, and that we will eventually get there. Still, ways must be found to bring the disadvantaged people together to fight for political, demographic and financial rights".

1.18 There is a very clear message from respondents that Coordination (or Harmonisation) must also be improved:

"Much stronger co-ordination between the various donor agencies and Government Parastatals who frequently `do their one thing' is needed".

"If DFID could promote better linkage of government health with existing micro-credit and development work, might get better synergy of grass-roots and powerful elite's working together for health".

Public-Private partnerships must be used wherever possible especially in areas where the private sector provides majority of the health care the private sector should be better leveraged. There is a need to encourage better NGO-government collaboration to reduce overlap of services.

"Encourage donors to put asied political gain in order to increase benefit to the population; reduce overlap and overheads, increase collaboration and co-ordination".

Where DFID is playing a key role to ensure better harmonisation and co-ordination this is seen as beneficial.

"there are few bilateral donors so harmonisation is less of an issue than elsewhere, but DFID pools its funding for some health and education programmes with the World Bank, USAID and the European Commission. Partnership agreements are in place between DFID and the World Bank, Asian Development Bank, UNICEF, UNDP and ILO and DFID is advising the Government as it establishes its own donor agency".

"DFID has made commitments to pool some of its resources aimed at supporting implementation of the sector wide approach and harmonisation of program activities".

1.19 Funding:

The overwhelming majority view is that funding by DFID to achieve MDG5 is currently insufficient and needs to be significantly increased.

"DFID is pooling its resources for the joint implementation of National Rural Health Mission, a flagship programme of Government, for increasing the public health spending from less than 1% of GDP to 4-5% of GDP" (India).

"The budget is a drop in the ocean and will not achieve much".

"There is a need to match the magnitude of the problem with sufficient resources".

It was felt support should be provided both through provision of Technical Support (knowledge and skills) as well as financial resources per se. Funding of work should be jointly by government, private and donor funds. Making funds available to countries should be on condition that there is significant investment in maternal health.

"Political structures (DFID) need to define criteria for overseas economic aid using maternal health care services investment and improvement in outcome as an indicator of continued investment. Money needs to be badged to defined criteria, otherwise the big black hole concept becomes a problem".

Ensuring that money reaches those who most need it.

"Use positive discrimination towards organisations that work and educate at grass-roots level—much international funding comes in at national or academic level—try reaching out to the local/village government/NGO workers".

And that money is used for the right type of activity:

"Encourage funding for rolling out of best practice".

1.20 In many cases there is lack of awareness of what exactly DFID is doing to particularly progress MDG5 (among key interested health care providers in UK and also from resource poor countries themselves ...)

Increased awareness by the population in the UK and more directly involving them with fundraising might be helpful (also for advocacy purposes) eg

"Perhaps newly safely UK delivered women should be given information on maternal mortality overseas and a suggested contribution asked for by the NHS as a government sponsored initiative".

Q2: How effectively is DFID working with recipient countries to make Emergency Obstetric Care available and to ensure that adequate numbers of Skilled Birth Attendants and other staff are being trained to meet MDG 5, and are integrated within a robust health system?

2.1 Several countries report that DFID is assisting with this in a constructive manner but ask that more time and input is given:

"DFID is assisting our government to increase the intakes in all health worker training institutions in the country as well as supplementing the salaries of some health workers so that they can remain in the system. DFID is also assisting in the construction of housing for staff especially for rural health facilities to make it attractive for health workers, especially midwives to work there and provide 24 hours obstetric service. The number of skilled attendants is still far below the required minimum standard and these initiatives are yet to show results—but are sound". (Malawi)

"DFID's contribution to strengthening the health sector is very high. However, DFID's initiative to create access to emergency obstetric care is yet to gain major momentum. DFID has to play an important leading role in developing and operationalising the Skilled Birth Attendant training and institutionalise them in public health domain, through franchising and accreditation processes. This cadre of SBAs, when coupled with focused behaviour change among the communities, could lead to significant change in the maternal health outcomes". (India)

"DFID has a broad and flexible approach that targets availability of EOC and Skilled Birth Attendance but also addresses the support systems surrounding the delivery of MNH services, including development of human resources. This approach is effective as it strengthens service delivery within the wider health systems. DFID has made a positive contribution". (Kenya)

"DFID is quite effective through—

    —  Sustained advocacy for recruitment of Skilled Birth Attendants and other staff.

    —  Designation and upgrading of health facilities to provide BEOC and CEOC services (infrastructure and equipment).

    —  Human Resource management (recruitment, retention, distribution and training of available staff in required competencies based on cadre).

    —  System strengthening initiatives (eg quality assurance, laboratory services, HMIS, drug revolving fund schemes, deferral and exemption schemes).

    —  Demand side initiatives (eg strengthening of facility health committees, addressing gender issues that relate to type 1 delays).

    —  Involvement of the professional bodies and councils". (Nigeria)

2.2 There are acknowledged and well recognised barriers to effective implementation of good ideas ...

"We have a focus on moving towards achieving MDG5 by establishing BEOC and CEOC centres including providing sound buildings, drugs, equipment and training of staff. However getting the staff to make the centres functional is not easy as having an effective public service impacts on their own pockets as most run their own private clinics and thus they do not want functional public services. Also in this state people do not have faith in the public sector (any more)". (Nigeria)

"There is what has been described as a `crisis of governance'—politicisation of public administration, corruption obstructing private sector investment and public service delivery. Formal accountability mechanisms are weak, demand for reform is mainly externally driven, and knowledge of governance is patchy ..." (Bangladesh)

"DFID support the training of SBAs and the funding to encourage hospital deliveries. Staff in the different centres I visit see the introduction of incentives for delivering in hospital as the major factor in increased hospital deliveries. These hospitals are now able to offer increased services including manual removal of placenta and management of complications of abortion which must also encourage women to seek help at the hospitals. But ... many district hospitals are still only a staging post from where the patient must be referred to a higher centre for the service they need". (Nepal)

2.3 Respondents clearly express the need to ensure that increasing availability of SBA and EOC needs strengthening of the health system as a whole. In addition there is the experience and observation that a focus on ensuring availability of and access to SBA and EOC will lead in itself to a better functioning complete health system. This leads respondents to believe that there should be a very strong continues and sustained emphasis on SBA and EOC.

"DFID has supported the establishment of EOC since 1997. In the first phase DFID supported the establishment of the Safe Motherhood Project for strengthening EOC in several districts. The lessons learnt from this project showed that scaling up EOC was not possible through projects and required a functioning health system at all levels. Thus DFID assistance has since been directed to providing support to the National Safe Motherhood Programme through the Support to the Safe Motherhood Programme (SSMP). The SSMP is supporting scale up of EOC and establishment of skilled attendance and BEOC services at primary health care centre.

Simultaneously, DFID is also providing support to the Health Sector Reform that aims to bring about change in national policies that would result in an increase in Ministry of Health and Population's capacity to deliver quality maternal health services as part of the package of essential health care services, with increased decentralization and public private partnerships. The reform process also aims to improve sector management—improved physical assets management, ensuring the availability of drugs and logistics, human resource management, financial management and improved monitoring systems.

This is a programme that aims to develop government capacity and build partnerships between major donors in Safe Motherhood and the Health Sector Reform Process, to strengthen the health system and simultaneously the National Safe Motherhood Programme. Changes in the health sector are critical for achieving results in the Safe Motherhood Programme and these results, concurrently, would provide the indicators for change in the health sector reform process". (Nepal)

2.4 Respondents from all countries want the international community and donors to realise and accept that meeting MDG5 is possible but will take time ...

There are repeated and emphatic calls to give this process more time ...

"While the concept requires strong partnerships to execute this tie up between two major programmes as well as government capacity building and stability, it also requires considerable time ..."

"MDG 5 seems to be the MDG seen as least likely to be achieved in the timescale, I would have to say that DFID and other agencies are not working effectively enough in these areas. But there are clearly huge obstacles ... Priorities must be in the area of increasing capacity and of course ongoing training and support for the health system and infrastructure ..."

There is also some doubt expressed as to whether DFID can ensure this ...

"Individual countries will receive aid for these elements. However, I imagine that DFID is a rather remote organisation to ensure the above".

2.5 More needs to be done:

"DFID is working in these areas in less than 10 countries, which is not enough to bring a critical movement".

Q3: What steps is DFID taking to mainstream maternal health across related policies?

3.1 Making the linkage between MDG5 and MDG 1 (poverty and hunger), 2 (universal primary education) and 3 (promote gender equity) is seen as key here.

DFID is known to be taking a number of steps to ensure maternal health is mainstreamed across related policies which include:

Ensuring MNH is part of the process of Harmonisation:

"DFID support the budget for the SWAp in the health sector where maternal health is a priority area".

"DFID has incorporated MNH into the Country Assistance Plan".

— developing plans and policies that cut across different sectors;

— ensuring commitment, cooperation and coordination from all key stakeholders;

— ensuring that strategic health plans at national and state/provincial level address MDGs with clear targets;

— MH is a key output of programme logframe;

— ensuring integration and alignment of other programmes eg HIV, TB, Malaria prevention and treatment programmes with MNH programmes (not the other way around);

as well as via the socio economic development and health rights approach

— Continued emphasis on MH as part of poverty reduction strategies;

— looking at microcredit and financing groups to improve women's access to health care;

— promotion of SRH rights-based approach;

— valuing role of women in society; and

— liberating women to give them an effective political voice and insist on change.

3.2 Advocacy for mainstreaming of MNH is being done but needs to be sustained:

— Agreement between host nation politicians and donors to prioritise MNH.

— Raising the political profile of MNH through advocacy and BCC strategies.

— Using civil society organisations to demand for better investment in systems to address high maternal morbidity and mortality.

— Advocacy in media and local government focusing on men and improving their knowledge base, since they are often key decision makers.

Some say that the mainstreaming is happening but less talk and more action is needed:

"it is not just policies that are required but clear implementation plans—ie getting policy into practice".

"I am unable to comment on what steps DFID should be taking to mainstream maternal health across policies. We have enough programmes and policies in place. It is the implementation which is faulty ...".

Several respondents are unaware of what steps DFID is taking and call for better dissemination and profiling of such activities by DFID.

Q4: How is achieving MDG 5 being prioritised and integrated into your countries' overall healthcare provision?

4.1 Countries report primarily that this is being done via a process of Harmonisation or and Central Coordination.

— DFID assistance in Nepal is directed to providing support to the National Safe Motherhood Programme through the Support to the Safe Motherhood Programme (SSMP).

— DFID Nepal is providing support to health sector reform that aims to bring about change in national policies resulting in better capacity to deliver quality maternal health services as part of the package of essential health care services, with increased decentralization and public private partnerships.

— Developing government capacity and building partnerships between major donors in Safe Motherhood and the Health Sector Reform Process is vital.

— Improving maternal health is one of the key priority areas in the National Health Sector Strategic Plan II and fully integrated into the delivery of KEPH, Kenya Essential Package of Health.

Suggestions for improvement include:

— A lot of political rhetoric but unsure how this is linked to resources to address the key issues.

— Professional societies need to be involved in policy, planning and implementation of safe motherhood.

Prioritisation of MDG 5 is reflected within the various government planning documents but lacking the necessary Government capacity and financial support for effective implementation. (Nigeria) In Malawi and Bangladesh, MDG 5 appears to be given priority but little commitment. In Mongolia it is very much a priority but in Laos this is reported to be "a different kettle of fish".

4.2 Advocacy is seen as an important mechanism through which prioritisation and integration of MDG5 can be achieved:

"DFID advocacy is necessary at all levels, at national and international levels and should be done together with the UN Agencies ... to increase ownership of maternal health and the benefits of achieving MDG5".

"MMR is the best indicator of a functioning health system—DFID advocacy for the recognition of this fact in health sector reform process is important".

"DFID advocacy has been successful in raising the profile of maternal health. However DFID's agenda must also become the agenda of national advocates particularly the Obstetricians and Gynaecologists as well as women's rights groups etc in order for government to make it their priority".

Q5: How is DFID supporting the 2006 recommendation by the UN General Assembly for an MDG target for universal access to reproductive health?

5.1 There was little or no awareness among respondents as to how DFID is supports the establishment of a target for universal access to reproductive health.

"The fact that several of us working in different aspects of health and development here do not know the answer to this question implies that there is little dissemination of what DFID is actually doing—at least, dissemination has not reached those at the grass roots level ..."

"DFID could support networks to enable people to have a greater knowledge of what is happening so that there can be a sharing of knowledge, resources and experiences ..."

5.2 It is suggested that international lobbying for this target is necessary if this is not already being done.

There is realisation however that sexual and reproductive health rights have remained a DFID priority with emphasis being given to adolescent reproductive and particularly comprehensive abortion care in the absence of US donor support.

5.3 There is a strong realisation that most developing country health facilities have minimal sexual and reproductive health provision capability at best distribution is not equitable with rural areas especially poorly affected and that universal access to functioning health services is desperately needed and should be a real priority for the next decade.

Q6: What progress is being made to reduce maternal deaths from unsafe abortions (which account for 13% of all maternal deaths)?

6.1 A variety of responses was received. Very good progress has been made in specific countries whereas in others progress is slow or non-existent.

Countries form which enthusiastic responses were received included:

Nepal:

Besides the support to EOC and skilled attendance, DFID has provided support through Government to the liberalization of abortion in Nepal and its implementation.

"Among many partners DFID supported training and service provision of Post Abortion Care (PAC) since 1997. Abortion was liberalized in 2002 and rolled out by Family Health Division, with the support of active women's' rights groups. Comprehensive Abortion Care (CAC) services are now available and integrated within the government system in most districts in Nepal. This programme provides a good example of service provision through public private partnership. Marie Stopes and other non-governmental agencies and the private sector have contributed significantly to the expansion of services to provide safe abortion care".

Issues of access (affordability sometimes remain ...).

"Many doctors and nurses are receiving training in comprehensive abortion care and this is now available at hospitals in all the districts I visit. Fees charged may be too much for the very poor".

Significant progress is also reported from India:

—  The Medical Termination of Pregnancy Act 1971 has been implemented since 1972.

—  Over the years, the number of centers where pregnancy can be terminated has increased and at present there are 11,025 recognized MTP clinics in the country. However, considering the fact that a large number of unsafe abortions still take place more facilities for MTP services are needed.

—  At present the Government of India under the RCH programme is undertaking training of medical personnel in MTP technique, and undertaking IEC activities for improving the awareness and knowledge of the community.

—  The MTP Act, 1971 has been amended with the objective of delegating power to a Committee at the district level to facilitate recognition of more centres where MTPs can be undertaken.

—  Use of Mifepristone (RU 486) followed by Misoprostol is an established and safe method for terminating early pregnancy. In April 2002, Drug Controller of India approved marketing of Mifepristone for termination of early pregnancy, a method also known as Medical Abortion. Currently its use in India is recommended up to 7 weeks (49 days of amenorrhea) in a facility with provision for safe abortion services and blood transfusion.

—  The Department of Family Welfare has introduced the Manual Vacuum Aspiration (MVA) which is a safe and simple technique for termination of early pregnancy that makes it feasible to be used in Primary Health Centres or comparable facilities, thereby increasing access to safe abortion services.

—  The project of introducing the MVA technique has been piloted in coordination with FOGSI, WHO and respective State Governments before accepted for implementation by the Ministry of Health and FW.

—  Improving public awareness nationally through print and electronic media.

—  Introducing sex education programme in the school curriculum (among pupils over 10 years of age).

—  Effective introduction of emergency contraceptive pills in the national programme.

Respondents from Nigeria report progress:

Progress is being made through:

    —  DFID supports partners at the federal and state levels to train doctors, CHEWs and midwives in Life Saving Skill competencies that include MVA and post-abortion care (PAC) services.

    —  Promotion of family planning/birth control practice and family planning services being provided down to community level.

    —  Support to `Girl child' education.

    —  Focus on adolescent reproductive health.

    —  Community awareness and advocacy.

    —  IPAS is the leading organization that partners with the government of Nigeria and other agencies to change the policy environment for abortion rights and PAC services).

    —  Ensuring effective referrals to reduce type 2 delays.

6.2 However, in several other settings progress is difficult and slow and respondents from especially eastern and SubSaharan Africa (SSA) were quick to point this out:

"Several interventions are ongoing but there is not much progress because the Church Lobby is strong and is against legalising abortions". (Kenya)

"I am aware that there is no progress. The need is for improved provision and use of family planning, and the proper hospital-based treatment of complicated abortion". (Nigeria)

"Several interventions are being implemented (adolescent health services, FP, decentralisation of PAC services) but religious and cultural views around abortion remain major barriers in achieving the desired reduction". (Kenya)

"Abortions are still illegal in East Africa, the part of the developing world I know best. Abortions are therefore still clandestinely provided at exorbitant prices. Those who can not afford the prices will therefore resort to untrained unlicensed abortionists with serious consequences". (East Africa)

"The majority of the 130 million women without access to reliable contraception in the world are in sub Saharan Africa, which explains why 58% of all induced abortions in the world occur in Africa".

"Minuscule efforts and progress is being made in most SSA countries. Most intervention efforts are in the curative arena, in the gynaecology wards, therefore missing the key preventive intervention of Family Planning both:

— to prevent the first abortion and (after septic abortion is treated in hospital); and

— to make it less likely that the same woman will be back again following a further unsafe abortion".

"Addressing the issue of effective Family Planning and access to safe, preferably medical, abortion has low priority ...". (Malawi, Bangladesh, Eastern Europe)

"There is more being given to adolescent reproductive health; however some of the health messages need to be refined—eg the message is out there to delay first childbirth, but this has not been interpreted as delaying first pregnancy—so there are now an (increasing?) number of abortions (`safe' and `unsafe') rather than promoting use of family planning and thus delaying first pregnancy.

Also at the other end of the reproductive health age, there is a need to understand of cultural/social/religious barriers to permanent methods of family planning once the family is complete". (Bangladesh)

6.3 Some see the combination of improved access to family planning services and liberalisation of abortion laws as the way forward to achieve significant reduction of maternal mortality from unsafe abortion:

"A major educational programme will be needed to convince certain religious groups of the need by women to limit their fertility by allowing birth control methods to be adopted. The obvious first step to reducing the incidence of deaths from unsafe abortion is reducing unsafe abortion itself, which means either legalising and professionalising abortion and/or (far preferably) increasing knowledge of and access to reliable contraception. I believe that this is expanding year by year but unfortunately—as with much good progress—advances are greater in the less poor countries while those with the lowest resources and associated worst rates of maternal mortality are still far from providing such access. Cultural and religious traditions also need to be taken into account".

"Developing countries have the biggest problems with maternal death in association with unsafe abortion but at the same time have the most restrictive laws about abortion. The UK and other respected developed countries should be trying to assist in changing attitudes towards dealing with unplanned and unwanted pregnancies and assisting countries to change their legislation to a more liberal stance".

6.4 In other settings preventing unwanted pregnancy through better provision of family planning services is seen as the primary key to achieving reduction in maternal deaths from unsafe abortion:

"Induced abortion is illegal; and unmet need for contraceptive services is high at about 30%. The option is the delivery of community-based family planning services to eliminate unwanted pregnancies, especially among the youth. No funding is available. USAID is planning to make the services in 8 of the 28 districts in the country and the country wishes for more support from other donors such as DFID". (Malawi)

6.5 There is also a strong consensus that there is lack of clear and accurate data on the extent of the problem and that such data are by definition difficult to obtain.

"We have no idea what the denominator for illegal abortions in the third world is. The women for whom it is successful would not come forward. I am afraid social taboos make this at least as much a social issue as a medical one".

"I have to look at these percentages with suspicious eyes since it is very difficult to get appropriate statistics from these countries".

6.6 In general reports indicate that professional associations/groups are in support of interventions to reduce maternal deaths from unsafe abortions:

"Our national organisation of Gynaecologists and Obstetricians organised workshops a couple of years ago along with WHO to showcase the MR syringe (MVA) as a tool for reducing blood loss during abortions".

6.7 Again there is a call for better dissemination of lessons learnt:

"Aware of reports commissioned to highlight the crisis in relation to unsafe abortion. Not clear what effective progress is being achieved although recent DFID Health Policy provides case studies of for example initiatives in Cambodia and Nepal. Would help to keep sharing lessons learnt from implementation and about what is effective in comprehensive abortion care programmes".

Q7: How effectively is family planning being promoted as a way to improve maternal health?

7.1 All respondents see family planning as an essential step to help reduce maternal mortality and improve maternal health:

"Prevention is better than cure ..."

"Family Planning should be the main emphasis for the next decade. FP is low tech, cost effective and the most effective strategy in reducing maternal mortality in the short term".

7.2 Many countries report that good progress is made in this area:

"Family planning has been promoted and well publicised". (Egypt)

"The methods are promoted in all public health facilities. The spacing method promotion has gained significant momentum. The promotion of IUDs, Oral Contraceptives and Condoms (both male aqnd female) for spacing is a major program in India. The community based programmes also work on promoting spacing for better maternal health". (India)

"Family planning is provided in 90% of cases through the government sector and only about in 9% cases through the NGO and private sector. The extensive reach of the government sector compared to the limited coverage of the private and NGO sector makes it imperative to further strengthen the government sector while also working on improved public private partnerships". (Nepal)

"Family planning promotion and uptake is very variable across the region. In many areas it is not given much priority and people are ignorant and fearful of side effects from temporary and permanent methods". (Nepal)

7.3 There are clear ideas on how better coverage and uptake of family planning could be effected:

Provision of FAR BETTER accessible, affordable voluntary family planning services and methods along with education including:

    —  correct information re FP;

    —  the removal of much MIS-information in many developing countries (eg in Sub-Saharan Africa (SSA) the widespread myth that the Pill causes life-time infertility; and

    —  the RE-education of the men in many societies: to reduce sexual abuse, but above all allow all women access and CHOICE to control their own fertility which is currently often denied (by their male partners).

7.4 There is clear realisation that more needs to be done and that access is by no means universal and especially poor for rural women:

"Facts reveal that 137 million women who wish to limit their family size have no access to any form of contraception".

"There is a need to take the services to the people through the Community Based Distribution (CBD) approach".

"The women at greatest risk are the elderly multiparous women. They tend to be from peasant families and often the poor and those who live in remote rural communities are neglected".

"Family planning is actively promoted, though services are scarce especially in rural areas".

7.5 Shortages in trained staff and supplies have hampered progress severely in some areas:

"All public health facilities, except for those run by the Catholic Church provide family planning service; but because of the shortage of staff, and the inadequate distribution of health facilities, contraceptive prevalence rate has stagnated at about 30% for the past five years". (Malawi)

"It can be seen in many low resource countries that regular supplies of FP methods to rural areas is still poor and there is often little access to modern, long-term FP methods. Means to address the issues need to be linked to HR and supplies systems and training and governance related to the latter".

"More funding required to procure supplies. Demand is there". (Kenya)

"There was a country wide shortage of Depot Provera at the end of 2006 and beginning of 2007, due to bureaucratic incompetence, and the result of this has been many unwanted pregnancies and subsequent abortions and `Menstrual regulation' procedures. Has the International donor community any role in ensuring that this does not happen again—years of hard work at promoting confidence in the FP system was shot to pieces through this". (Bangladesh)

7.6 There has also been "competition" for priority especially with regard to countries with programmes to address the problem of HIV/AIDS:

"Support for family planning has decreased over the past decade with a shift of resources from FP to HIV/AIDS. It is slowly coming back on the agenda, not only to reduce fertility rates, but also for PMTCT of HIV and improving maternal health".

"Promotion of FP is ineffective and in some areas FP is not promoted at all. Money for HIV programmes often donated by Christian organisations who do not support and indeed actively discourage contraceptive usage including condom worsening HIV rates".

Uptake of FP is seen to be related to general education, sex education and to health education:

"Educating and empowering women is the most important factor as has proved in countries like Bangladesh, Sri-Lanka and Kerela state of India".

"General education of women will lead to their emancipation, to their being valued and to the spread of sexual and birth control education. Such will lead to a reduction in the population in the continents where the population explosion is most fierce".

"Advocate the dissemination of messages supporting later marriage, spacing of births—including the practice of exclusive breastfeeding to six months or more—and care following abortion or miscarriage to include contraceptive advice. Families may accept such advice even more readily if it is understood it will improve the survival of existing children under 5, as well as that of the mother".

"One area of improvement is education in sexual health aimed at school children as well as adults. A novel initiative organised by Rotarians is the `Health Fair' initiative for countries in need. Projects in South America and Eastern Europe are particularly effective".

"The uptake of FP is variable and depends on religious views in country. In some areas FP may not even get discussed. Improving this is probably best achieved by educating women so that they demand access to good family planning".

7.7 The need for involvement and dialogue with religious leaders is recognised in many regions:

"You will be aware of the religious influences on family planning in large Catholic communities in East Africa".

7.8 There is also the need to see the issue of FP in the wider context of the position of women in the community:

There are too many economic issues with regard to family size for this to be considered in isolation. As we recently heard at Africa Day1—"t is easier and more economic for a man to get a new wife than to spend scarce resources on the existing wife's treatment to save her life".

7.9 And a caution that a combination of efforts is needed not "just" FP:

"Family planning is just one method to improve maternal health, but the remaining indicators should not be neglected".

"It is available where other health services are available but not seen as a priority by families for whom most healthcare choices are limited to crisis situations by their socio-economic situation. It should find its place in the pattern of service development together with SBA and EOC".

"The National Family Planning programme is being implemented in all districts and is making reasonably good progress. It offers a good contraceptive mix and the most commonly used methods are female sterilization and Depot Provera. Family planning service provision is one of the important roles of the SBA". (Nepal)

Q8: How effectively does DFID work with bilateral and multilateral donors, NGOs and other stakeholders to promote maternal health (in your country)?

8.1 In general the approach of DFID to work with other donors, NGOS and stakeholders was seen as positive and effective:

"DFID is a member of the technical working group on Reproductive Health and is also a member of the Donors Group on Reproductive Health which also include maternal and child health".

"DFID has taken key roles in SWAPs and health systems support programmes but still works with and supports NGOs".

"They collaborate with other partners to provide financial and technical support for training, equipment etc".

"There is engagement with NGOs, CBOs at the community level on mobilization, awareness creation and monitoring and evaluation activities".

"DFID is partnering effectively with other agencies on the Inter-Agency Coordinating Committee (IACC). At state levels DFID funded programmes are collaborating with other donors and NGOs in promoting maternal health".

"DFID's approach to addressing the problem of maternal health is well conceptualized and ambitious. Perhaps it is the only way that it can be done—by strengthening Safe Motherhood and linking it with efforts to reform the health sector, without which scaling up Safe Motherhood is not really possible".

"DFID advocacy has been successful in raising the profile of maternal health through its work in Safe Motherhood and the Health Sector Reform process. In both these areas, it works with a multitude of partners—government, multilaterals, bilaterals, the World Bank, NGOs, professional societies etc".

"There are few bilateral donors so harmonisation is less of an issue than elsewhere, but DFID pools its funding for some health and education programmes with the World Bank, USAID and the European Commission. Partnership agreements are in place between DFID and the World Bank, Asian Development Bank, UNICEF, UNDP and ILO. DFID is advising the Government as it establishes its own donor agency".

8.2 The need to engage more with the professional associations was expressed as well as the difficulties that arise when there are new initiatives launched (? too often, or insufficiently well disseminated ... ):

"DFID works quite effectively in the health sector with all other development partners for promoting maternal health. DFID could work more effectively with professional bodies like FOGSI, AICC RCOG to promote maternal health".

"There appears to be little public information disseminated through the professional organisations".

"There was a good momentum of working in partnership with bilateral and multilateral donors and civil societies, until the confusing announcement of the new initiatives ...".

8.3 In some cases it is recognised that despite DFID's good intentions, effective partnerships may be hindered by local factors:

"The current strategy seems to be to strengthen government capacity to prioritise under served areas and subcontract with other private/NGO providers, however the government has been reluctant to do so".

"DFID is no longer working directly with small NGOs but is trying to co ordinate and promote larger consortia of private and NGO providers to cover underserved areas. There are big variations in implementation and government capacity and vision; compounded by political instability".

Q9: What leadership is the UN is providing and how well co-ordinated are its agencies?

9.1 The "reviews" were very mixed with some excellent examples of co-ordination but in some countries health care providers or staff working at national level were pretty negative about the level of coordination and partnership ...

"UNFPA and WHO have coordinated the development of the `Roadmap for the Prevention of Maternal Deaths' and are providing technical support for the implementation of the Roadmap at district and national levels. WHO is supporting training in Skilled Birth Attendance. UNICEF is actively involved in the prevention of vertical transmission of HIV. There is a UN working group which provides a forum to share information about the various program activities that each organisation is providing". (Malawi)

"Through the flagship program of NRHM (National Rural Health Mission) all the UN agencies and bilateral donors are well coordinated". (India)

"The UN provides the needed leadership role in terms of collaborating with National and State Governments. Its agencies are well co-ordinated and provide support in terms of project design and implementation in various sectors of health care provision". (Nigeria)

"The four UN agencies are working more and more closely and have now delineated areas of comparative advantages and strengths in maternal newborn and child health (New York meetings of 13 September 2006 and 11 July 2007, and forthcoming Washington meeting of 17 September). But it remains to fine tune co-operation at country level". (UNFPA)

In contrast to the above ...

"Technical guidance is provided but coordination between WHO, UNICEF and UNFPA could be improved". (Kenya)

"I found there was very poor co-ordination with other UN agencies. This may have been because the purposes for which I went to the old Soviet Republics were short term and time limited".

"Difficult to comment but as far as I know there is no one UN agency taking responsibility for MDG 5, and this is extremely unfortunate. WHO offers technical expertise from its Making Pregnancy Safer department, and of course this is also available from INGOs such as FIGO and ICM, who work closely with WHO, UNFPA and other agencies where appropriate. The Partnership for Maternal Neonatal and Child Health also has good aims in this area to do in-country work but I do not believe it is very clear exactly how all the agencies' various strands of work cohere and complement each other, and I believe there is scope for improved co-ordinations".

"WHO is providing good leadership and technical support. UNFPA could be much more effective if there was better leadership. UNICEF is fairly useless". (Papua New Guinea)

"Resolutions are passed but it is difficult to see the practical impact of these resolutions".

"None, and poorly co-ordinated". (Bangladesh)

Q10: How is DFID addressing socio-economic barriers to women's empowerment and the low status of women in relation to maternal health (in your country)?

"Community mobilisation to empower women to take up maternal and newborn care services is one of the strategies of the Roadmap for Maternal Health which DFID is supporting.

In addition DFID is supporting basic education for increased enrolment of girls, but still the dropout of girls in secondary school is very high". (Malawi)

"Gender specialists at Division of RH are not aware of any specific activities by DFID in this field". (Kenya)

10.1 Multiple examples were given from Nigeria although no comment was made on the effectiveness or not of these:

The focus is on a combination of education and reduction of health care costs for women:

    —  Girl child education programme.

    —  Empowerment of women including taking part in home decision making.

    —  Supporting male involvement in maternal health.

    —  Introducing community based Emergency Loan Fund (ELF) schemes for pregnant women.

    —  Introducing Emergency Transport Schemes (ETS) for conveying pregnant women to health facilities at any given time.

    —  Support to Free MCH policy.

    —  Design of voucher scheme for pregnant women.

    —  Design and implementation of Deferment and Exemption Schemes for paying for health care.

10.2 There is a general consensus that empowerment of women is directly linked to financial independence/dependence and that this is a key area that must be addressed:

"Women's empowerment can only be achieved through a comprehensive strategy of poverty reduction through micro credit etc reduction of illiteracy, improving health and supplying of clean water".

"Practising compassionate care is more effective that talking about a matter that may be politically correct but culturally inappropriate".

"DFID provides support to addressing equity and access issues through the `increasing access' component of the Support to the Safe Motherhood Programme. This component of SSMP works on issues of women's empowerment and with the more disadvantaged sections of society to increase their access to services. While this is implemented in selected districts, DFID provides cash incentives to women delivering in health institutions to promote skilled attendance at delivery, at a national level". (Nepal)

"An example of DFID support to women's rights is an income generation program".

10.3 Most health care providers said they were unaware what DFID was doing specifically to address these issues:

"Do not know. There are adverts on the TV channels about the girl child's value, This I suspect must be sponsored by a donor because its very expensive to advertise. DFID should note that in the cities the private channels are watched, not the government run channels and DFID should rather use these".

"DFID prioritises programmes which are poverty focused, demand driven and owned by `an agent of change'—be that government, NGO or private; programmes which have impact on the lives of women and girls; have potential for pro-poor change; etc etc but how these aims are being worked out in practice is not clear to us where we are working" (rural Bangladesh)

Q11: How can the international community improve maternal health in crisis and conflict settings?

11.1 The central consensus was that the primary focus should be on ensuring and/or rebuilding the peace ...

"Firstly assist to end the cause of the crisis. Secondly mobilise maternal health services for the displaced persons. Finally assist in the rehabilitation of the affected people as soon as possible".

"The international community should have principles that stick and are not abandoned for commercial considerations. Maternal health crucially depends on stable political and economic environment. When there is conflict the first to suffer are the vulnerable mother and child. It ought to be made a Crime against humanity that in any conflict situations if women and children are not specifically protected, warring parties should be punished".

Specific points:

—  Do its utmost to support adhesion to the Geneva Convention and UN Declaration of Human Rights to prevent all civilians, but in particular families with babies and small children, suffering death, injury, illness or forced disruption because of conflict.

—  Ensure the severest penalties against the use of rape as a weapon of war against women.

—  Support safe transport and facilities for medical and midwifery staff working in refugee camps or settings of potential danger.

—  Ensure that emergency response activities integrate maternal and child health issues especially access to Emergency Obstetric Care, Skilled Attendance at birth and access to Family Planning.

—  Integrated provision by the Relief Agencies of family planning (including especially Emergency Contraception by both hormonal and IUD methods) and safe abortion services and ideally counselling services, to the hugely increased number of victims of sexual violence and rape in these settings.

11.2 In addition there were many practical suggestions for how immediate help could be given and/or organised:

"An international maternity squad can be sent to areas of conflict by the UNO. Squad should have Obstetrician, midwives, nursing staff and appropriate resources".

"Highlight the need to prevent and where necessary address gender-based violence and the aftermath of crises where there is significant loss of life and the extra pressure on women to reproduce, marry younger, drop out of education etc".

"Adequate funding from all concerned to ensure free or heavily subsidised maternal services via accessible and functional health facilities".

"Promote and facilitate retired and concerned practicing obstetricians and Midwives to offer their assistance to those who organise healthcare in those situations. They may need support with appropriate technological resources, orientation and training".

"Antenatal mothers can be grouped in special care hospital settings in a protected area, where doctors and nurses can look after them round the clock, with living quarters provided close by for immediate family members".

"Set up equipped mobile health units".

"Organise sustainable education courses for emergency response teams".

"Develop a pool of emergency obstetric responders for crisis/conflict settings who can secure rapid release from regular duties".

"Increase the profile of the RCOG IO among the relevant aid agencies".

The need to work closely with the relevant local community was emphasised:

"Understanding the local cultural influences is essential before one can `plunge' in with something the international community may view as effective".

"A non-partisan non-judgemental approach is needed".

"Identify and communicate through an effective body who command respect".

and the need to work with experienced people:

"Using UNHCR and NGOs like the RED CROSS and MSF who have experience in this field".

"The activities of the Finnish International Red Cross give a perfect example of maternal health provision and improvement in conflict situations. Material for erection and operation of field hospitals and supporting health and physical infrastructure are kept in secure storage. Fully trained personnel, pre-selected, tested and passed fit to cope with the demands of the task are always in readiness for rapid deployment. Once the emergency period is over, medium and long-term needs are not much different from what they are in non-conflict situations".

11.3 Interestingly it was pointed out that the underlying cause of such conflict was related to absence of good maternal health services (in particular family planning) in the first place by a number of respondents:

— In these situations, as with global warming, the problem is of man's (generic) making. The human population is greater than can be accommodated and radical worldwide means need to be undertaken to tackle the human population explosion on every continent except Europe.

— If the human population is allowed to continue to increase exponentially, conflict, war, disease and crisis are the normal expected results. Thus, the international community can only improve the situation by agreeing to limit and then reduce its human population to that which its land can support.

11.4 Finally if and where comprehensive maternal health services (especially with CEOC) are in place it is anticipated and has been shown that in case of conflict existing services are equipped to deal with this better than if such maternal health services are not in place ...

"The scope of work of DFID is expanded to support the establishment of CEOC in many districts. The populations in crisis have access to better district health systems—improved surgical services, operation theatres, blood transfusion and infection prevention. This recommendation is based on an assessment of mass casualty management by the UN agencies in 2006, which showed that hospitals providing CEOC were better able to manage casualties during emergencies". (Nepal)

165 As defined by the UN bodies with specific signal functions agreed for BEOC and CEOC and minimal acceptable coverage defined. Back