Safe Motherhood: Continuum of Care for Maternal Health in Disasters

Safe Motherhood: Continuum of Care for Maternal Health in Disasters

This weekend marked Mother’s Day and as such is a poignant reminder of the challenges and needs of pregnant women and new mothers in disaster prone countries. Save the Children’s 2015 report ‘State of the Worlds Mothers’ highlights how maternal mortality is often highest in resource poor disaster-prone areas.  Wider issues of population pressures, poorly planned urban, rural development and climate change often mean that, when disaster strikes, sexual and reproductive health issues are low on the priority list for needs assessment, despite the clear demand for such services. Yet, these deaths are preventable, especially when disaster responses and disaster risk reduction (DRR) reflect more comprehensive and inclusive service provision. By doing so, more communities become resilient by preparing for and responding to sexual and reproductive health (SRH) to implement a spectrum of broad maternal care needs.

Maternal deaths during an emergency are most commonly caused by pregnancy-induced hypertension, haemorrhage, infection and obstructed labour. Emergencies increase these risks when food insecurity rises causing nutritional decline on essential vitamins, diseases spread and maternal services become scarce or unavailable. After a disaster, prenatal care declines rapidly as expectant mothers focus on securing food, water and shelter for their families. Women who don’t seek out medical care early on increase the risk of life-threatening complications resulting in poor maternal outcomes

The following seven key facts highlight the widespread impact of inadequate maternal health care, more profoundly in disaster-prone developing countries (John Hopkins and Red Cross Red Crescent 2008):

  1. Over 585,000 women die every year (an average of 1,600 per day) as a result of causes related to pregnancy or childbirth—almost all in developing countries.
  2. Another 15 million women in developing countries suffer acute complications that can lead to lifelong pain, illness, and infertility.
  3. For the refugee population within the post-emergency phase, pregnancy and child-delivery complications are the leading cause of mortality and morbidity among women.
  4. Between 25-33% of all deaths of women of reproductive age in the developing world, is the result of pregnancy or childbirth. It is the leading cause of death and disability for women between the ages of 15 and 49 in the developing world.
  5. Skilled attendants are present at only 53% of deliveries worldwide and only 40% of deliveries take place at a hospital or health centre.
  6. Unsafe abortion is a leading cause of maternal mortality world-wide, accounting for 70,000 deaths every year. Millions more suffer long-term health problems such as chronic infection, pain, and infertility.
  7. 50% of all prenatal deaths are due primarily to inadequate maternal care during pregnancy and delivery.

To address these issues, the minimal initial services package (MISP) is a priority set of life-saving initiatives to be implemented at the outset of an emergency and so addresses SRH from the start.

SRH is a critical public health need in all communities, especially those facing emergencies. It is worth noting, that appropriate responses to SRH should be contextualised to recognise and overcome particular in-country challenges. Key SRH interventions include (WHO 2012):

  • Family planning (all methods – including long-term and permanent, as well as emergency contraception)
  • Safe abortion care to the full extent of the law and post-abortion care
  • Pregnancy care
  • Childbirth care (including emergency obstetric care)
  • Postnatal care (mother and newborn)
  • Prevention and management of sexually transmitted infections and HIV, including mother-to-child transmission of HIV and syphilis.

Rio 20+ United Nations Conference on Sustainable Development urges the integration of SRH programmes, such as universal access to reproductive care that includes sexual health and family planning, into national health action plans. Very often however there is a lack of services around SRH during emergencies. These need to be strengthened to ensure future events are better able to reduce maternal mortality and morbidity as well as improve the overall quality and timeliness of maternal health interventions to save more lives. 

In recognising this gap, in a WHO-led policy brief (2012), five key policy areas emerged to integrate SRH into emergency risk management systems, programmes and plans:

Priority 1: Incorporate SRH into multisectoral and health emergency risk management policies and plans at national and local levels.

Priority 2: Integrate SRH into health risk assessment and provide early warning for communities and vulnerable groups.

Priority 3: Create an environment of learning and awareness.

Priority 4: Identify and reduce risks for vulnerable communities and SRH services by reducing underlying risk factors.

Priority 5: Prepare existing SRH services to absorb impact, adapt, respond to and recover from emergencies.

Essential to the effective delivery of SRH during emergencies is ensuring that there are sufficient numbers of trained health-care workers and adequate facilities and supplies. The case below indicates how services can be built up around SRH need:

In focus: Maternal Health Failings and Responses During and After Haiti Earthquake 2010.
Haiti has the highest maternal mortality in the Western Hemisphere. In times of disasters, the risks to mothers and their newborn rise starkly. Eve de Poecker, MSF midwife, highlighted the stress and burden expectant mothers were facing at the time: “we’ve delivered so many premature babies as a result of trauma…women are coming to us with pre-eclampsia or eclampsia – serious conditions exacerbated by stress.” The earthquake caused 60 percent damage and destruction to hospitals and clinics, meaning many women were in need of urgent assistance to deliver their babies, many with complications. With families seeking shelter in the streets, significant numbers of women found themselves without a home to take their newborns.

Even after the initial response period for the disaster, MSF reports that in the first year following the earthquake, more than 15,000 women gave birth in MSF clinics and hospitals. In some instances, obstetric-related surgery contributed 60 percent of all surgical activity.

On top of these challenges, the DFID review report ‘Women, Girls and Disasters’ (2013), suggests that post-recovery disaster situations have exposed women and girls to violence and abuse in Haiti. The heightened risk of rape, trafficking and forced marriages has not been adequately factored into the definition of ‘disaster risk’ for women and girls. Plan International in 2013 reported that early marriage increased after the earthquake. The consequences have been severe: young girls with underdeveloped reproductive organs are more likely to die in child birth, drop out of school, and enjoy limited economic choices. MISP must absorb the ever growing risks faced by women and girls in disasters. Community education is a key route to prevent early marriage as well as specialised maternal care units.

The new MSF Centre for Urgent Obstetric Referral (CRUO) opened in March 2011 and provides 24-hour free care for women experiencing serious complications. The hospital also has a dedicated neo-natal unit for newborns. Thousands have since given birth at the hospital, 70 percent with life-threatening conditions.  This case shows how setting up a specific care unit has given additional support to specialised staff to better deal with obstetric and neo-natal aspects of maternal care.

Community knowledge and responses have been critical to reduce maternal deaths and injuries during disasters. In emergencies, communities are the first responders and are able to identify pregnant women so that they can get the care and support they need. In 2013, UNFPA partnered with the Women’s Refugee Commission (WRC) in the Philippines to promote and improve communities’ responses to sexual and reproductive health needs during disasters. WRC’s universal information, education, and communication materials can be distributed to communities to inform them about priority reproductive health services.

UNFPA has indicated several positive traits of community DRR actions plans for reproductive health resilience that include:

  1. Advocacy for positioning sexual and reproductive health supplies and safe delivery kits in health facilities.
  2. Development of committees to monitor pregnant women during emergencies.
  3. Conscious awareness and the building of knowledge within a broader community about SRH and gender-based violence during emergencies.
  4. Emergency transportation for pregnant women.

Additionally, UNFPA also delivered nation-wide and regional training on MISP as well as reproductive health and gender mainstreaming on DRR. Overall, such measures have helped strengthen the capacity of health systems to respond prepare for and to natural disasters with MISP, providing informed choice, access and protection. By engaging at the community level, women are recognised as key stakeholders and partners with innate knowledge, skills and resilience for which interventions should reflect.

Women-led local health governance groups are pivotal in plugging gaps in service provision especially as they help mobilise women as health volunteers, help collaborate with public health centres, and facilitate education programmes around sexual and reproductive health. Overall, this leads to more access to, demand for and use of pre-and post-natal care.  Women are vitally important for promoting childbirth with skilled birth attendants and ensuring referrals for emergency obstetric care.

Spotlight: Hunger in a Time of Motherhood
The 2011 famine crisis in the Horn of Africa placed even greater burden on women and girls already suffering malnutrition, stress and family trauma. Heightened health risks are compounded by the lack of awareness on public health provisions and the reluctance to use these available services.

International Medical Corps (IMC) tackled this problem by integrating MISP in their WASH programmes with the aim to improve quality and uptake of existing maternal health facilities. IMC also ensured these health facilities catered to the specific needs of adolescent girls, which is critically important because many women and girls marry extremely young; child marriage is leading to further complications during pregnancy as a result of underdeveloped reproductive organs.

By integrating sexual and reproductive health services within wider needs-based programmes, including primary health care, nutrition, and WASH, ensures more holistic approaches towards promoting effective and efficient health interventions.   

IMC strategy in Ethiopia provides an example of best practice in maternal health during disasters, which looks at developing four cores aspects of service provision during disasters:
     1. Stocking 48 government health facilities with medicines, supplies, and equipment; training health care workers at these facilities in maternal health with a focus on MISP implementation;
     2. Conducting maternal health education campaigns in these communities;
     3. Enhancing the capacity of community volunteers to provide health information to women and girls; and
     4. Providing stretchers to community volunteers to facilitate transport of mothers with complications from the community to health facilities.
     5. Providing mothers with clean delivery kits.

Additionally, IMC supports the national health ministries to strengthen existing public health systems and train community health workers to better respond to the wide range of health needs in their community and promote more timely intervention through active engagement with health services. In all, these comprehensive strategies provide better protection against the detrimental human, economic and social costs that follow maternal and newborn deaths. Together, communities become more resilient to prepare for and see through a disaster to build a safer, more care-driven future for mothers.

WHO, UNFPA and UNICEF have developed a list of priority medicines for mothers and children, which include medicines to prevent postpartum haemorrhage, high blood pressure and maternal sepsis. The Inter-Agency Reproductive Health Kits for Crisis Situations contains the drugs and supplies needed to implement comprehensive reproductive health services and MISP. This includes community-level and public health care-level supplies such as clean delivery packages and injectable contraception.   Mobile clinics have become a valuable asset capable of delivering priority medicines in remote areas during a disaster.

Save the Children’s State of the World’s Mothers 2015 report highlights five core recommendations for governments, NGOs, private sector and civil society to support effective accountability over maternal health interventions in disaster and ensure more women survive through childbirth:

  1. Ensure that every mother and newborn living in crisis has access to high quality health care.
  2. Invest in women and girls and ensure their protection.
  3. Build longer term resilience to minimize the damaging effects of crises on health
  4. Design emergency interventions with a longer term view and the specific needs of mothers and newborns in mind.
  5. Ensure political engagement and adequate financing, coordination and research around maternal and newborn health in crisis settings

Nepal After April 25th Earthquake
Nepal was once seen as one of the worst places to be a mother, ranking in the bottom 10 on Save the Children’s Mothers’ Index until 2005.  Communities continue to suffer through food insecurity alongside a multitude of natural disasters including droughts, floods and earthquakes. Despite these challenges, Nepal has since made impressive headways to reduce maternal mortality and morbidity so much so that pregnancy-related deaths have been cut by 78 percent, which is a massive reduction from 770 to 170 deaths per 100,000 live births.

Integral to Nepal’s success story comes down to a compressive effort to tackle the challenges through multiple avenues. This was seen through increasing funding for SRH services and scaling up evidence-based health interventions that have proven to work. Cash incentives also promoted wider access to medical services and encouraging girls’ education and support women’s livelihoods as supported survival gains. Large investment has gone into training skilled health attendants to educate communities on safe motherhood, child health, family planning, and providing referrals to hospitals in more complicated cases.

Overall this has reinforced the Nepal’s SRH system to be more resilient to the impact of disasters. The devastating earthquake on April 25th will set back maternal care progress substantially.  Reproductive health kits and dignity kits are in critical need as the risk to unborn children, pregnant women and mothers escalates: UNFPA has rushed through the delivery of kits to reach the 2 million women and girls at reproductive age, including the 126,000 pregnant women.

The foundational premise of these programmes, that of scaling up comprehensive maternal health care interventions during emergencies, apply just as much to resource-rich developed nations. The cases of Hurricane Katrina in 2005 and Hurricane Sandy that battered the northeast coast of the United States in 2012 clearly show that poor mothers and children face many challenges accessing resources for their maternal health needs within a wider public health framework that remains at best highly fragile and at worst fails to meet the needs of those most in need.  The stress of experiencing a hurricane and its aftermath complicates pregnancies exposing mothers to even greater risk. 

The immediacy of recognising maternal needs cannot be overemphasised. West Africa’s Ebola crisis shines a light on the continuing need to integrate maternal health provision into wider public health interventions to fight the disease. Ebola is one of the most deadiest diseases affecting humans, with a fatality rate of up to 90 percent. Even before the crisis, Sierra Leone had one of the highest maternal mortality rates in the worlds. UNFPA is continuing to supply reproductive kits for safe delivery, obstetric gloves, disinfectants and protective gear for health workers to prevent infection. The Ebola crisis has forced the humanitarian sector to evolve the way it responds to emergencies. With more protracted disasters taking place across the world, governments and the humanitarian sectors must ensure that responses extend to maternal care throughout the crisis.

In all, these measures help empower mothers to help and protect themselves and their children even in times of disasters. It will also help support the implementation of the post-2015 framework on DRR, which identifies national and community action for resilience to disasters.  SRH should be promoted as a fundamental component of primary health care pre-and post-disasters (WHO 2012) and must be expanded if we are to see a more sustained decline in maternal mortality. Mothers Day is an opportunity to reinforce the responsibility and duty of governments to provide a continuum of care to support women’s SRH needs.

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