Every minute a woman dies in pregnancy orchildbirth, over 500,000 every year. Andevery year over one million newborns diewithin their first 24 hours of life for lack
of quality care. Maternal mortality is the largesthealth inequity in the world, with 99 per cent ofdeaths occurring in developing countries–half ofthem in Africa. A woman in Niger faces a 1 in 7risk of dying during her lifetime from pregnancy-related causes, while a woman in Sweden has arisk of 1 in 17,400, a greater than one thousand-fold difference. No other health indicator illus-trates as starkly the global disparities in humandevelopment.
Though maternal mortality and morbidity con-tinue to be a major health problem in many parts ofthe world, notable progress has been achieved in over100 countries. Unfortunately, this progress has beenslow and unequal. During the 15-year period be-tween 1990 and 2005, Asia experienced a 20 percent reduction in maternal mortality ratio (MMR).During the same time period, MMR in sub-SaharanAfrica decreased a mere two per cent.
Fortunately, the vast majority of maternal andnewborn deaths can be prevented with proven in-terventions to ensure that every pregnancy is wantedand every birth is safe. Progress in many countrieshas led to a growing consensus in the maternal healthfield that reducing maternal and newborn mortalityand morbidity can be achieved by ensuring:
1) Access to family planning2) A skilled health professional present at ev-
ery delivery3) Access to emergency obstetric and newborn
care (EmONC), when needed
Mobilizing communities and governments tounderstand a woman’s right to these resources com-bined with efforts to eliminate financial, geographicand sociocultural barriers will allow universal ac-
cess to reproductive health and lead to a dramaticreduction in the number of maternal deaths.
On September 25th 2008, as world leadersgathered for the High-Level Event on the Millen-nium Development Goals (MDGs), the heads of theWorld Health Organization (WHO), the United Na-tions Population Fund (UNFPA),the United NationsChildren Fund (UNICEF) and the Vice-President ofHuman Development of the World Bank issued aJoint Statement on Maternal and Newborn Health –Accelerating Efforts to Save the Lives of Womenand Newborns (see Annex 2). The leaders jointlypledged to intensify their support to countries toachieve Millennium Development Goal 5, To ImproveMaternal Health, and the MDG showing the leastprogress:
During the next five years, we will enhancesupport to the countries with the highest mater-nal mortality. We will support countries instrengthening their health systems to achieve thetwo MDG 5 targets of reducing the maternal mor-tality ratio by 75 per cent and achieving univer-sal access to reproductive health by 2015. Ourjoint efforts will also contribute to achievingMDG 4 To Reduce Child Mortality.
We will work with governments and civil so-ciety to strengthen national capacity to:
Conduct needs assessments and ensure thathealth plans are MDG–driven and perfor-mance–basedCost national plans and rapidly mobilize re-quired resourcesScale-up quality health services to ensureuniversal access to reproductive health, es-pecially for family planning, skilled atten-dance at delivery and emergency obstetricand newborn care, ensuring linkages withHIV prevention and treatment
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Executive Summary
1
Address the urgent need for skilled healthworkers, particularly midwivesAddress financial barriers to access, espe-cially for the poorestTackle the root causes of maternal mortalityand morbidity, including gender inequality,low access to education–especially for girls–child marriage and adolescent pregnancyStrengthen monitoring and evaluation systems
In the countdown to 2015, we call on Mem-ber States to accelerate efforts for achieving re-productive, maternal and newborn health. To-gether we can achieve Millennium DevelopmentGoals 4 and 5.
As part of this effort, UNFPA, through the Ma-ternal Health Thematic Fund (MHTF), aims to boostprogress towards reducing maternal mortality andmorbidity by supporting countries in working withcivil society, the United Nations and other key part-ners to implement and scale up effective maternaland newborn health interventions as part of perfor-mance-driven national health plans and systems.
UNFPA aims to raise $500 million over fouryears for the MHTF, which will help save women’slives and prevent maternal morbidity such as ob-stetric fistula, one of the most devastating compli-cations of childbirth. While this amount representsless than 2 per cent of the $7-8 billion needed an-nually to improve maternal and newborn health,it is a significant effort intended to be catalytic inleveraging resources for maternal and newbornhealth services.
One of the fundamental principles underpinningthe work will be country-owned and country-drivendevelopment and support to the one national healthplan. The specific outputs and activities supportedby the MHTF in each country will be identified bythe government through a consultative process withkey partners and stakeholders and in close coordi-nation with UNFPA’s Global Programme on Repro-ductive Health Commodity Security and the Cam-paign to End Fistula.
In collaboration with government and key part-ners the MHTF will support:
1. An enhanced political and social environmentfor Maternal and Newborn Health (MNH) andSexual and Reproductive Health (SRH)
2. Up-to-date needs assessments for the SRHpackage with a particular focus on family plan-ning, human resources for MNH, and EmONC
3. National health plans focus on SRH, especiallyfamily planning and EmONC with strong RH/HIV linkages to achieve the health MDGs
4. National responses to the human resource crisisin MNH, with a focus on planning and scaling upof midwifery and other mid-level providers
5. National equity-driven scale-up of family plan-ning and EmONC services and maternal andnewborn health commodity security
6. Monitoring and results-based management ofnational MNH efforts
7. Leveraging of additional resources for MDG5from government and donors
A detailed results framework is presented, an-chored to MDG5 targets and indicators and toUNFPA’s Strategic Plan 2008-2011. This includesthe key outputs of UNFPA’s Midwifery Programme,now a central component of the MHTF.
The MHTF Results Framework is linked to twoother key UNFPA programmes and their respectiveresults frameworks:
The Global Programme on Reproductive HealthCommodity Security, UNFPA, 2008The Campaign to End Fistula, GlobalProgramme Proposal; Making MotherhoodSafer by Addressing Obstetric Fistula 2006-2010, UNFPA, 2006
UNFPA is currently examining how best to in-tegrate the work of its three health thematic funds—Maternal Health, Fistula, and the Global Programmeon Reproductive Health Commodity Security. Theresults framework for the MHTF is closely linked tothose of the other two thematic funds. While main-taining the focus on specific results, it is envisagedthat the thematic funds will move towards a jointcountry application, annual work-planning and re-porting process in 2009.
Resources required for the MHTF are esti-mated at $25M, $72M, $138M and $269M each yearfrom 2008 to 2011 respectively, for a total of $504Mover the period. At the time of this writing in early2009, the MHTF was in the process of supporting11 countries, and had raised a total of $25M includ-
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ing the resources for the Midwifery Programme.A management structure and processes for the
MHTF are presented, based on UNFPA thematicfund guidelines and closely coordinated with the otherthematic funds, all housed within its Technical Divi-sion. A Maternal Health Inter-Divisional WorkingGroup ensures strong representation from regionaloffices and other key units and meets regularly viateleconferencing.
The country-specific UNFPA outputs, activitiesand indicators will be prepared with the ministries ofhealth (MoH) in close consultation with WHO,UNICEF, the World Bank and other key partners.
At the global level, the work of UNFPA, in-cluding the work supported by its thematic funds,will be closely coordinated with WHO, UNICEF andthe World Bank through the UN-MNH Joint Sup-port to Countries.
A consolidated annual report will be preparedwith overall and country-specific results. This willalso include financial reporting on income and onthe use of resources.
Based on a solid review of the scientific evi-dence and the results of programmes in countrieswhich have tackled maternal mortality, we believethat much progress can be accomplished betweennow and 2015, with a community outreach andhealth systems approach of scaling-up familyplanning, skilled attendance at delivery and emer-gency obstetric care, so that every pregnancy iswanted and every birth is safe. We could thenenvisage, in a not too distant future, a world wherematernal mortality has been eliminated as a pub-lic health problem and where the burden of suf-fering from maternal morbidity has been reducedconsiderably.
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List of Abbreviations and Acronyms
AMDD Averting Maternal Death and Disability Program – Columbia University
AWP Annual work plan
EmONC Emergency obstetric and newborn care
FP Family planning
GAVI Global Alliance for Vaccines and Immunization
IHP+ International Health Partnership
HMIS Health management information system
ICM International Confederation of Midwives
ICPD International Conference on Population and Development
IMMPACT Initiative for Maternal Mortality Programme Assessment – University of Aberdeen
M&E Monitoring and evaluation
MDG Millennium Development Goal
MHTF Maternal Health Thematic Fund
MMR Maternal mortality ratio
MNH Maternal and newborn health
MoH Ministry of Health
MVA Manual vacuum aspiration
ODA Official Development Assistance
OFWG Obstetric Fistula Working Group
PMNCH Partnership for Maternal Newborn and Child Health
PMTCT Prevention of mother-to-child transmission (for HIV)
RHCS Reproductive health commodity security
Sida Swedish international development agency
SRH Sexual and reproductive health
SWAp Sector-wide approach
UNFPA United Nations Population Fund
UNICEF United Nations Children Fund
VCT Voluntary counselling and testing (for HIV)
WHO World Health Organization
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Executive Summary .................................................................................................................................................................... 1
Background and Strategic Vision .............................................................................................................................................. 6
1. The Goal, Vision and Mandate ............................................................................................................................ 6
2. Challenges ............................................................................................................................................................ 7
3. Opportunities ....................................................................................................................................................... 12
4. Building on the Momentum ................................................................................................................................. 17
The Business Plan .................................................................................................................................................................... 19
1. Overall Goal .......................................................................................................................................................... 19
2. Guiding Principles ................................................................................................................................................ 19
3. The Maternal Health Thematic Fund embedded in UNFPA’s Strategic Plan and Joint UN work on Maternal and Newborn Health ........................................................... 21
4. Supporting National Capacity Building ............................................................................................................. 21
5. The Maternal Health Thematic Fund Results Framework ............................................................................... 21
6. Budget .................................................................................................................................................................... 34
7. Management and Governance .............................................................................................................................. 35
8. Monitoring and Evaluation and Reporting ......................................................................................................... 36
9. Conclusion ............................................................................................................................................................. 36
Annexes ..................................................................................................................................................................................... 37
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Table of Contents
1. THE GOAL, VISION AND MANDATE
Together as a global community, we havecommitted ourselves to achieve the fifthMillennium Development Goal (MDG)–ToImprove Maternal Health–and to reduce
the maternal mortality ratio (MMR) by three quar-ters by 2015 from a 1990 baseline. This goal wasfurther strengthened in 2007 by the addition of a newtarget: Achieve, by 2015, universal access to re-productive health, enshrining in the Millennium De-velopment Goal framework what had been agreedto by Member States at the International Confer-ence on Population and Development (Box 1).
Making rapid progress towards this goal overthe coming years will enable us to envision a worldwhere maternal mortality has been eliminated asa public health problem and where women willenjoy their reproductive rights. As seen with somany public health successes, rapid progress canonly be achieved when the global community unitesunder one common vision and strategy. Such a vi-sion was recently announced by the Secretary-General for the elimination of malaria mortality.The same can be done for maternal health. Thetime is now to muster all of the world’s creativeenergies to address maternal mortality, the great-est health inequity in the world.
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Background and Strategic Vision
“Too many women die duringpregnancy and childbirth because
their right to sexual andreproductive health is denied.”
– Ban Ki-Moon, United nations Secretary-General November 2007
We have an in-depth understanding of the prob-lem and its causes. Progress has been made in wellover 100 countries by strengthening national healthsystems to ensure near universal access to highlycost-effective maternal health interventions. Withstrong political commitment and improved manage-ment of health systems, similar progress can be madein even the world’s poorest countries.
There is now unprecedented international com-mitment to make maternal health a global priority.The recent Women Deliver and Countdown to 2015conferences reaffirmed this international mandate,as well as the need for rapid progress to reach theMDG5 targets. On 22 July 2008, the heads of WHO,UNICEF, UNFPA and the Vice President of Hu-man Development of the World Bank pledged toaccelerate joint support to all high maternal mortal-ity countries. On 25 September they followed up onthis pledge and issued a Joint Statement on Mater-
[1] United Nations. Report of the Secretary-General on thework of the Organization. General Assembly. OfficialRecords. Sixty-second Session. Suppl No. 1 (A/62/1).October 2007.
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BOX 1.MILLENNIUM DEVELOPMENT GOAL 5 [1]
Targets and Indicators
Reduce maternal mortality ratio by three quar-ters, between 1990 and 2015
• Maternal mortality ratio• Proportion of births attended by skilled
health personnel
New Target: Achieve, by 2015, universal accessto reproductive health
• Adolescent birth rate• Antenatal care coverage (at least one visit
and at least four visits)• Unmet need for family planning• Contraceptive prevalence rate
nal and Newborn Health during a high level MDGevent (see Annex 2). This United Nations jointprogramme will provide enhanced support to 25countries before the end of 2009 and all 60 highmaternal mortality countries within five years.
WHY A THEMATIC FUND
FOR MATERNAL HEALTH?
MDG5 may well be the most challenging MillenniumDevelopment Goal to achieve. The link betweenprogress towards MDG5, newborn survival and childhealth (MDG4), and poverty reduction (MDG1) isinextricable. Improving maternal health is an ur-gent mandate that requires focused attention andsupport to save the lives of women, newborns andchildren.
In line with the UNFPA mission (Box 2) andStrategic Plan (2008-2011), the Executive Directorannounced the creation of a Maternal Health The-matic Fund (MHTF) at the Executive Board in Sep-tember 2007 as part of a much needed global move-ment. The MHTF, focusing on 60 high maternalmortality countries, will complement UNFPA’s coreresources which are used to cover 140 programmecountries and its entire mandate (population and de-velopment, gender and the whole of reproductivehealth).
Designed as a pro-poor, performance-based and MDG-driven mechanism, the MHTFwill provide more focused capacity develop-ment, technical assistance, financial resourcesand life-saving equipment, supplies and drugsto those countries in greatest need, and thusfurther contribute to achieving national results.
Such funding, in support of national health plansand integrated within UNFPA’s country programmesrather than as a separate funding mechanism, maycircumvent the need for a multitude of parallelprojects, and therefore reduce transaction costs forall concerned: donors, UNFPA, and most importantly,countries.
UNFPA foresees raising $500 million over thefour-year period from 2008 to 2011 for the MHTF.While this is not an insignificant sum, it representsonly two per cent of the funding required to achieveMDG5. WHO estimates that at least $6 billion a yearwill be needed to improve maternal health with anadded $1.5 billion annually to meet the unmet needfor family planning. Therefore, the MHTF is in-tended to be catalytic in leveraging major MDG5
resources by strengthening the capacity of nationalhealth systems to achieve results towards reducingmaternal mortality and morbidity. MDG5 will onlybe achieved with both a major effort by high mater-nal mortality countries, including the allocation of 15per cent of their national budget to health, and a sig-nificant increase in donor funding for maternal andnewborn health and health system strengthening. Asmaternal health is a litmus test for the functioning ofa health system, maternal health programmes shouldbe a priority entry point for health system strength-ening in the context of primary health care for ev-ery district and every community.
2. CHALLENGES
MATERNAL MORTALITY:THE GREATEST HEALTH INEQUALITY IN THE WORLD
Maternal mortality represents the greatest healthinequity in the world. No other health indicator asstarkly illustrates global disparities in human devel-opment. Each year more than 500,000 women dieduring pregnancy or childbirth–one every minute.Nearly all of these deaths occur in developing coun-tries with a greater than one thousand-fold differ-ence in lifetime risk between parts of Africa andmore industrialized countries. A woman in Nigerhas a 1 in 7 risk of dying from maternal causes ascompared to a 1 in 17,400 risk for a woman in Swe-den. Half of the maternal deaths that occur eachyear are in Africa–a continent which represents 11per cent of the world’s population.[2] It is no won-der that maternal and newborn mortality have re-mained so high when the time around delivery is such
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BOX 2. UNFPA’S MISSION
UNFPA, the United Nations Population Fund, is aninternational development agency that promotes theright of every woman, man and child to enjoy a life ofhealth and equal opportunity. UNFPA supports coun-tr ies in using populat ion data for pol icies andprogrammes to reduce poverty and to ensure thatevery pregnancy is wanted, every birth is safe, everyyoung person is free of HIV/AIDS, and every girl andwoman is treated with dignity and respect.
[2] Maternal Mortality in 2005: Estimates developed by WHO,UNICEF, UNFPA and The World Bank. October 2007.Geneva. WHO.
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[1] Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank. October 2007. Geneva.WHO.
[2] Round II Country Reports on Health, Nutrition, and Population Conditions Among the Poor and the Better-Off in 56Countries. 2004. Washington, D.C. the World Bank.
[5] Measuring Maternal Mortality. Challenges, Solutions, and Next Steps. Impact. Population Reference Bureau. February 2007.http://www.prb.org/pdf07/MeasuringMaternalMortality.pdf. Accessed 4 June 2008.
[6] Murray C and Lopez A (1998). Health Dimensions of Sex and Reproduction. Geneva. WHO.[7] State of the World’s Children 2008: Child Survival. December 2007. UNICEF.
BOX 3. RISK OF MORTALITY AND COVERAGE
The graph shows estimates of carecoverage for the 51 most indebtedcountries along a continuum frompregnancy through to birth and thecare of the child through newborncare, breastfeeding and immunisation.Superimposed is an illustrative dia-gram of the risk of mortality formothers and children loosely basedon Demographic and Health surveysand selected studies. The diagramshows that health care is accessedleast where the risks are highest forwomen and their babies–at the timeof birth.
a risky period for both mother and newborn and whencoverage of health interventions has remained so low(Box 3).
Though maternal mortality and morbidity con-tinue to be a major health problem in many parts ofthe world, notable progress has been achieved in over100 countries. Unfortunately, this progress has beenslow and unequal. During the 15-year period be-tween 1990 and 2005, Asia experienced a 20 percent reduction in MMR. During the same time pe-riod MMR in sub-Saharan Africa decreased a meretwo per cent.[3]
Poor women often lack access to the life sav-ing interventions provided by skilled health person-nel (emergency obstetric and newborn care). Fig-ure 1 shows the tremendous difference in the pro-portion of births attended by skilled personnel amongthe poorest and richest wealth quintiles in six devel-oping countries. In countries such as Ethiopia,
Bangladesh and Mauritania the proportion of womengiving birth with a skilled attendant in the highestwealth quintiles is between 7 and 25 times greatercompared to those in the poorest wealth quintiles.[4]
As can be seen in Figure 2, women in the poor-est quintile may have more than double the risk ofmaternal death when compared to the wealthiestquintile.[5]
For each woman who dies during pregnancyor delivery, there are many more who suffer com-plications resulting in disability. An estimated twomillion women and girls around the world are livingwith obstetric fistula, a devastating, and potentiallylifelong injury, caused by prolonged, obstructedlabour.[6] When mothers die or face serious illness,their children suffer; over one million newborns andchildren die each year because of poor maternal andneonatal health services.[7]
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FIGURE 1. BIRTHS ATTENDED BY SKILLED PERSONNEL* AMONG THE POOREST AND RICHEST WOMEN
FIGURE 2. MATERNAL DEATHS BY
SELECTED WEALTH QUINTILES
* Defined to include a doctor, nurse or trained midwife.Source: World Bank, 2004, Round II Country Reports on Health, Nutrition, and Population Conditions Amongthe Poor and the Better-Off in 56 Countries.
FEW CAUSES ACCOUNT FOR THE MAJORITY OF
MATERNAL MORTALITY
Figure 3 shows that a small number of direct causesaccount for around 80 percent of maternaldeaths.[8] Fortunately, we have cost-effectiveand proven interventions for each of these causes.
Other contributing causes of maternal mor-tality include malnutrition, HIV, malaria and vio-lence against women. All of these factors arelinked to larger health determinants including gen-der inequality, poverty and low education level,and when combined can have catastrophic re-sults. Cultural norms and religious beliefs mayalso interact with socio-economic status and gen-der to restrict a woman’s access and right to thefull continuum of reproductive and sexual healthservices including maternal health services, as dis-cussed below.
[8] The World Health Report 2005: Make every mother andchild count. 2005. Geneva. World Health Organization.
MATERNAL MORBIDITY: OFTEN SEVERE,LONG-LASTING WITH HIGH BURDEN OF SUFFERING
Maternal morbidity affects millions of women eachyear often with severe and long-lasting physical andmental suffering. In 2003, UNFPA and partnerslaunched a global Campaign to End Fistula with thegoal of making obstetric fistula as rare in developingcountries as it is in the industrialized world. Thereader is referred to the website of this highly suc-cessful campaign.[9]
Complications of unsafe abortion leavewomen with long-lasting problems such as infer-tility. Perinatal depression is another severe, andoften neglected, pregnancy related condition re-sponsible for high numbers of suicides and dis-ability in many countries.[10]
GENDER AND SOCIO-CULTURAL
NORMS AND PRACTICES
Maternal mortality and morbidity are, at their core,a consequence of gender inequality and health ineq-uity. Data from national surveys reveal that accessto maternal health services is highly inequitable, with
[9] www.endfistula.org[ 1 0 ] UNFPA Emerging Issues: Mental, Sexual and Reproduc-
tive Health. 2008. UNFPA.
FIGURE 3. DIRECT CAUSES OF MATERNAL MORTALITYthe lowest socio-economic quintiles andrural populations having the least ac-cess. Other marginalized groups, suchas adolescents, minorities and indig-enous groups, face similar barriers toaccess. Gender inequality further con-tributes to poor maternal health on vari-ous levels from the prioritization ofwomen’s health by governments intheir health plans and budgets to gen-der norms within villages and commu-nities. Women, and particularly poorwomen, are often unable to access carebecause they lack the decision-makingpower, the financial resources, and theempowerment to obtain a full range ofreproductive health services and infor-mation, including family planning,skilled attendance at birth and emer-gency obstetric care.
Cultural norms and practices mayseverely restrict or enhance maternalhealth. The perceptions of health and
risks during pregnancy, birth and the postpartum/newborn period strongly influence both health-seek-ing behaviour and appreciation of the quality of theavailable services. For adolescents in particular, highlevels of maternal mortality and morbidity stem fromgender norms that force them into child marriageand to drop out of school, and deprive them of basicknowledge and decision-making about reproductivehealth, as discussed further below. Meeting the chal-lenge of MDG5 will rely heavily on efforts to re-duce health and gender disparities and improve ac-cess to primary and secondary education for girls.
ADOLESCENTS
Pregnancy and childbirth-related deaths are the num-ber one killers of 15-19 year old girls worldwide.Each year, nearly 70,000 die. At least two millionmore are left with chronic illness or disabilities thatmay bring them life-long suffering, shame and aban-donment. Pregnancy rates among adolescents arehigh in many countries, particularly among the poor(see Figure 4). In 2004 in Niger, for example, 72per cent of adolescents in the poorest quintile hadgiven birth by age 18, compared to 39 per cent inthe richest quintile. High fertility rates among ado-lescents are associated with higher maternal mor-tality due to complications from pregnancy and de-
*Total is more than 100% due to roundingSource: The World Health Report 2005, WHO
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FIGURE 4. CHILDBEARING AMONG THE POOREST AND RICHEST ADOLESCENTS
livery as well as from unsafe abortions. Adolescentgirls are twice as likely to die during pregnancy orchildbirth as women in their 20s. For those under15, the risks are five times higher.
In many countries girls are married at a youngage, often against their will, and are expected to havechildren soon after to prove their fertility. Globally,the overwhelming majority of adolescents who be-come pregnant are married. Married adolescent girlsoften lack awareness of their rights and have lim-ited access to family planning. Unmarried adoles-cent girls face a different set of challenges. Theyare more likely than married girls to suffer unplanned,financially unsupported and socially unsanctionedpregnancies. An unmarried adolescent mother mayface the social stigma of single motherhood and lackthe financial means to take care of herself and herchild. Adolescent girls confronted with unplannedpregnancy are more likely to resort to unsafe abor-tions than older women.
Both married and unmarried pregnant adoles-cents are likely to face poverty, ill health and abuse,and to have frequent pregnancies, engage in unpro-tected sex carrying HIV risk, lack education and havefew positive life options. Their children are more
likely than those of older mothers to be malnour-ished and have developmental problems. One mil-lion babies born to adolescent mothers will not makeit to their first birthday. Several hundred thousandmore will be dead by age five.[11]
HIV/AIDS
Around 2.2 million HIV positive women give birthevery year.[12] In areas of high prevalence, HIV isthe cause of a significant number of maternal deaths.In a scientifically robust cohort study in rural RakaiDistrict, Uganda, the MMR was 5.4 times greaterin HIV-positive women as compared to HIV-nega-tive women.[13]
The HIV/AIDS epidemic is increasingly moreprominent among women; over 60 per cent of peopleliving with HIV in sub-Saharan Africa are women.HIV and AIDS have also had a devastating effecton health systems in many high prevalence coun-tries by depleting the health workforce. In theseareas, women are less likely to be accompanied bya skilled attendant at the time of delivery leading toan increased risk of maternal death or disability.
Source: Rani, M. and E. Lule, 2004, “Exploring the Socioeconomic Dimension of Adolescent Repro-ductive Health: A Multicountry Analysis” International Family Planning Perspectives 30 (3): 112.
[11 ] Giving Girls Today and Tomorrow: Breaking the Cycle of Adolescent Pregnancy. UNFPA. 2007[ 1 2 ] WHO, World Health Report, 2005[ 1 3 ] Sewankambo NK et al. Mortality associated with HIV infection in rural Rakai District, Uganda. AIDS, 2000, 14:2391-2400.
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FIGURE 5. NUMBER OF YEARS TO HALVE MATERNAL MORTALITY, SELECTED COUNTRIES
3. OPPORTUNITIES
PROVEN INTERVENTIONS
Fortunately, the vast majority of maternal and new-born deaths can be prevented with proven, highlycost-effective interventions to ensure that every preg-nancy is wanted and that every birth is safe. First,we must tackle the root causes of maternal mortal-ity, including gender inequality, low access to edu-cation—especially for girls—child marriage and ado-lescent pregnancy. Many countries with limited re-sources have been able to reduce maternal mortal-ity by half in less than 10 years (see Figure 5).Progress in these countries has led to a growingconsensus in the global health community on threesets of interventions most effective in reducing ma-ternal mortality and morbidity:
1) universal access to family planning2) a skilled health professional present at ev-
ery delivery3) access to emergency obstetric and newborn
care, when needed
Working towards the elimination of financial, geo-graphic and sociocultural barriers will allow universalaccess to these interventions. Community mobilizationand communication for social change will empowerindividuals to demand services and enhance politicalsupport. In successful countries, this increased demandtogether with universal access has resulted in high uti-lization and thus rapid declines in maternal mortality.
Source: The World Health Report 2005, WHO
Family planning
World leaders reaffirmed their commitment to achiev-ing universal access to reproductive health at the WorldSummit in 2005. Despite these renewed pledges, anestimated 137 million women around the world still hadan unmet need for contraception in 2008.[14] In sub-Saharan Africa, the proportion of married women us-ing modern family planning–the contraceptive preva-lence rate–remains under 20 per cent while unmet needstands at 27 per cent.[15] Despite declines in globalfertility, lack of access to resources and informationabout family planning, particularly among adolescents,has contributed to total fertility rates of more than 5children per woman in over 30 countries is sub-Sa-haran Africa. In Gambia, 1 in 5 adolescent girls (aged15-19) becomes pregnant compared to 1 in 140 ado-lescent girls in Sweden.[16] Meeting the need for fam-ily planning could reduce maternal mortality by at least33 per cent.[17]
The recent adoption of a new MDG5 target—to achieve universal access to reproductive health—recognizes the importance of family planning in improv-ing maternal health as part of the greater sexual andreproductive health continuum. Empowering womenwith the resources they need to exercise their right toplan the number of children they have will signifi-cantly reduce the number of unintended pregnan-cies and unsafe abortions. Meeting the unmet needfor family planning will thus have a profound impacton a woman’s risk of dying from pregnancy-relatedcomplications over the course of her lifetime.
[ 1 4 ] Guttmacher Institute, UNFPA. Contraception: An Investment in Lives, Health and Development. November 2008.[ 1 5 ] UNFPA – UN Population Division 2008.[ 1 6 ] Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and The World Bank. October 2007. Geneva. WHO.[ 1 7 ] UNFPA 2007.
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It will be important to insure a judicious mix offamily planning policies, advocacy and communica-tion, client education and quality service delivery toensure optimal impact with available resources.
To help meet the unmet need for family plan-ning, particularly in isolated rural areas, many coun-tries have enlisted community health workers to pro-vide basic primary care including family planningeducation and services at the community level. Forexample, the Government of Ethiopia has decidedto accelerate its successful community health workerprogram to cover the entire country by 2009. TheHealth Extension Program is working towards uni-versal access to primary care through the trainingand deployment of over 30,000 health extensionworkers to deliver services at the community level.For the first time in Ethiopia’s history, every com-munity should have access to family planning infor-mation, education and services.
A skilled health professional present at everydelivery: towards quality facility-based deliveries
Prevention of death and disability during labour anddelivery is greatly increased by the presence of askilled health professional. Life threatening compli-cations occur in around 15 per cent of deliveries andcannot be predicted. In regions with high maternalmortality and morbidity, such as sub-Saharan Africaand Asia, the proportion of births attended to by a skilledprofessional are as low as 47 and 61 per cent, respec-tively. In the least developed nations in Eastern Af-rica, only 34 per cent of women give birth with the helpof a skilled attendant.[18] These proportions fall signifi-cantly short of the ICPD+5 target of 85 per cent by2010, and are thought to be overestimates due tomethodological problems in determining the skill levelof birth attendants as well as their lack of suppliesand/or an enabling environment.[19]
Countries face serious challenges in ensuringskilled attendance at birth due to major global short-ages in the health workforce and in particular, mid-wives. Midwives have an essential role in providingnormal pregnancy, delivery and post-partum care;in managing complications and providing basic emer-gency obstetric and newborn care; and in referringwomen, when needed, for comprehensive emergencyobstetric newborn care (EmONC).
These human resource challenges are com-pounded by poor training, unequal geographic distri-bution and decreasing retention of health profession-als. The Global Health Workforce Alliance estimates
the deficit of trained health providers to be over fourmillion in 57 countries.[20] In Afghanistan, a countrywith one of the highest MMR, there were less than500 midwives in the entire country in 2002.[21] In manycountries shortages are increasing due to “brain drain”caused by skilled health-care providers leaving theircountries to seek more advantageous opportunitieselsewhere. Health workforce shortages have also beenexacerbated by the death and illness of many pro-fessionals due to AIDS.
In 2007, WHO developed global recommenda-tions for task-shifting to create more effective healthsystems through the redistribution of tasks amonghealth-workers. By allocating tasks to health pro-fessionals with less training and fewer qualificationsthrough standardized protocols, facilities can moreoptimally use existing human resources to improveservice delivery.[22] If health providers work in teamsand are effectively supervised, task-shifting can helpto relieve overburdened health systems and rapidlyimprove coverage. To this end, great emphasis has beenplaced on the need to scale up the training and deploy-ment of non-physician providers, such as midwives andsurgical technicians. Several countries have developednational human resource strategies to increase the num-ber of mid-level providers and improve their retention,particularly in more isolated, rural areas. These pro-viders are essential to increasing coverage of familyplanning services and EmONC, through direct pro-vision or through referral systems, as is the casewith comprehensive EmONC.[23], [24], [25]
Given the importance of the issue of skilled healthprofessionals for maternal health and in particular mid-wives, UNFPA has developed the Midwives Pro-gramme (See Box on Midwives Programme next page).
[ 1 8 ] Proportion of births attended by a skilled attendant- 2008updates. WHO Factsheet. Department of ReproductiveHealth and Research.
[ 1 9 ] Ibid.[ 2 0 ] The World Health Report 2006- Working together for
health. 2006. Geneva, World Health Organization.[ 2 1 ] Ronsman C, Graham WJ. Maternal mortality: who, when,
where, and why. Lancet 2007;368:1189-200.[ 2 2 ] Task Shifting: Global Recommendations and Guidelines.
World Health Organization 2007.[ 2 3 ] Freedman et al. Practical lessons from global safe moth-
erhood initiatives: time for a new focus on implementa-tion. Lancet 2007; 370: 1383-1391.
[ 2 4 ] Global Health Workforce Alliance Forum, Kampala, 2008.www.ghwa.org.
[ 2 5 ] Global Health Workforce Alliance and Health Systems forEquity Project. Report of a meeting. London 10 November2008 (forthcoming).
13
THE MIDWIVES PROGRAMME
Jointly implemented by UNFPA and the International Confederation of Midwives (ICM), the MidwivesProgramme was officially launched in April 2008 with the slogan “The world needs midwives now more thanever to save the lives of mothers and babies”. It was conceived as UNFPA’s response to the growing need forhuman resources for health in many countries. UNFPA chose to focus on midwives as they are a keycomponent to reducing maternal and newborn deaths and are in critical demand in most high maternalmortality countries.
The Midwives Programme calls for a global effort to promote the work and role of midwives and others withmidwifery skills in order to accelerate progress towards MDG5. The Programme is aligned with the ICPDagenda and the international call for investing in sexual and reproductive health and rights. The aim is todevelop national capacity in high maternal mortality countries, ensuring skilled attendance at all births.Increasing the number and capacity of midwives will also contribute to the other health MDGs: reducingneonatal mortality (MDG4), promoting gender equality and empowering women (MDG3) and combating HIV/AIDS, malaria and other diseases (MDG6).
With initial funding received from Sida in 2008, support was provided to an initial group of 11 high prioritycountries through the posting of national midwife advisors in each country who are supervised by regionalmidwife advisers. An international UNFPA Programme Coordinator and an international ICM Midwife Adviserwere also brought on board to coordinate the global efforts of the two partners—UNFPA and ICM. Thecountries involved in this first wave are in Francophone Africa (Benin, Burkina Faso, Burundi, Côte d’Ivoire,Madagascar), in Anglophone Africa (Ethiopia, Ghana, Uganda, Zambia) and in the Arab region (Djibouti andSudan). UNFPA country offices in Haiti and Cambodia have also initiated midwifery activities.
The Midwives Programme aims at building a critical mass of midwife advisers in all regions who will leadcountry level efforts in capacity building on four focus areas: strengthening regulatory mechanisms; devel-oping/strengthening education and accreditation mechanisms; promoting the development of midwiferyassociations and promotion of midwives as a key health workforce for the achievement of MDGs 4 and 5.These advisers will also have the necessary capacity to participate in policy level discussions and deci-sions concerning maternal and reproductive health. Working in full coordination with the ministries of healthand national training institutions, the advisers will receive technical support from international and regionalmidwifery schools or universities, as well as from international training programmes.
The Programme is initially planned for three years and aims at addressing at least 20-25 priority countriesthat will also be supported under the Maternal Health Thematic Fund. The two programmes will thus harmo-nize with aligned financial flows, monitoring frameworks and reporting procedures. This will create syner-gies with the three key pillars of safe motherhood (family planning, skilled attendance at birth and emer-gency obstetric care) and ensure a concerted response in addressing maternal mortality and morbidity andneonatal survival.
Emergency Obstetric and Newborn Care(EmONC)
Basic and comprehensive EmONC represent a setof interventions that address each of the directcauses of maternal death. The term has been broad-ened recently to include life-saving newborn caresuch as newborn resuscitation (Figure 6).
Access to basic and comprehensive EmONCgreatly increases a woman’s chance of survival dur-ing childbirth. Lack of access to simple interven-tions such as oxytocics to prevent or treathaemorrhage or antibiotics to treat infection often
leads to death or severe disability. Many countrieslack the health infrastructure to provide emergencycare to women, particularly poorer women andwomen living in isolated, rural areas.
Even in areas where adequate basic and com-prehensive EmONC facilities exist, significant bar-riers prevent women from reaching facilities or re-ceiving care upon arrival. The three major delays inobtaining EmONC are a delay in 1) deciding to seekcare 2) identifying and reaching a medical facilityand 3) receiving adequate and appropriate treatment.Many factors influence the delays at each stage ina woman’s path to obtaining EmONC (Figure 7).
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In Primary Health Care Facility
Basic EmONC
• Antibiotics IV• Oxytocics IV• Anticonvulsivant• Manual removal of placenta• Post abortion care (MVA)• Assisted vaginal delivery (vacuum extraction)• Newborn care
In District Hospital
Comprehensive EmONC
All Basic EmONC +
• Surgery (caesarean section)• Blood transfustion• Care to sick and low birth weight
newborns
FIGURE 6. EMERGENCY OBSTETRIC AND NEWBORN CARE
Women often fail to recognize labour complications;they may not have the means for timely transporta-tion to facilities or the money to afford quality careonce they have arrived; and the cost of EmONCcan be catastrophic for households.[26] Preventingdelays in obtaining EmONC can only occur whensolid health infrastructure is combined with outreachand education as part of a functioning national healthsystem.
There is now universal agreement that coun-tries should move as rapidly as possible to ensurethat every woman has access to a quality, facility-based delivery:
“The advantages of facility-based deliver-ies–both from a technical perspective andfrom systematic analysis of mothers’ expe-riences–are many. They enable teamwork,so that midwives can attend far more birthsthan if would be possible in home deliver-ies. They also enable non-professionals, suchas assistants and auxiliaries, to help, mak-ing care more cost-effective. This allows asingle midwife to attend up to 220 deliveriesper year, compared with less than 100 for asingle-handed midwife visiting mothers athome. In addition, the mixture of profession-als in a facility means that life-saving emer-gency care can be given quickly. Skilled care
[ 2 6 ] Renaudin P, Prual A, Vangeenderhuysen C et al. Ensuring financial access to emergency obstetric care: Three years ofexperience with Obstetric Risk Insurance in Nouakchott, Mauritania. Int J of Gynecol and Obstet (2007), doi: 10.1016/j.ijgo.2007.07.006.
[ 2 7 ] The Global Campaign for the Health Millennium Development Goals. First year report 2008. Published by the Office of thePrime Minister of Norway, Oslo, September 2008.
at facilities also ensures safety, cleanlinessand the availability of supplies. Other workcan be performed, and referrals are easier,as is emergency transport.”
— Margaret Chan, Director General, WHO[27]
UNFPA’s Campaign to End Fistula is intendedto address the devastating childbearing injury causedby prolonged obstructed labour (See box on the Cam-paign to End Fistula next page).
FIGURE 7. THE “THREE DELAYS” FRAMEWORK
Source: UNFPA Website: http://www.unfpa.org/ mothers/obstetric.htm
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THE CAMPAIGN TO END FISTULA
Obstetric fistula is a devastating childbearing injury caused by prolonged, obstructed labour that is unre-lieved by medical intervention. Women with fistula constantly leak urine and/or faeces and suffer life shatter-ing consequences—the baby usually dies and the smell associated with fistula combined with misperceptionsabout the condition often causes women to be stigmatized within their communities and abandoned by theirhusbands. Left untreated, fistula can lead to medical problems such as bladder infections, painful genitalulcerations, kidney failure and infertility. This physical and emotional suffering is frequently accompanied bya loss of financial support and inability to work.
It is estimated that at least two million women are currently living with obstetric fistula and 50,000 to 100,000more are affected each year—almost all in sub-Saharan Africa and parts of Asia and the Arab World.1, 2 Thechronic incidence of obstetric fistula in low-resource settings highlights the enormous disparities in mater-nal health care between the developed and the developing world. The women affected are among the mostmarginalized—young, poor, illiterate and rural—and as a result, they have remained invisible and the issuehas been largely neglected.
Fortunately, the means to prevent and treat fistula are well understood. Prevention is the ultimate goal,through universal access to high quality and accessible maternal health care services, including familyplanning, skilled birth attendance and emergency obstetric care, particularly caesarean section. Recon-structive surgery can mend the injury, and with comprehensive care to address the social consequences,most women can resume full and productive lives.
As part of its commitment to universal access to reproductive health, UNFPA launched a global Campaign toEnd Fistula with partners in 2003 aiming to prevent and treat fistula and to rehabilitate and empower womenafter treatment. The Campaign has grown from 12 countries to over 45 countries in Africa, Asia and the ArabStates. The Campaign has helped to spotlight the need to reduce morbidity as well as mortality in order toimprove maternal health. In addition, a focus on fistula has contributed to promoting equitable access tomaternal health care that responds to women’s needs. The target for achieving fistula elimination is 2015, in linewith ICPD and MDG targets.
Significant progress is being made toward this goal, as shown by some of the following results to date:• Thirty-six countries have now assessed the national need to address fistula• At least 16 countries have integrated fistula in relevant national health policies and plans• More than 7,800 women have received fistula treatment 3
The Campaign to End Fistula emphasizes coordination and partnership building. Global efforts to eliminatefistula are coordinated among partners via the international Obstetric Fistula Working Group (OFWG), forwhich UNFPA serves as the Secretariat. Established in 2003, the group is comprised of approximately 25institutional members including international and regional NGOs, universities, health facilities and UnitedNations agencies. While UNFPA and partners provide support, the Campaign emphasizes locally-drivensolutions and South-South collaboration, addressing communities' awareness of fistula and women's ac-cess to care and building on existing capacities.
The voices of women who have lived with fistula are joining the global call to urgently make maternal healthcare accessible and affordable for all. In recognition of the unique perspective fistula survivors lend to thematernal health dialogue, UNFPA sponsored the first-ever fistula advocate delegation to attend the WomenDeliver Conference in 2007. Following the conference, countries engaged in the Campaign have also begunefforts to create platforms for women to engage in dialogue at community and national levels for the reduc-tion of maternal mortality and morbidity.
The Campaign has made remarkable progress, but the needs are great. Ending fistula worldwide will demandpolitical will, resources and strengthened collaboration between governments, civil society and health professionals.Support for governments’ efforts to improve maternal health, including the Campaign to End Fistula, can helpbring the world closer to the day when safe and healthy childbirth is a reality for all women, not just the lucky few.
[1] Wall, L. 2006. “Obstetric Vesicovaginal fistula as an international public-health problem.” The Lancet 368 (9542):1201-1209.
[2] Abou Zahr, C (2003). “Global Burden of Maternal Death and Disability,” British Medical Bulletin 67 (1).[3] Treatment services supported by UNFPA may have also received support from governments and other partners.
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Scaling-up coverage of effective interventionsthrough MDG-driven, performance-basedhealth systems strengthening
Maternal mortality is increasingly accepted as a lit-mus test of a functioning health system. Strong na-tional health systems are necessary for makingprogress towards MDG5 and the other health MDGs.To achieve universal access to the interventionsneeded to prevent maternal death, national healthsystems must be strengthened to improve overallfunctioning, coverage and quality. Investments inmaternal health must be fully integrated into, and inline with national strategies, plans and budgets asthey relate to health systems and services. Initia-tives must support country-led processes that bringtogether important stakeholders to develop, cost andimplement national plans and strategies for improv-ing maternal health services within a larger healthsystems framework.
WHO has identified six building blocks of thehealth system: service delivery; health workforce;information; medical products, vaccines and tech-nologies; financing; and leadership and governance(stewardship).[28] Identifying the problems andbottlenecks within each building block will help coun-tries identify and prioritize areas within the healthsystem that need support to improve maternal sur-vival. Improving the national health system to de-liver quality care to all will allow women more regu-lar access to medical services. More regular in-teractions with the health system—including pre-and postnatal visits—will also allow women con-sistent support for family planning, preventing un-wanted pregnancies and diminishing the unmet needfor contraception.
Investments in maternal health will also con-tribute to the building of health systems better ableto respond to all medical needs and emergencies,not just those faced in pregnancy and childbirth. Thestrengthening of health systems at the national, dis-trict and community levels to expand coverage willcontribute to sustainable improvements in health atthe population level. For example, the sound func-
tioning of a primary health centre will contribute tothe reduction of child mortality from severe disease(pneumonia, diarrhoea, malaria). The availability ofsurgery, anesthesia and a blood bank made avail-able for maternal health in the district hospital willcontribute to much improved survival rates fromsevere injuries or other urgent surgical conditions.
Costs and financial resources required
In developing countries, it costs approximately $50to ensure a safe pregnancy and delivery, protectingthe life of the mother and newborn child. This cor-responds to about $3 to $4 per capita annually.[29] Arecent review of estimates has calculated that in 51aid-dependent countries, these services will costaround $2.4 billion in 2009, increasing to $7 billionby 2015 plus an estimated $1 to $1.5 billion annuallyfor family planning services.[30]
With an increase in the share of governmentexpenditures for health by developing countries to-wards the 15 per cent target and increased develop-ment assistance by OECD countries towards 0.7 percent of GNI by 2015, this financial target can bereached.
4. BUILDING ON THE MOMENTUM
A positive momentum is building around MDG5 asinternational organizations are joining forces. ThePartnership for Maternal Newborn and Child Health(PMNCH) has helped to ensure that maternal healthreceives a far greater priority in the global healthagenda.
Several major international conferences havetaken place in the last year, bringing together gov-ernment leaders, ministry of health officials, NGOsand civil society. The landmark Women Deliver Con-ference in London in October 2007 convened over1,800 participants from 109 countries to mark the20th anniversary of the Safe Motherhood Initiative.The Statement from the Ministers’ Forum and the
[ 2 8 ] Everybody's Business: Strengthening health systems to improve health outcomes: WHO's framework for action. WorldHealth Organization. 2007.
[ 2 9 ] Graham WJ, Cairns J, Bhattacharya S, Bullough CHW, Quayyum ZQ, Rogo K. Maternal and Perinatal Conditions. Chapter26 in Disease Control Priorities in Developing Countries. Second Edition. Oxford University Press and The World Bank2007.
[ 3 0 ] The Global Campaign for the Health Millennium Development Goals. First year report 2008. Published by the Office of thePrime Minister of Norway, Oslo, September 2008.
17
call from the participants put forth a renewed com-mitment to improving maternal health.[31] Sixmonths later the Countdown to 2015 Conferencebrought together important members of the globalhealth community to track progress on the maternaland child health MDGs and to commit to a call forfuture action.[32]
Following these conferences, United NationsSecretary General Ban Ki-moon declared in May2008 that the world’s maternal death rates are “un-acceptable” and that strengthening national healthsystems is key to improving them. The G8, at their2008 summit in Japan, committed to greater effortsin support of reproductive, maternal and child health.
The Global Campaign for the Health MDGs,which started in 2007, has already received signifi-cant commitments, including Norway’s pledge of $1billion for maternal, newborn and child health overthe next 10 years and Canada’s contribution to theUNICEF Catalytic Initiative to save a million lives.The United Kingdom is also playing a prominent role.In September 2007, Prime Minister Gordon Brownconvened leaders in London to create an Interna-tional Health Partnership to support developing coun-tries in strengthening their national health systemsto achieve the health MDGs. The Prime Minister’s
wife, Sarah Brown, is working closely with the WhiteRibbon Alliance on a maternal mortality campaigncalling for $10 billion annually for maternal new-born and child health, as well as increases in thenumber of trained health workers. Recently theBill & Melinda Gates Foundation convened a ma-ternal health task force, with support fromEngenderHealth.
The heads of the eight global agencies work-ing in health meet regularly to discuss how to fur-ther strengthen their contribution to progress in glo-bal health and how to better support countries. Thisgroup, known as the H8, comprises WHO, UNICEF,UNFPA, the World Bank, UNAIDS, The GlobalFund, the GAVI Alliance and the Bill & MelindaGates Foundation. As part of this effort towardsalignment and harmonization, WHO, UNICEF,UNFPA and the World Bank are increasingly pro-viding joint support to countries as they work towardsimproving maternal and newborn health (Annex 2).
Based on the principles of the Paris Declara-tion and of national ownership, this work must leadto coordinated country support to the one MDG-driven, results-based national health plan, withpredictable, progressively increasing and sustainedfinancing.
[ 3 1 ] http://2007.womendeliver.org/closing/pdf/WD_Ministers_Statement_English_FINAL.pdf[ 3 2 ] http://www.countdown2015mnch.org/
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The Business Plan
1. OVERALL GOAL
The MHTF aims to boost support to high maternalmortality countries to reduce maternal mortality andmorbidity.
2. GUIDING PRINCIPLES
#1. Maternal and reproductive health as ahuman right and as key to addressing genderequality
The World Health Organization states in itsconstitution, “the enjoyment of the highest attainablestandard of health is one of the fundamental rightsof every human being...” and that every country inthe world recognizes at least one treaty that includeshuman rights related to health.[33]
The rights-based approach to public health anddevelopment work is increasingly promoted by in-ternational health organizations, translating thesefundamental rights into quantitative measures ofaccess, coverage and ultimately impact: survival andreduction of morbidity. The right to reproductiveand maternal health underlies the ICPD Programmeof Action and Millennium Development Goal 5, asexpressed in the target universal access to repro-ductive health.
Working to ensure that every pregnancy iswanted and that every birth is safe promotes genderequality, as maternal mortality is the greatest healthinequity in the world.
The work of UNFPA’s MHTF is driven by thefundamental right to safe pregnancy and childbirthfor every woman, regardless of socio-economic sta-tus, geographic location, cultural or religious beliefs.Support to countries will assist in expanding the cov-erage of family planning and maternal health ser-vices to increase access for vulnerable andmarginalized populations such as adolescent girls,women living in rural areas, persons with disabilities
and members of ethnic minorities. By focusing onthe countries with the highest maternal mortality andby combining national capacity building, the provisionof reproductive health and maternal health commodi-ties as well as catalytic funding, the MHTF is able tocontribute to maternal survival where it is needed most.
The strategies and outputs of the MHTF aredrawn from–and align with–UNFPA’s Strategic Plan2008-2011 and UNFPA’s Sexual and ReproductiveHealth Framework as part of the support for theprovision of a basic package of SRH services, in-cluding family planning, pregnancy-related services,skilled attendance at delivery and emergency ob-stetric care.[34]
The MHTF will address high adolescent fertil-ity, and therefore will contribute to UNFPA’s focuson young people. Meeting the unmet need for fam-ily planning will also address high and unwanted fer-tility which is the root of inter-generational trans-mission of poverty. Meeting this need will improvequality of life and contribute to sustainable humandevelopment.
The work of the MHTF is also guided by therecognition that improvements in maternal health areheavily dependent on the information, knowledgeand opportunities individuals and couples have toexercise their rights. When empowered, communi-ties are not just recipients; they can play an activerole in reducing maternal mortality and morbidity byadvocating for their right to quality health care andsupporting women’s access to services. The MHTFwill support efforts to raise awareness and commu-nity mobilization around the importance of maternalhealth and family planning as part of the nationalagenda and the need for strong national governanceand leadership to make women’s health a priority inevery country.
#2. Country-owned and country-driven devel-opment
The work of the MHTF will promote nationalownership and capacity building in line with the prin-ciples of the Paris Declaration on Aid Effectiveness.The improvement of maternal health is viewed withinthe broader spectrum of sexual and reproductivehealth and as part of the one national health plan
[ 3 3 ] http://www.who.int/hhr/en/[ 3 4 ] Making Reproductive Rights and Sexual and Reproductive Health a Reality for All. Reproductive Rights and Sexual and
Reproductive Health Framework. United Nations Population Fund. May 2008.
19
and health systems strengthening. The MHTF willwork with governments and key partners tostrengthen MDG-driven national health systems toensure universal access to the three recognized pil-lars for improving maternal health:
• Family planning• Skilled care in pregnancy and childbirth, includ-
ing quality facility deliveries• Emergency Obstetric and Newborn Care
The MHTF will provide strategic capacity build-ing and resources to address priorities identified atthe country level by ministries of health in collabo-ration with key partners. This work will be guidedby the WHO Health System Framework and its sixbuilding blocks (Figure 8).[35]
In response to requests from countries for morestreamlined funding processes and reporting, UNFPAis working to closely coordinate the activities of thethree health thematic funds - Maternal Health, Fis-tula, and Reproductive Health Commodity Security.The results framework for the MHTF is closelylinked to the other Thematic Funds, as well as to theUNFPA’s Midwives Programme. While maintain-ing the focus on specific results, it is envisaged thatthe thematic funds will move towards a joint coun-try application and reporting process in 2009.
[ 3 5 ] Everybody`s Business: Strengthening health systems to improve health outcomes: WHO`s framework for action. WorldHealth Organization. 2007.
FIGURE 8. THE WHO HEALTH SYSTEM FRAMEWORK
Source: WHO Health System Strengthening Strategy 2007
Similarly, enhanced maternal and newbornhealth support from agencies within the United Na-tions will be better streamlined to avoid duplicate ef-forts and further burden countries. As noted in theJoint Statement (Annex 2), UNFPA, UNICEF, WHOand the World Bank are committed to working to-gether at the global, regional and country levels.
#3 A focus on results and strong support tonational monitoring and evaluation: MDG-driven and performance-based national healthsystem strengthening
Much attention will be given to measuring re-sults and strengthening national capacity to do so.
As will be seen in the Results Framework andin the Monitoring and Evaluation Sections of this docu-ment, we now have a solid set of internationally-agreed upon impact, outcome and coverage indica-tors. The challenge is to strengthen, with part-ners, the capacity of the one national health man-agement information system (HMIS) and to se-cure periodic facility and district reporting on aminimum number of robust indicators of progressin all countries supported by the MHTF. This,together with periodic population-based surveys,
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should enable UNFPA to better report to finan-cial contributors and its Executive Board.
Lessons learned on effective performance-based financing for health, including those from thecurrent efforts supported by the World Bank, willbe shared with countries so as to ensure inclusionas deemed appropriate.
3. THE MATERNAL HEALTH THEMATIC
FUND EMBEDDED IN UNFPA’S STRATEGIC
PLAN AND JOINT UN WORK ON
MATERNAL AND NEWBORN HEALTH
The work of the MHTF stems from UNFPA’s Stra-tegic Plan 2008-2011 Outcome 2.2- Access and uti-lization of quality maternal health services in-creased in order to reduce maternal mortality andmorbidity. The work of the MHTF will also con-tribute to Outcomes: 2.1 Universal access to Sexualand Reproductive Health, 2.3 Access to and uti-lization of Family Planning and 2.4 Demand,access and utilization of quality HIV preventionservices.
As part of the WHO-UNICEF-UNFPA-WorldBank joint support to countries to accelerate progresstowards MDG5, the MHTF will support an increas-ing number of countries through a series of waves,reaching around 25 countries before the end of 2009and reaching all 60 high maternal mortality countriesno later than 2012, subject to funding. In each country,the level of effort should increase progressively. Thus,it will be critical to rapidly expand the resource basefor the MHTF. Through solid reporting on results, it ishoped the MHTF will foster a virtuous cycle similar tothat at the Global Fund under the theme: “raise it, spendit, prove it”, to use the words of Richard Feachem, theGlobal Fund’s former head.
4. SUPPORTING NATIONAL CAPACITY
BUILDING
Strengthening UNFPA’s Country Offices to bet-ter contribute to national capacity buildingIn order to optimally support national capacity build-
ing and health system strengthening, and to managethe additional resources provided through the MHTF,UNFPA is strengthening its country office capacity,in numbers and skills mix, through the provision oftools and job aids, and timely access to internationalexperts. This effort aligns with UNFPA’s re-orga-nization towards a greater field focus.
Network of regional institutions and roster ofexperts
UNFPA and partners are in the process of estab-lishing a network of regional institutions and a ros-ter of international experts. Long-term arrangementsare being explored and will include institutions fromAfrica and Asia to foster South-South collaboration.The roster will include national experts who will beavailable for short periods to support countries intheir region, sharing lessons learned and best prac-tices. This roster will be developed in close collabo-ration with WHO, UNICEF, the World Bank and keyacademic partners, in particular the Columbia Uni-versity Averting Maternal Death and Disability Pro-gram. This is described at length in the MOU signedbetween UNFPA, UNICEF and Columbia Univer-sity on strengthening national capacity forEmONC.[36]
5. MATERNAL HEALTH THEMATIC FUND
RESULTS FRAMEWORK
The Maternal Health Thematic Fund Results Frame-work is anchored to MDG5 and to the UNFPA Stra-tegic Plan 2008-2011.
The MHTF Results Framework is linked tothree other key UNFPA programmes and their re-spective results frameworks:
• The Global Programme on ReproductiveHealth Commodity Security
• The Campaign to End Fistula, GlobalProgramme Proposal; Making Mother-hood Safer by Addressing Obstetric Fis-tula 2006-2010
• The UNFPA- ICM Midwives Programme
[ 3 6 ] Contributing to Millennium Development Goal 5 to Improve Maternal Health. Delivering Emergency Obstetric and New-born Care at Scale: A UNFPA, UNICEF and Mailman School of Public Health / AMDD Alliance to develop technical supportcapacity in the countries and regions. UNFPA, UNICEF, Columbia University, 17 July 2008.
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OUTPUTS
One of the fundamental principles underpinning thework supported by the MHTF will be country-ownedand country-driven development and support to theone national health plan. Therefore the specific out-puts and activities supported by the MHTF in eachcountry will be determined by the country through aconsultative process with key stakeholders.
There will be, however, a set of seven essen-tial outputs which the MHTF will support in everycountry (unless otherwise fully supported). In col-laboration with government and key partners theMHTF will support:
1. An enhanced political and social environmentfor Maternal and Newborn Health (MNH) andSexual and Reproductive Health (SRH)
2. Up-to-date needs assessments for the SRHpackage with a particular focus on family plan-ning, human resources for MNH, and EmONC
3. National health plans focus on SRH, especiallyfamily planning and EmONC with strong RH/HIV linkages to achieve the health MDGs
4. National responses to the human resource cri-sis in MNH, with a focus on planning and scal-ing up of midwifery and other mid-level pro-viders
5. National equity-driven scale-up of family plan-ning and EmONC services and maternal andnewborn health commodity security
6. Monitoring and results-based management ofnational MNH efforts
7. Leveraging of additional resources for MDG5from government and donors
1. AN ENHANCED POLITICAL AND SOCIAL
ENVIRONMENT FOR MATERNAL AND NEWBORN
HEALTH (MNH) AND SEXUAL AND
REPRODUCTIVE HEALTH (SRH)
As stated in UNFPA’s Sexual and ReproductiveHealth Framework, [37] a main strategy for improv-ing maternal health will be advocacy and policy dia-logue. The MHTF will contribute to an evidencebase for advocacy and resource mobilization at thecountry, regional and global levels. This will con-
tribute to universal access to a basic package of SRHservices as described in the framework.
The MHTF will act as a leveraging mechanism,generating awareness and support for maternalhealth. Increased visibility and understanding amonggovernments, civil society, the general public andprivate sector on the issues related to maternal healthwill build greater awareness and support for action.This is true at the national, regional and global lev-els. It will thus be important to increase recognitionof the issues surrounding maternal health and re-productive health among the media, donors, policymakers, communities and the general public throughadvocacy, media, communication for social changeand community mobilization.
MHTF resources will be used to support theministries of health, convene partners and bring to-gether district health management teams for plan-ning, problem-solving during scale-up, emulation be-tween districts and monitoring of progress.
The MHTF will also focus on partnership-build-ing in order to provide more harmonized support tocountries, as well as to raise awareness about ma-ternal and reproductive health. The MHTF will buildon UNFPA’s existing partnerships with key stake-holders at national, regional and global level. Thepositioning of the MHTF within the joint UN-MNHaccelerated support to countries represents a har-monized effort by United Nations agencies in accel-erating progress towards MDG5.
As part of this effort, UNFPA and UNICEFhave signed a memorandum of understanding withColumbia University (Averting Maternal Deathand Disability Program) to provide joint technicalsupport to countries, focusing on the area ofEmONC.
UNFPA is a member of the Partnership for Ma-ternal, Newborn and Child Health (PMNCH) andsits on the advisory board of the Women DeliverInitiative—a global advocacy and outreach effortfocused on promoting and advancing maternal andwomen’s health. As a member of these and othercommunication and advocacy initiatives, UNFPAis well positioned in the global framework of ma-ternal health initiatives and will carry out a sup-portive role based on its comparative advantagein advocacy, media, communication, technical as-sistance and programming to raise awareness andresources for MDG5.
[ 3 7 ] Making Reproductive Rights and Sexual and Reproductive Health a Reality for All. Reproductive Rights and Sexual andReproductive Health Framework. United Nations Population Fund. May 2008.
22
2. UP-TO-DATE NEEDS ASSESSMENTS FOR THE
SRH PACKAGE WITH A PARTICULAR FOCUS ON
FAMILY PLANNING, HUMAN RESOURCES FOR
MNH, AND EMONC
The MHTF will prioritize supporting national as-sessments in the areas of family planning/RHCS(with the Global Programme on RH Commodity Se-curity), human resources for MNH and EmONC.These assessments will provide valuable quantita-tive and descriptive information for advocacy andpolicy dialogue. For countries lacking up-to-dateassessments, this process will provide baselinesagainst which progress can be measured. Most im-portantly, information collected through these assess-ments will contribute to solid national and districtplanning, allowing for a more targeted, results-fo-cused approach in each country.
3. NATIONAL HEALTH PLANS FOCUS ON SRH,ESPECIALLY FAMILY PLANNING AND EMONCWITH STRONG RH/HIV LINKAGES TO ACHIEVE
THE HEALTH MDGS
The MHTF will support ongoing national planningprocesses including the enhancement of existingnational and district health plans, including ser-vice delivery plans, to ensure that they include com-munity mobilization, family planning education andservices, quality facility deliveries, and RH/HIV in-tegration.
a) Community mobilizationNational efforts in community mobilizationaround SRH, including demand creation forfamily planning and birth planning, should besupported as part of UNFPA’s general sup-port and in close collaboration with the GlobalProgramme on RH Commodity Security.
b) Family planning education and servicesFamily planning education and services shouldbe offered in every community and in everyprimary health facility (public and private).Meeting the unmet need for family planningwill require that every health facility provides
quality family planning services as an integralpart of SRH and primary health care. Repro-ductive health commodity security (RHCS) willneed to be ensured at every level (national,district and facility).
c) Quality facility deliveriesIn order to reduce maternal mortality, coun-tries will need to ensure that all women, espe-cially those from marginalized areas and popu-lations, have access to a quality facility deliv-ery in a primary health centre (public and pri-vate) with a skilled health professional capableof providing basic EmONC. Referral to a dis-trict hospital for comprehensive EmONC, in-cluding caesarean section and/or blood trans-fusion, should also be readily available.[38] Inorder to achieve this level of access, servicedelivery plans must include:
• For every 500,000 population and everysub-national area / district, a minimum of fivebasic EmONC primary health facilities
• For every 500,000 population and everysub-national area / district, at least one of thesefacilities provides comprehensive EmONC.[39]
d) RH/HIV Integration and prevention ofmother-to-child transmissionReducing maternal mortality in countries withhigh HIV prevalence will involve support toHIV prevention initiatives and their integra-tion within reproductive health. In line withUnited Nations Resolution 60/262 PoliticalDeclaration on HIV/AIDS, the MHTF willsupport the United Nations commitment to:
...ensuring that pregnant women have ac-cess to an tenata l care , in format ion ,counseling and other HIV services andto increasing the availability of and ac-cess to effective treatment to women liv-ing with HIV and infants in order to re-duce mother-to-child transmission of HIV,as well as to ensuring effective interven-tions for women living with HIV, includ-ing voluntary and confidential counsel-
[ 3 8 ] The Global Campaign for the Health Millennium Development Goals. First year report 2008. Published by the Office of thePrime Minister of Norway, Oslo, September 2008.
[ 3 9 ] The Indicators for Monitoring the Availability and Use of Obstetric Services: A Handbook. WHO, UNFPA, UNICEF,Columbia University, Draft 9 September 2008. Publication expected first quarter 2009.
23
ing and testing, with informed consent,access to treatment, especially life-longantiretroviral therapy and, where appropri-ate, breast-milk substitutes and the provi-sion of a continuum of care.[40]
Support from the MHTF will align with thefour elements of comprehensive prevention ofmother-to-child transmission (PMTCT):
• Prevent primary HIV infection among girlsand women
• Prevent unintended pregnancies amongwomen living with HIV
• Reduce mother-to-child transmission throughanti-retroviral drug treatment or prophylaxis,safer deliveries and infant feeding counseling
• Provide care, treatment and support towomen living with HIV and their families[41]
4. NATIONAL RESPONSE TO THE HUMAN
RESOURCE CRISIS IN MNH, WITH A FOCUS ON
PLANNING AND SCALING-UP OF MIDWIFERY AND
OTHER MID-LEVEL PROVIDERS
A national MNH service delivery plan will require awell deployed, competent and motivated healthworkforce, a key building block of the health sys-tem. A major thrust of the MHTF will be to supportcountries to increase skilled attendance at deliverywith a focus on midwives. This will involve supportto national assessments and planning of human re-sources for maternal health as part of broader na-tional health human resource planning.
The joint UNFPA-International Confedera-tion of Midwives (ICM) Midwives Programme,described in detail elsewhere, is a priority compo-nent of the MHTF.[42]
The following issues will be addressed:
• Numbers and deployment of midwives andothers with midwifery skills (MOMS)
• Regulatory environment to enable midwives
[ 4 0 ] Resolution Adopted by the General Assembly. 20/262 Political Declaration on HIV/AIDS. United Nations General Assembly60th Session. 15 June 2006.
[ 4 1 ] A Framework for Priority Linkages. WHO, UNFPA, IPPF, UNAIDS, 2005.[ 4 2 ] UNFPA investing in Midwives and others with midwifery skills to accelerate progress towards MDG5. A proposal for 3
years. 14 March 2008.
to perform the seven signal functions of basicEmONC
• Scale-up of production to achieve the re-quired numbers for the service delivery plan(midwifery schools, skills-based curricula, clini-cal training sites, etc.)
• Team work within primary health centresand district hospitals including task shiftingwith standardized protocols and adequate su-pervision to increase the number of deliveriesthan can be safely overseen by midwives
• Strengthening of national midwifery asso-ciations and councils
Countries participating in the MHTF will re-ceive midwifery support, particularly in the form ofnational and/or international midwifery advisers.
5. NATIONAL EQUITY-DRIVEN SCALE-UP OF
FAMILY PLANNING AND EMONC SERVICES AND
MATERNAL AND NEWBORN HEALTH COMMODITY
SECURITY
A dual approach: addressing systemic issues andresolving bottlenecks to scale-up
Teaming up with key development partners, thein-country approach to health system strengtheningwill use a combination of addressing systemic is-sues (such as building up the midwifery cadre), whilesupporting the resolution of bottlenecks. Coveragerates often progress slowly because of bottleneckswhich may be relatively straightforward to solve.
For example, in a meeting with a minister ofhealth from West Africa and his team in early 2008,it was revealed that family planning was being of-fered in only one out of five primary health carefacilities. A cursory assessment indicated that thisshould be relatively simple and low cost to addressthrough MoH decisions and management, sometraining, logistics capacity strengthening, contracep-tive supplies and modest additional financing. Simi-larly, ensuring that midwives are authorized to carryout the seven signal functions of basic EmONC
24
through national regulation and ensuring the requiredin-service training, could increase the provision ofbasic EmONC at a relatively low marginal cost andeffort. This could have a rapid and significant im-pact on reducing maternal mortality from causessuch as haemorrhage or eclampsia.
This approach to resolving bottlenecks is oneof the components behind some highly successfulchild survival programmes. Figure 9 represents theapproach, which aims to achieve the highest in-crease in coverage of an effective intervention inthe least amount of time and with the least amountof resources. Such an approach addresses the morelong-term systemic issues, such as scaling up theproduction of midwives.
Family planningMHTF support to family planning is closely
coordinated with the Global Programme on RH Com-modity Security, which will provide key resources.There are many factors that affect access to anduse of family planning services. A variety of ap-proaches will be considered and areas of supportwithin family planning carefully selected by eachcountry. For some countries advocacy and commu-nication campaigns are needed to address lack ofinformation or misinformation—and to enhance po-
100%
FIGURE 9. SCALING-UP COVERAGE FOR IMPACT: THE BEST USE OF RESOURCES TO
SCALE-UP RAPIDLY... MAKING THE MONEY WORK TO ACHIEVE RESULTS RAPIDLY
litical support. In other countries, quality of familyplanning services needs to be improved throughskills building amongst health care providers, moreuser-friendly health services, or community-baseddistribution of contraceptives and other RH ser-vices, including for HIV prevention. Outreachactivities should be implemented to galvanize com-munity participation and target those at risk for so-cial exclusion from such services. Family planningservices may need to be strengthened in some re-gions / districts through improvement in HMIS, link-ages of family planning services with post-partumand post-abortion services, or supply managementand distribution.
The most conservative estimates indicate thatunsafe abortions are responsible for about 13 percent of maternal deaths. Therefore, it is importantto prevent unsafe abortions by increasing access tofamily planning, emergency contraception and accessto post-abortion care. Post-abortion care also providesa very important entry point for provision of family plan-ning services to women who need it most at a timewhen they are most open to receive it.
Most women want to use family planning afterchildbirth and are thus open to information andmethod provision immediately after their delivery,while still in contact with the health system. Provi-
25
sion of voluntary family planning to post-partumwomen will prevent short intervals between deliver-ies, and will positively affect both maternal and childhealth.[43],[44]
EmONC services including upgrading of prior-ity EmONC facilities
Much has been learned about supporting ma-ternal health in resource-poor settings. One of theprograms that has achieved high impact is the Co-lumbia University-UNFPA-UNICEF Averting Ma-ternal Death and Disability (AMDD) Programfunded by the Bill & Melinda Gates Foundation(1999-2005). Peer-reviewed publications, its exter-nal evaluation and extensive documentation haveclearly demonstrated the impact of this programmeand have provided many practical lessons for pro-gramming in resource-poor settings.[45], [46] Over aperiod of five years, this programme has succeededin doubling the number of women served and reduc-ing by half the obstetric case fatality rate (the pro-portion of women dying from obstetric complica-tions). The reader is referred to one of the moreuseful publications for revitalizing and scaling-upEmONC services, Practical Lessons from GlobalSafe Motherhood Initiatives: Time for a New Focuson Implementation.[47]
UNFPA will work with governments in collabo-ration with Columbia University, UNICEF and WHOto carry forward this successful approach. Basedon the needs assessments in each country, a sys-tematic approach to strengthening national healthplans will be undertaken in the area of EmONC ser-vice delivery, including the costing of these plans.
More and more is known about the potentialimpact of reviewing maternal deaths and near-missesat facility level in terms of reducing the third delayand improving the quality of care and reporting.Based on national strategies, the MHTF will sup-port efforts to institutionalize such practices. [48]
The MHTF will also provide resources for therevitalization of priority maternal health services, to
bring them up to basic or comprehensive EmONCstandards as required. This will be done through in-service training, MNH commodities (see below),upgrading of facilities and strengthening of HMIS.Basic and comprehensive EmONC facilities thathave important clinical training responsibilities willreceive particular attention in order to contribute tothe scale-up in production of quality skilled healthprofessionals and midwives in particular.
Essential maternal and newborn health commod-ity security improved
UNFPA, UNICEF and WHO are in the pro-cess of updating their lists of MNH equipment andsupplies, and are planning to further strengthen pro-curement services to address quality, price, and main-tenance, including strategic spare parts, and otherimportant issues. This work, to be completed in 2009,will facilitate the capacity building work in countriesas they move towards self-sufficiency in nationalprocurement, supply chain management and main-tenance of equipment. The MHTF and the GlobalProgramme on Reproductive Health CommoditySecurity (GPRHCS) will support the strengtheningof this key health system building block. Access toquality essential equipment, supplies and drugs willthus be strengthened with national, MHTF, GPRHCSand other resources.
6. MONITORING AND RESULTS-BASED
MANAGEMENT OF NATIONAL MNH EFFORTS
Support will be provided to countries to strengthentheir capacity to monitor progress. Ensuring thatevery country supported by the MHTF has up-to-date assessments in family planning/RHCS, humanresources for MNH and for EmONC will enablecountries to determine baselines for measuringprogress towards MDG5. Support will also be pro-vided to national HMIS to ensure the adoption and
[ 4 3 ] Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deathscan we prevent this year? Lancet 2003; 362: 65–71.
[ 4 4 ] Report of a WHO Technical Consultation on Birth Spacing, Geneva, Switzerland, 13-15 June, 2005. www.who.int.[ 4 5 ] Caro DA, Murray SF, Putney P. Evaluation of the Averting Maternal Death and Disability Program. A Grant from the Bill and
Melinda Gates Foundation to the Columbia University Mailman School of Public Health. 26 July 2004.[ 4 6 ] www.amddprogram.org.[ 4 7 ] Freedman LP, Graham WJ, Brazier E, et al. Practical lessons from global safe motherhood initiatives: time for a new focus
on implementation. Lancet 2007; 370:13831390.[ 4 8 ] Beyond the numbers. Reviewing maternal deaths and complications to make pregnancy safer. WHO, Department of Repro-
ductive Health and Research, 2004.
26
regular use of the internationally-agreed MNH indi-cators within the HMIS in each country. Technicalassistance will be provided to improve HMIS at fa-cility, district and national levels, use for programmemanagement at each level and regular bi-directionalinformation flows between levels. This should fos-ter friendly emulation between districts, a highly suc-cessful strategy for scale-up. The organization anddelivery of monitoring and evaluation (M&E)courses for maternal and newborn healthprogrammes by universities in developing countriesis part of the MHTF-funded partnership withIMMPACT – University of Aberdeen.
7. LEVERAGING OF ADDITIONAL RESOURCES FOR
MDG5 FROM GOVERNMENT AND DONORS
The work supported by the MHTF will contribute toinvesting current resources more effectively and ef-ficiently, and with a greater focus on SRH andMNH. It will also support government and partnersin leveraging additional resources for maternal andnewborn health. This will be done through policydialogue; the availability of detailed quantitative in-formation on the national situation provided by theneeds assessments; the quality and results focus ofthe national health plans to reduce maternal mortal-ity; the costing of these plans; the improved report-ing on results through strengthened monitoring; andthe momentum created through the national partner-ship building.
OTHER OUTPUTS AS DETERMINED BY EACH
COUNTRY
While the above seven outputs are essential, unlessthey have already been fully supported through othermeans, countries are encouraged to prioritize their
requests for support for other important areas ofmaternal health such as improving financial, socio-cultural and geographic access to sexual and repro-ductive health services.
Many women in high maternal mortality coun-tries experience significant barriers to accessing thefull range of sexual and reproductive health ser-vices. Countries may request support from theMHTF for a number of activities related to re-ducing gaps in health equity such as mapping ex-ercises to determine coverage rates amongmarginalized groups, community-based initiativesto extend coverage to isolated communities, andpartnership with and contribution to national per-formance-based funding.
In line with UNFPA’s Sexual and Reproduc-tive Health Framework, the MHTF will encour-age and support countries in their efforts to em-power communities to demand access to qualitymaternal health services, including family plan-ning. Demand-creation and community mobili-zation activities, supported by the MHTF, couldinclude communication or social marketing cam-paigns around family planning and MNH, maleinvolvement initiatives, training of community rep-resentatives on health issues and verbal autop-sies. Efforts may also be supported to increasecommunity participation in order to create culture-and gender-sensitive maternal and reproductivehealth initiatives.
UNFPA recognizes that special efforts mustbe made to reach out to adolescents, both mar-ried and unmarried, with reproductive health in-formation, including HIV prevention. Dependingon the expressed needs of each country, theMHTF will support advocacy for the rights ofyoung people to education and to access reproduc-tive health services and the campaign for changesin policies and laws, particularly around access tocare and child marriage.[49]
[49] PATH and United Nations Population Fund. Meeting the Need: Strenthening Family Planning Programs. Seattle: PATH/UNFPA; 2006.
27
MIL
LEN
NIU
M D
EVEL
OP
MEN
T G
OA
L 5:
TO
IMP
RO
VE
MA
TER
NA
L H
EALT
H
Targ
et:
Red
uce
the
mat
erna
l mor
talit
y ra
tio b
y th
ree
quar
ters
, be
twee
n 19
90 a
nd 2
015
Indi
cato
rs:
•M
ater
nal m
orta
lity
ratio
•P
ropo
rtio
n of
birt
hs a
ttend
ed b
y sk
illed
hea
lth p
erso
nnel
Targ
et: A
chie
ve, b
y 20
15, u
nive
rsal
acc
ess
to r
epro
duct
ive
heal
thIn
dica
tors
:•
Ado
lesc
ent
birt
h ra
te•
Ant
enat
al c
are
cove
rage
(at
leas
t one
vis
it an
d at
leas
t fou
r vi
sits
)•
Unm
et n
eed
for
fam
ily p
lann
ing
•C
ontra
cept
ive
prev
alen
ce r
ate
UN
FPA
ST
RA
TEG
IC P
LAN
Out
com
e 2.
2 A
cces
s to
and
util
izat
ion
of q
ualit
y m
ater
nal h
ealth
ser
vice
s in
crea
sed
in o
rder
to
redu
ce m
ater
nal m
orta
lity
and
mor
bidi
tyA
nd c
ontr
ibut
ing
to O
utco
mes
2.1
Uni
vers
al A
cces
s to
SR
H, 2
.3 A
cces
s to
and
util
izat
ion
of fa
mily
pla
nnin
g an
d 2.
4 D
eman
d, a
cces
s to
and
util
izat
ion
of q
ualit
yH
IV a
nd S
TI p
reve
ntio
n se
rvic
es.
Indi
cato
rs a
s ab
ove
plus
:•
Pro
port
ion
of c
ount
ries
with
nat
iona
l de
velo
pmen
t pl
ans
that
allo
cate
dom
estic
res
ourc
es f
or a
n es
sent
ial
sexu
al a
nd r
epro
duct
ive
heal
th p
acka
ge•
Pro
port
ion
of c
ount
ries
whe
re C
aesa
rean
sec
tion
as a
pro
port
ion
of a
ll bi
rths
fal
ls in
the
ran
ge o
f 5-
15 p
er c
ent
(nat
iona
l, ru
ral a
nd u
rban
)•
Pro
port
ion
of s
ervi
ce d
eliv
ery
poin
ts o
fferin
g at
leas
t th
ree
mod
ern
met
hods
of
cont
race
ptio
n
CO
UN
TR
Y L
EVEL
– A
S P
AR
T O
F U
NFP
A’S
CO
UN
TR
Y P
RO
GR
AM
ME
(SU
PP
OR
T T
O T
HE
ON
E N
AT
ION
AL H
EALT
H P
LAN
IN C
LOSE
CO
OR
DIN
AT
ION
WIT
H W
HO
, UN
ICEF
, TH
E W
OR
LD B
AN
K. R
EGIO
NA
L D
EVEL
OP
MEN
T B
AN
KS
AN
D O
TH
ER K
EY P
AR
TN
ERS)
1.
Enh
ance
d po
litic
al a
nd s
ocia
len
viro
nmen
t for
MN
H a
nd S
RH
: na-
tiona
l ad
voca
cy,
enga
gem
ent
ofci
vil s
ocie
ty, n
atio
nal c
oord
inat
ion
and
part
ners
hip
build
ing
•N
atio
nal
com
mun
icat
ion
and
advo
cacy
stra
tegy
dev
elop
ed
•C
oord
inat
ion
Team
in p
lace
, led
by M
oH, w
ith U
NFP
A, W
HO
, UN
ICE
F,th
e W
orld
Ban
k, R
egio
nal D
evel
op-
men
t Ban
k, k
ey b
ilate
rals
, civ
il so
ci-
ety
and
othe
r pa
rtne
rs
•S
uppo
rt n
atio
nal
stew
ards
hip,
adv
ocac
y,co
mm
unic
atio
n an
d co
nven
ing
of k
ey p
artn
ers
incl
udin
g ci
vil s
ocie
ty fo
r M
NH
•S
uppo
rt a
ctiv
ities
to
prom
ote
natio
nal a
p-pr
oach
es fo
r th
e in
tegr
atio
n of
mat
erna
l hea
lthin
to t
he d
istr
ict
prim
ary
heal
th c
are
pack
age
and
into
sec
tora
l fra
mew
orks
and
nat
iona
l de-
velo
pmen
t in
stru
men
ts
•M
oH l
eade
rshi
p
•C
omm
itm
ent
by n
atio
nal
lead
ersh
ip i
nclu
ding
in
MoF
•C
omm
itmen
t by
dono
r age
n-ci
es t
o pr
ovid
e pr
edic
tabl
e, s
us-
tain
ed a
nd in
crea
sing
fun
ding
inea
ch M
HTF
-sup
porte
d co
untry
Out
puts
Indi
cato
rs (N
ote:
Bas
elin
es a
nd T
ar-
gets
for i
ndic
ator
s to
be
iden
tifie
dby
eac
h co
untr
y)[5
0]
Pot
entia
l Are
as o
f MH
TF S
uppo
rt /
Act
iviti
esba
sed
on N
atio
nal P
rior
ity S
ettin
gA
ssum
ptio
ns /
Ris
ks
[50]
See
Anne
x 1.
MH
TF R
esul
ts F
ram
ewor
k In
dica
tor
Tabl
e fo
r M
eans
of v
erifi
catio
n, F
requ
ency
of r
epor
ting
and
othe
r in
form
atio
n.
28
MA
TER
NA
L H
EALT
H T
HEM
AT
IC F
UN
D R
ESU
LTS
FRA
MEW
OR
K
•D
istr
ict
Hea
lth
Man
agem
ent
Team
s (D
HM
T) c
onve
ned
regu
larly
by M
oH t
o pl
an a
nd m
onito
r qu
ality
MN
H s
cale
-up
•S
uppo
rt a
ctiv
ities
to
incl
ude
the
issu
e of
child
mar
riag
e an
d un
wan
ted
preg
nanc
yam
ong
adol
esce
nts
in n
atio
nal
asse
ssm
ents
,pl
anni
ng a
nd a
dvoc
acy
stra
tegi
es
•S
uppo
rt t
he r
egul
ar c
onve
ning
of
dist
rict
heal
th m
anag
emen
t te
ams
to s
uppo
rt p
lan-
ning
, sc
ale-
up a
nd M
&E
2. S
uppo
rt to
up-
to-d
ate
need
s as
-se
ssm
ents
for
the
SR
H p
acka
gew
ith a
par
ticul
ar f
ocus
on
fam
ilypl
anni
ng,
hum
an r
esou
rces
for
MN
H, a
nd E
mO
NC
•U
p-to
-dat
e ne
eds
asse
ssm
ents
for
MN
H a
s pa
rt o
f na
tiona
l he
alth
plan
inc
ludi
ng:
FP
/RH
CS
; H
uman
Res
ourc
es fo
r MN
H in
the
cont
ext o
fhu
man
res
ourc
es f
or h
ealth
; a
ndE
mO
NC
•Fa
cilit
ate
tech
nica
l ass
ista
nce
and
prov
ide
finan
cial
res
ourc
es t
o su
ppor
t up
-to-
date
na-
tiona
l an
d di
stric
t as
sess
men
ts a
nd p
lans
as
rela
ted
to E
mO
NC
, FP
/RH
CS
, and
HR
for M
NH
•M
oH f
ully
ow
ns
natio
nal
asse
ssm
ents
and
MD
G-d
riven
plan
ning
pro
cess
es
•A
vaila
bilit
y of
tim
ely
tech
ni-
cal
assi
stan
ce /
cap
acity
bui
ld-
ing
from
nat
iona
l ex
pert
s an
dre
gion
al i
nstit
utio
ns
3.
Nat
iona
l hea
lth p
lans
focu
s on
SRH
, esp
ecia
lly fa
mily
pla
nnin
g an
dEm
ON
C w
ith s
tron
g R
H/H
IV li
nkag
esto
ach
ieve
the
heal
th M
DG
s
•U
p-to
-dat
e co
sted
nat
iona
l pla
nsfo
r FP
/RH
CS
and
Em
ON
C
•P
ropo
rtio
n of
ser
vice
del
iver
ypo
ints
whe
re w
omen
at
tend
ing
an-
tena
tal c
are
rece
ive
VC
T an
d P
MTC
T
•S
uppo
rt n
atio
nal
and
dist
rict
heal
th p
lans
incl
udin
g th
eir
serv
ice
deliv
ery
plan
s to
ens
ure
that
they
incl
ude
com
mun
ity m
obili
zatio
n, fa
mily
plan
ning
edu
catio
n an
d se
rvic
es,
qual
ity f
acili
tyde
liver
ies,
and
RH
/HIV
inte
grat
ion:
natio
nal
effo
rts
in c
omm
unity
mob
iliza
tion
arou
nd S
RH
, inc
ludi
ng d
eman
d cr
eatio
n fo
rfa
mily
pla
nnin
g an
d bi
rth
plan
ning
fam
ily p
lann
ing
educ
atio
n an
d se
rvic
es t
obe
offe
red
in e
very
com
mun
ity a
nd in
eve
rypr
imar
y he
alth
faci
lity
(pub
lic a
nd p
rivat
e)re
prod
uctiv
e he
alth
com
mod
ity s
ecur
ity(R
HC
S)
be e
nsur
ed a
t eve
ry le
vel (
natio
nal,
dist
rict a
nd fa
cilit
y)al
l w
omen
hav
e ac
cess
to
a qu
ality
fac
ility
deliv
ery
in a
prim
ary
heal
th c
entr
e (p
ublic
and
priv
ate)
with
a s
kille
d he
alth
pro
fes-
sion
al c
apab
le o
f pr
ovid
ing
basi
c E
mO
NC
.re
ferr
al to
a d
istr
ict h
ospi
tal f
or c
ompr
ehen
-si
ve E
mO
NC
•S
uppo
rt R
H-H
IV in
tegr
atio
n, jo
int F
P/H
IV p
re-
vent
ion,
ant
enat
al V
CT
and
PM
TCT
•S
uppo
rt n
atio
nal
plan
ning
pro
cess
es f
orco
stin
g an
d fin
anci
ng o
f MN
H c
ompo
nent
s w
ithin
the
natio
nal h
ealth
pla
ns in
clud
ing
wor
k on
sec
tor
•M
oH fu
lly o
wns
nat
iona
l as-
sess
men
ts a
nd M
DG
-dri
ven
plan
ning
pro
cess
es
•A
vaila
bilit
y of
tim
ely
tech
ni-
cal
assi
stan
ce /
cap
acity
bui
ld-
ing
from
nat
iona
l ex
pert
s an
dre
gion
al i
nstit
utio
ns
•N
atio
nal H
IV /A
IDS
con
stitu
-en
cy fu
lly c
omm
itted
to R
H /
HIV
inte
grat
ion
29
MTE
Fs, p
redi
ctab
ility
and
sus
tain
abili
ty o
f fun
d-in
g, a
nd fi
scal
spa
ce; s
uppo
rt th
e av
aila
bilit
y of
cost
ing
pack
ages
;
•S
uppo
rt p
lann
ing
to i
mpr
ove
finan
cial
ac-
cess
(e.
g. w
ork
with
Wor
ld B
ank
on p
erfo
r-m
ance
-bas
e fin
anci
ng)
4. S
uppo
rt t
he n
atio
nal
resp
onse
to t
he h
uman
res
ourc
e cr
isis
in
MN
H, w
ith a
focu
s on
pla
nnin
g an
dsc
alin
g up
of m
idw
ifery
and
oth
erm
id-le
vel
prov
ider
s (a
s pe
r M
id-
wiv
es P
rogr
amm
e D
ocum
ent)
4.1
Nat
ion
al h
ealt
h h
um
an r
e-so
urce
pla
ns f
or M
NH
incl
ude
in-
tern
atio
nally
-agr
eed
upon
requ
ire-
men
ts fo
r fa
mily
pla
nnin
g, n
orm
alde
liver
y an
d ba
sic
and
com
preh
en-
sive
Em
ON
C d
istr
ict-b
ased
ser
vice
deliv
ery
4.2
Upg
rade
d m
idw
ifery
edu
catio
nan
d tr
aini
ng p
rogr
ams
with
cur
-ri
cula
bas
ed o
n th
e IC
M e
ssen
tial
com
pete
ncie
s fo
r bas
ic m
idw
ifery
prac
tice
4.3
Incr
ease
d nu
mbe
r of m
idw
ifery
asso
ciat
ions
with
cap
acity
to
ad-
voca
te fo
r and
impl
emen
t the
sca
l-in
g up
of m
idw
ifery
ser
vice
s in
the
coun
try
4.4
Nat
iona
l re
gula
tory
pro
fes-
sion
al s
tand
ards
and
mon
itori
ngsy
stem
s in
p
lace
to
en
sure
sust
aina
bilit
y of
hig
h qu
ality
mid
-w
ifery
ser
vice
s an
d ca
re
•N
atio
nal
MN
H h
uman
res
ourc
ene
eds
asse
ssm
ents
up-
to-d
ate
•N
atio
nal
MN
H h
uman
res
ourc
epl
an d
evel
oped
•N
umbe
r an
d P
ropo
rtio
n of
mid
-w
ifery
tra
inin
g in
stitu
tions
, in
all
par-
ticip
atin
g co
untr
ies,
with
rev
ised
and
cult
ural
ly a
ppro
pria
te c
urri
cula
-ba
sed
on I
CM
ess
entia
l co
mpe
ten-
cies
ado
pted
and
im
plem
ente
d
•A
nnua
l nu
mbe
r of
mid
wif
ery
grad
uate
s fr
om n
atio
nal
mid
wife
rytr
aini
ng i
nstit
utio
ns i
n al
l pa
rtic
ipat
-in
g co
untr
ies
bein
g de
ploy
ed a
t ba
-si
c an
d co
mpr
ehen
sive
Em
ON
C f
a-ci
litie
s
•N
umbe
r an
d pr
opor
tion
of m
id-
wiv
es,
in a
ll th
e pa
rtic
ipat
ing
coun
-tr
ies,
who
are
aut
horiz
ed a
nd e
mpo
w-
ered
to a
dmin
iste
r the
cor
e se
t of l
ife-
savi
ng i
nter
vent
ions
(th
e 7
Bas
icE
mO
NC
fun
ctio
ns)
•P
ropo
rtio
n of
mid
wiv
es,
in t
hepa
rtic
ipat
ing
coun
trie
s, w
ho b
enef
itfr
om s
yste
ms
for c
ompu
lsor
y su
ppor
t-iv
e su
perv
isio
n an
d co
ntin
ued
edu
-ca
tion
for
mid
wiv
es
•P
ropo
rtio
n of
par
ticip
atin
g co
un-
trie
s w
ith a
nat
iona
l m
idw
ifery
cou
n-ci
l/boa
rd, w
ith in
tern
atio
nal s
tand
ards
See
join
t UN
FPA
-Inte
rnat
iona
l Con
fede
ratio
nof
Mid
wiv
es (I
CM
) Mid
wiv
es P
rogr
amm
e do
cu-
men
t fo
r de
taile
d de
scri
ptio
n of
UN
FPA
sup
-po
rt fo
r thi
s ou
tput
.
This
out
put
can
incl
ude:
•S
uppo
rt t
o na
tiona
l po
licie
s, p
lann
ing
and
prog
ram
mes
for
HR
for
MN
H w
ith a
foc
us o
nm
idw
ifery
: p
rodu
ctio
n, d
eplo
ymen
t, re
tent
ion
incl
udin
g ta
sk s
hifti
ng a
nd t
eam
wor
k (n
atio
nal
regu
latio
ns b
ased
on
inte
rnat
iona
l st
anda
rds,
prof
essi
onal
ass
ocia
tions
, st
anda
rdiz
ed p
roto
-co
ls a
nd s
uper
visi
on, j
ob a
ids,
etc
.) a
nd n
atio
nal
scal
e-up
of
trai
ning
ins
titut
ions
•S
uppo
rt to
the
expa
nsio
n/up
datin
g of
exi
st-
ing
mid
wife
ry s
choo
ls–a
nd t
he d
evel
opm
ent
ofne
w s
choo
ls–b
ased
on
inte
rnat
iona
l st
anda
rds
•S
uppo
rt t
he d
evel
opm
ent
of n
atio
nal
bur-
sary
pro
gram
mes
for
mid
wife
ry s
tude
nts
from
rura
l ar
eas–
refu
ndab
le t
hrou
gh p
rovi
sion
of
serv
ice
in u
nder
serv
ed a
reas
for
equ
ival
ent
num
ber
of y
ears
•C
apac
ity b
uild
ing
with
the
natio
nal m
idw
ifery
asso
ciat
ion
•S
uppo
rt t
he d
evel
opm
ent
of r
oste
r of
mid
-w
ifery
sch
ools
(in
tern
atio
nal
and
regi
onal
) ca
-pa
ble
of s
uppo
rtin
g de
velo
pmen
t of n
ew s
choo
lsin
MH
TF c
ount
ries
•A
gree
men
t an
d st
rong
sup
-po
rt b
y M
oH
•E
xist
ing
buy-
in a
nd w
illin
g-ne
ss o
f th
e in
stitu
tions
to
en-
hanc
e sc
alin
g-up
and
tra
inin
g(R
isks
: m
idw
ifery
tra
inin
g in
sti-
tutio
ns a
nd p
rogr
amm
es d
o no
tha
ve s
uffic
ient
res
ourc
es a
ndsu
stai
ned
supp
ort)
•S
uffic
ient
nat
iona
l fin
anci
alre
sour
ces
•IC
M t
rain
ing
prog
ram
mes
in
advo
cacy
and
cap
acity
bui
ldin
g fo
rm
idw
ifery
ass
ocia
tions
are
cul
tur-
ally
app
ropr
iate
and
effe
ctiv
e
•St
rong
sup
port
from
MoH
and
legi
slat
ors
for
cont
inue
d pr
ofes
-si
onal
mid
wife
ry t
rain
ing,
sup
er-
visi
on a
nd m
idw
ives
’ pr
otec
tion
30
5. N
atio
nal e
quity
-dri
ven
scal
e-up
of fa
mily
pla
nnin
g an
d Em
ON
C s
er-
vice
s, m
ater
nal
an
d n
ewb
orn
heal
th c
omm
odit
y se
curi
ty (
incl
ose
coor
dina
tion
with
UN
FPA
’sG
loba
l P
rogr
amm
e on
RH
CS
and
with
join
t fin
anci
al s
uppo
rt)
5.1
Acc
ess
to fa
mily
pla
nnin
g im
-pr
oved
5.2
Acc
ess
to q
ualit
y E
mO
NC
im-
prov
ed
5.3
Ess
entia
l mat
erna
l and
new
born
heal
th c
omm
odity
sec
urity
impr
oved
(in c
lose
coo
rdin
atio
n w
ith U
NFP
A’s
Glo
bal P
rogr
amm
e on
RH
CS
and
with
join
t fin
anci
al s
uppo
rt)
•P
ropo
rtio
n of
ser
vice
del
iver
ypo
ints
offe
ring
at l
east
thr
ee m
oder
nm
etho
ds o
f co
ntra
cept
ion
Uni
ted
Nat
ions
Em
ON
C In
dica
tors
•C
ase
fata
lity
rate
for d
irect
obs
tet-
ric c
ause
s in
fac
ilitie
s
•A
vaila
bilit
y of
em
erge
ncy
obst
et-
ric a
nd n
ewbo
rn c
are:
bas
ic a
nd c
om-
preh
ensi
ve E
mO
NC
fac
ilitie
s
•P
ropo
rtio
n of
all
birt
hs in
Em
ON
Cfa
cilit
ies
•M
et n
eed
for
Em
ON
C
•P
ropo
rtio
n of
cou
ntry
com
mod
ityre
ques
ts s
atis
fied
•S
uppo
rt t
he s
calin
g-up
of
fam
ily p
lann
ing
serv
ices
to
ever
y he
alth
fac
ility
and
res
olvi
ng o
fbo
ttlen
ecks
in r
eal t
ime
•S
uppo
rt t
rain
ing
of s
taff
for
fam
ily p
lann
ing
•S
uppo
rt p
ost-
part
um f
amily
pla
nnin
g
•A
dvoc
acy
and
supp
ort
for
fam
ily p
lann
ing
serv
ices
to
be in
tegr
ated
into
pos
t-pa
rtum
car
e•
Sup
port
the
scal
ing-
up
of m
ater
nal
heal
thse
rvic
es–
and
res
olvi
ng o
f bo
ttlen
ecks
-, i
nclu
d-in
g su
ppor
ting
stre
ngth
enin
g se
rvic
e de
liver
y in
–an
d up
grad
ing–
prio
rity
basi
c an
d co
mpr
ehen
sive
Em
ON
C f
acili
ties
•S
uppo
rt a
ppro
ache
s w
ith o
ther
sec
tors
to
redu
ce th
e th
ree
dela
ys (
com
mun
icat
ion,
tran
s-po
rt, e
.g. t
axi a
ssoc
iatio
n vo
uche
r sy
stem
s et
c.)
•C
apac
ity b
uild
ing
for
qual
ity o
f ca
re (
e.g.
,ac
cred
itatio
n of
faci
litie
s, w
ork
with
pro
fess
iona
las
soci
atio
ns,
natio
nal
regu
latio
ns,
mat
erna
lde
ath
audi
ts,
etc.
)•
Sup
port
the
pro
visi
on o
f co
ntra
cept
ives
•S
uppo
rt t
he p
rovi
sion
of
esse
ntia
l M
NH
drug
s, s
uppl
ies
and
equi
pmen
t•
Stre
ngth
enin
g of
nat
iona
l cap
acity
dev
elop
-m
ent
in h
ealth
sup
plie
s lo
gist
ics
syst
ems
•S
usta
ined
and
suf
ficie
nt n
a-tio
nal
and
dono
r fin
anci
al c
om-
mitm
ents
•C
omm
itte
d di
stri
ct h
ealt
hm
anag
emen
t te
ams
•M
otiv
ated
hea
lth w
orke
rs
6.
Mon
itori
ng a
nd r
esul
ts-b
ased
man
agem
ent
of n
atio
nal
MN
H e
f-fo
rts
supp
orte
d
•In
tern
atio
nally
-agr
eed
MN
H i
ndi-
cato
rs in
tegr
ated
in n
atio
nal H
MIS
•M
anda
tory
not
ifica
tion
of m
ater
-na
l de
aths
•A
nnua
l num
ber o
f mat
erna
l dea
thau
dits
•P
ropo
rtio
n of
dis
tric
ts r
epor
ting
year
ly o
n na
tiona
lly-a
gree
d M
NH
in-
dica
tors
•S
uppo
rt to
nat
iona
l HM
IS: r
evie
w a
nd a
dop-
tion
of i
nter
natio
nal
MN
H i
ndic
ator
s w
ithin
na-
tiona
l HM
IS
•N
atio
nal c
apac
ity b
uild
ing
for
HM
IS, i
nclu
d-in
g te
chni
cal
assi
stan
ce a
nd p
artic
ipat
ion
intr
aini
ng c
ours
es (e
.g.,
IMM
PAC
T –
IPA
CT)
•S
uppo
rt to
HM
IS s
tren
gthe
ning
incl
udin
g in
-se
rvic
e tr
aini
ng w
ith d
istr
ict
team
s an
d he
alth
faci
litie
s te
ams
•S
uppo
rt t
o pe
riod
ic n
atio
nal
cens
us a
ndsu
rvey
s (D
HS
, M
ICS
, ot
hers
) to
mea
sure
ma-
tern
al m
orta
lity
and
rela
ted
popu
latio
n-ba
sed
MN
H/F
P in
dica
tors
•In
tegr
atio
n of
inte
rnat
iona
lly-
agre
ed in
dica
tors
for
RH
/MN
H in
heal
th s
yste
m s
tren
gthe
ning
ef-
fort
s su
ch a
s IH
P+,
etc
.
•M
oH
com
mit
ted
to
sus-
tain
ed r
esul
ts-b
ased
app
roac
han
d to
reg
ular
faci
lity
and
dist
rict
repo
rtin
g th
roug
h st
rong
HM
IS
31
•S
uppo
rt p
erio
dic
MN
H/R
H r
evie
ws/
eval
ua-
tions
as
part
of
heal
th s
ecto
r re
view
s
7. S
uppo
rt to
cou
ntri
es in
leve
rag-
ing
addi
tiona
l res
ourc
es fo
r M
DG
5fr
om g
over
nmen
t and
don
ors
•S
hare
of g
over
nmen
t exp
endi
ture
for
heal
th (a
s pe
r ann
ual g
over
nmen
tfig
ures
)
•N
atio
nal
budg
et f
or M
NH
ove
rall
and
per
capi
ta (
incl
udin
g al
l flo
ws:
dom
estic
and
ext
erna
l), a
s m
easu
red
thro
ugh
nati
onal
hea
lth
acco
unts
whe
re th
ey e
xist
•S
uppo
rt g
over
nmen
t to
mob
ilize
and
lev
er-
age
reso
urce
s fo
r m
ater
nal
and
repr
oduc
tive
heal
th f
rom
dom
estic
and
ext
erna
l so
urce
s
•S
usta
ined
nat
iona
l an
d do
-no
r fin
anci
al c
omm
itmen
ts
Oth
er o
utpu
ts a
s de
term
ined
by
each
cou
ntry
Ple
ase
refe
r to
cou
ntry
-spe
cific
pro
posa
ls to
the
MH
TF fo
r ea
ch M
HTF
sup
port
ed c
ount
ry
REG
ION
AL
LEV
EL -
AS
PA
RT O
F U
NFP
A’S
REG
ION
AL P
RO
GR
AM
MES
: T
O S
TR
ENG
TH
EN R
EGIO
NA
L ST
EWA
RD
SHIP
AR
OU
ND
MN
H -
PO
LIC
Y
DIA
LOG
UE
AN
D C
OO
RD
INA
TIO
N
1. In
crea
sed
regi
onal
reco
gniti
on o
fM
NH
by
polic
y m
aker
s
2. E
nhan
ced
regi
onal
coo
rdin
atio
nar
ound
MN
H
3. In
crea
sed
Sou
th-S
outh
sup
port
to n
atio
nal c
apac
ity b
uild
ing
4. I
ncre
ased
sup
port
at
regi
onal
leve
l for
mid
wife
ry a
s a
key
heal
thw
orkf
orce
for
the
ach
ieve
men
t of
MD
G5
5. I
ncre
ased
sha
ring
of
less
ons
lear
ned
and
prod
uctio
n of
evi
denc
e
•N
umbe
r of
reg
iona
l m
eetin
gs o
nM
NH
•A
nnua
l nu
mbe
r of
Sou
th-S
outh
MN
H c
apac
ity b
uild
ing
mis
sion
s /
exch
ange
s w
ith
MH
TF
-sup
port
edco
untr
ies
•P
rese
nce
of re
gion
al e
fforts
to s
tan-
dard
ize
mid
wife
ry c
urric
ula
with
in r
e-gi
ons
base
d on
inte
rnat
iona
l sta
ndar
ds
•N
umbe
r of M
HTF
-sup
porte
d co
un-
trie
s in
eac
h re
gion
with
a fu
nctio
ning
natio
nal M
idw
ifery
Cou
ncil
/ B
oard
•S
uppo
rtin
g U
NFP
A R
egio
nal
Pro
gram
mes
with
add
ition
al t
echn
ical
cap
acity
•S
uppo
rt r
egio
nal a
dvoc
acy
and
com
mitm
ent
for M
NH
(e.g
., M
aput
o P
lan
of A
ctio
n, p
arlia
men
-ta
ry a
ssoc
iatio
ns,
high
-leve
l m
eetin
gs,
etc.
)
•W
ork
with
WH
O t
o en
sure
MN
H h
igh
onag
enda
of r
egio
nal h
ealth
mee
tings
and
with
the
Wor
ld B
ank
for
regi
onal
fin
ance
mee
tings
•S
uppo
rt r
egio
nal
capa
city
bui
ldin
g th
roug
hth
e te
chni
cal
assi
stan
ce n
etw
ork
of r
egio
nal
in-
stitu
tions
and
indi
vidu
als,
wor
king
with
UN
ICE
Fan
d C
olum
bia
Uni
vers
ity (
see
UN
FPA
-UN
ICE
F-C
olum
bia
Uni
vers
ity A
MD
D M
OU
)
•S
uppo
rt r
egio
nal
inte
r-ag
ency
coo
rdin
atio
non
MN
H (
WH
O,
UN
ICE
F, U
NFP
A,
Wor
ld B
ank,
Reg
iona
l Dev
elop
men
t B
anks
(e.
g.,
Har
mon
iza-
tion
for
Hea
lth in
Afr
ica,
reg
iona
l dire
ctor
s m
eet-
ings
, et
c.)
•S
uppo
rt
stan
dard
izat
ion
of c
urric
ula
and
exch
ange
of
expe
rienc
es a
s re
late
d to
hum
anre
sour
ces
for
MN
H
•R
egio
nal
com
mit
men
t to
SR
H (
such
as
Map
uto
Pla
n of
Act
ion
in A
fric
a)
•E
ffect
ive
Uni
ted
Nat
ions
re-
gion
al c
oord
inat
ion
(e.g
. H
arm
o-ni
zatio
n fo
r Hea
lth in
Afri
ca, r
egu-
lar m
eetin
gs o
f reg
iona
l dire
ctor
s)
•E
ffect
ive
and
cultu
rally
ap-
prop
riate
adv
ocac
y fo
r mid
wife
ryis
fea
sibl
e
32
GLO
BA
L LE
VEL
- A
S P
AR
T O
F U
NFP
A’S
GLO
BA
L P
RO
GR
AM
ME:
TO
ST
REN
GT
HEN
GLO
BA
L ST
EWA
RD
SHIP
AN
D C
OO
RD
INA
TIO
N A
RO
UN
D M
NH
1. G
loba
l ste
war
dshi
p an
d le
ader
-sh
ip fo
r MN
H e
nhan
ced
2. J
oint
UN
-MN
H s
uppo
rt to
cou
n-tr
ies
3. T
echn
ical
ass
ista
nce
netw
ork
esta
blis
hed
and
func
tioni
ng
4. In
crea
sed
supp
ort a
t glo
bal l
evel
for
mid
wif
ery
as a
key
hea
lth
wor
kfor
ce f
or t
he a
chie
vem
ent
ofM
DG
5
5. A
dvoc
acy
for m
ater
nal h
ealth
•Le
vel o
f fin
anci
ng fo
r MN
H fo
r hig
hm
ater
nal
mor
talit
y co
untr
ies
•N
umbe
r of
cou
ntri
es r
ecei
ving
join
t U
N-M
NH
sup
port
•N
umbe
r of
ins
titut
ions
act
ivel
ypa
rtic
ipat
ing
in t
he t
echn
ical
ass
is-
tanc
e ne
twor
k
•S
uppo
rt g
loba
l ad
voca
cy a
nd r
esou
rce
mo-
biliz
atio
n / l
ever
agin
g fo
r M
NH
•S
uppo
rt jo
int U
N-M
NH
wor
k an
d co
ordi
nate
dac
tion
to p
rovi
de e
nhan
ced
supp
ort t
o 25
prio
rity
coun
trie
s by
end
of
2009
and
to
the
60 p
riorit
yco
untr
ies
by e
nd o
f 20
12
•C
ontr
ibut
e to
the
dev
elop
men
t of
a g
loba
lpr
ogra
mm
e of
wor
k w
ith k
ey s
take
hold
ers
to a
c-ce
lera
te p
rogr
ess
tow
ards
MD
G5
(par
ticip
ate
info
llow
-up
to t
he c
ampa
ign
for
the
heal
th M
DG
san
d ef
forts
of N
orw
ay, U
K, S
wed
en a
nd th
e B
ill &
Mel
inda
Gat
es F
ound
atio
n)
•S
uppo
rt t
he P
artn
ersh
ip f
or M
ater
nal,
New
-bo
rn a
nd C
hild
Hea
lth
•S
uppo
rt g
loba
l com
mun
icat
ion
and
advo
cacy
initi
ativ
es f
ocus
ing
on M
NH
•D
evel
opin
g pr
int
and
audi
o-vi
sual
adv
ocac
yan
d m
edia
mat
eria
ls i
n se
vera
l la
ngua
ges
•P
itchi
ng s
torie
s to
the
med
ia,
issu
ing
pres
sre
leas
es a
nd h
oldi
ng p
ress
eve
nts
to i
ncre
ase
med
ia c
over
age
of t
he i
ssue
•W
orki
ng w
ith h
igh
net
wor
th i
ndiv
idua
l do
-no
rs a
nd p
hila
nthr
opic
gro
ups
that
rai
se f
unds
and
awar
enes
s ab
out
mat
erna
l he
alth
•G
loba
l com
mitm
ent t
o M
NH
sust
aine
d
•E
ffec
tive
follo
w-u
p of
the
WH
O-U
NF
PA
-UN
ICE
F-W
orld
Ban
k Jo
int
Stat
emen
t on
Mat
er-
nal
and
New
born
Hea
lth
•D
onor
gov
ernm
ents
and
foun
datio
ns p
rovi
de s
uffic
ient
mul
tilat
eral
fund
ing
for
MN
H, i
n-cl
udin
g to
the
MH
TF
Ris
ks:
•D
onor
fatig
ue /
insu
ffic
ient
dono
r sup
port
•G
loba
l fin
anci
al c
risi
s
•C
ompe
titio
n fo
r ot
her
de-
velo
pmen
t pri
oriti
es
33
Country Level Outputs
1. Enhanced political and social environment for MNH
2. Needs assessments
3. National Health Plans strengthened for FP and EmONC
4. National response to human resource crisis-midwifery
5. Support to national scale-up of FP an EmONC*
6. Monitoring and results-based management
7. Leveraging of additonal resources for MDG5
Country Level Total
Regional Level
Global Level
Total less indirect costs**
Total
6. BUDGET
The proposed MHTF budget is based on a progres-sively increasing income scenario for 2008-2011,totaling around $500 million. Under such incomeprojections, significant progress can be made in 25countries mostly of middle size, but with some largerones (such as Bangladesh and Ethiopia); and workcould begin towards the end of the 2008-11 cycle inapproximately 48 countries. We would thus be onthe way to providing support to the 60 high maternalmortality countries by no later than 2012.
It is worth remembering that the MHTF fundingis meant to be catalytic; $500 million over four yearsrepresents less than two per cent of the $6 billion to $7billion annually estimated by WHO, plus the $1.5 bil-lion annually for family planning. It is assumed thatpriority countries will receive the bulk of their healthODA through other mechanisms, ideally through pooledsector funding of an MDG-driven national health planthrough a Sector Wide Approach (SWAp).
Financial requirements for the MHTF increaserapidly over the next four years, based on both theincreasing number of countries (12 countries peryear) and the rapidly increasing level of yearly ef-fort in each country supported as scale-upprogresses.
Ideally, pledges from donors should be multi-year (for the period 2008-2011) and progressivelyincreasing, commensurate with the growing finan-cial requirements of the MHTF.
These resources should provide an importantcontribution to the WHO-UNICEF-UNFPA-WorldBank joint support to countries to accelerate progresstowards MDG5.
Impact of different levels of funding on theMHTF-supported programme of work
Scenario One: $70 million to $75million a year:initial work in 25 countriesA total of around $72 million will be required for
2008 2009 2010 2011 2008-2011
% ofTotal
Number of countries added each year
Total number of MHTF-supported countries12
12
$M
12
24
$M
12
36
$M
12
48
$M
48
$M
1.02
2.04
2.04
6.12
6.12
2.04
1.02
20.40
0.70
2.18
23.28
24.90
3.06
6.12
6.12
18.36
18.36
6.12
3.06
61.20
1.40
4.35
66.95
71.64
6.12
12.24
12.24
36.72
36.72
12.24
6.12
122.40
1.40
5.35
129.15
138.19
12.24
24.48
24.48
73.44
73.44
24.48
12.24
244.80
1.40
5.35
251.55
269.16
22.44
44.88
44.88
134.64
134.64
44.88
22.44
448.80
4.90
17.23
470.93
503.89
95.3
1.0
3.7
100
Notes: * In close collaboration with Global Programme on Reporductive Health Commodity Security ** Indirect costs = 7%
34
MATERNAL HEALTH THEMATIC FUND BUDGET–$500 MILLION OVER FOUR YEARS
operations in 2009. Since the four United Nationsagencies have committed to accelerated support in25 countries by the end of 2009, the minimum sce-nario to begin work in the 25 countries would befunding of the order of $25 million in 2008 and $70million to $75 million per year thereafter. However,such a funding level would not allow much supportto scale up in those 25 countries, and would pre-clude expanding to the other 35 or so high maternalmortality countries.
Scenario Two: Continued expansion to $140 mil-lion in 2010 and $270 million in 2011: impor-tant contribution in 48 of the 60 high maternalmortality countriesAdding 12 countries in each of 2010 and 2011 andscaling up coverage within each country would re-quire around $140 million in 2010 and $270 million in2011. This, coupled with the resources of UNICEF,the World Bank and the continued technical supportof WHO, could go a long way in ensuring that thenational health system can improve maternal andnewborn survival, achieving better results—andvalue for money—with its overall sector resources.
7. MANAGEMENT AND GOVERNANCE
The management and governance of the MHTF willrespect the usual UNFPA accountability lines, as wellas the approved thematic fund guidelines. Specifi-cally, accountability for country activities rests withthe representative who is supervised by her/his re-gional director. Regional activities are the responsi-bility of the respective regions supervised by theirregional director. All global activities will be super-vised under the Director of the Technical Division(TD) or the Information and External Relations Di-vision (IERD), as relevant. The overall programstewardship rests with the Deputy Executive Direc-tor of Programs and with the Executive Director.
A small team at UNFPA headquarters, withinthe Sexual and Reproductive Health Branch of theTechnical Division, will manage and coordinate theMHTF. The team will include a coordinator, an M&Especialist and a finance associate, as well as admin-istrative and consultative support where needed.Most importantly, the coordination team will workto ensure that the MHTF effort represents aUNFPA-wide approach by including input from alldivisions as we work towards a common goal. In
order to operationalize this integrated strategy, oneconsolidated annual workplan including all relevantdivisions is being developed.
The Maternal Health Inter-Divisional WorkingGroup (MH-IDWG) has been created as a mecha-nism for communication and coordination. The MH-IDWG operates on both a policy and working levelto assure coherence in planning, funding allocations,reporting and other functions for country, regionaland global programs. At the working-group level,focal points have been identified within each divi-sion to participate in the MH-IDWG and liaise be-tween divisions and the MHTF team to ensure thatevery relevant unit is effectively involved. The MH-IDWG meets monthly at the working level and an-nually at the policy level.
All countries considered for support from theMHTF have high maternal mortality, defined as anMMR greater than 300 maternal deaths for every100,000 live births. The country selection process ishighly interactive, involving consultations with coun-tries, regions and other United Nations agencies.Beyond high MMR, countries selected for supportmust be identified as having the potential for rapidsuccess based on the criteria listed below or be fac-ing significant maternal health needs due to humani-tarian crisis.
Criteria for the selection of countries for MHTFsupport:
1. Participation in recent global initiatives, andin particular the International Health Part-nership (IHP+)
2. Strong national commitment
3. Strong country office commitment and lead-ership
Countries will be selected to join in successivewaves as funding becomes available, until eventu-ally all 60 high maternal mortality countries are sup-ported.
Application ProcessCountries are asked to submit a simple proposal
outlining the maternal and reproductive health out-comes they would like to achieve and the associ-ated activities for which they need support. Coun-tries will be allocated funding on an annual basisthrough an annual workplan based on the amountrequested in the proposal and the availability ofMHTF resources. This funding will support the
35
country programme as part of “other resources” inthe country programme document approved by theExecutive Board. The MHTF is not intended to bea parallel funding entity, but an integrated compo-nent of each country’s programme to ensure opti-mal in-country results.
Contributions received by the MHTF from do-nors will be pooled. Donors will receive one con-solidated annual report that will include both genericand country-specific results. The funding mecha-nism is intended to be simple and flexible to allowcountries to adapt to changing situations and needs.Pooling resources under one thematic area, ratherthan many separate projects, will also reduce trans-actional costs at every level and allow for a moreharmonized development effort in countries. To fur-ther streamline support to countries, and increasecontinuity, UNFPA is considering the integration ofthe Fistula Programme into the MHTF. As men-tioned earlier, the Midwives Programme, which isstill in part funded as a separate project, has beenrecently integrated within the MHTF. There will beclose coordination of country support with the glo-bal programme for RHCS so as to decrease trans-action costs with ministries of health and streamlineworkflows and business processes with country of-fices, regions and headquarters.
The work of the MHTF will be guided by thisbusiness plan as well as a set of tools and publica-tions. Most of these tools for MNH needs assess-ment, planning, implementation, scale-up and moni-toring already exist. Work is on-going to make themeasily available to countries. Some will requiredevelopment / adaptation, particularly those relatedto human resources planning for MNH.
8. MONITORING AND EVALUATION
AND REPORTING
Strengthening national capacity for monitoring MNHis a prominent feature of MNH support. Supportfrom the MHTF will aim to strengthen the na-tional HMIS to ensure that a minimal set of inter-nationally agreed MNH indicators are includedand reported on annually. In this regard, work
led by WHO is on-going, including in particular sup-port through the International Health PartnershipM&E framework.[51]
It will be critical to capture these indicators atfacility, district and national levels. StrengtheningM&E capacity at district-level will thus be impor-tant. This will be supplemented with periodic popu-lation-based surveys, to measure such indicators asunmet need for family planning and contraceptiveprevalence.
Preliminary discussions have begun with aca-demic institutions to explore the feasibility and costsof measuring maternal mortality every three yearsin all priority countries (60 of them) so as to providea few time points between now and 2015 (for ex-ample 2009, 2012, 2015).
The coverage, outcome and impact indicatorsare imbedded in the MHTF Results Framework.Please see Annex 1 (the MHTF Results FrameworkIndicator Table), for means of verification, frequencyof reporting and other relevant information on eachindicator.
The country-specific UNFPA outputs and ac-tivity indicators will be prepared by UNFPA countryoffices in close consultation with MoH and partners.
Annual reportA consolidated annual report will be prepared
with both overall and country-specific results. Thiswill also include reporting financially on income andon the use of resources.
9. CONCLUSION
Based on a solid review of the scientific evidenceand the results of programmes in countries whichhave tackled maternal mortality, we believe thatmuch progress can be accomplished between nowand 2015, with a health systems approach of scalingup family planning, skilled attendance at delivery andemergency obstetric care, so that every pregnancyis wanted and every birth is safe.
We could then envisage, in a not too distantfuture, a world where maternal mortality has beeneliminated.
[ 5 1 ] A common framework for monitoring performance and evaluation of the scale up for better health. Monitoring & EvaluationWorking Group, International Health Partnership+. February 2008.
36
Indi
cato
rsN
atio
nal B
asel
ines
(to
be c
ompl
eted
by e
ach
coun
try
Nat
iona
l Tar
gets
(to
be c
ompl
eted
by e
ach
coun
try
Mea
ns o
f Ver
ifica
tion
Freq
uenc
y
AN
NEX
1.
MH
TF
RES
ULT
S FR
AM
EWO
RK I
ND
ICA
TO
R T
AB
LE
MD
G5
•M
ater
nal m
orta
lity
ratio
•P
ropo
rtio
n of
birt
hs a
ttend
ed b
y sk
illed
hea
lthpe
rson
nel
•C
ontr
acep
tive
prev
alen
ce r
ate
•A
dole
scen
t bi
rth
rate
•A
nten
atal
car
e co
vera
ge (
at le
ast o
ne v
isit
and
atle
ast
four
vis
its)
•U
nmet
nee
d fo
r fa
mily
pla
nnin
g
UN
FPA
Str
ateg
ic P
lan
(with
all
of th
e ab
ove)
•P
ropo
rtion
of
coun
tries
with
nat
iona
l dev
elop
men
tpl
ans
that
allo
cate
dom
estic
res
ourc
es f
or a
nes
sent
ial s
exua
l and
rep
rodu
ctiv
e he
alth
pac
kage
•P
ropo
rtio
n of
cou
ntrie
s w
here
Cae
sare
anse
ctio
n as
a p
ropo
rtio
n of
all
birt
hs f
alls
in t
hera
nge
of 5
-15%
(na
tiona
l, ru
ral a
nd u
rban
)
•P
ropo
rtio
n of
ser
vice
del
iver
y po
ints
offe
ring
atle
ast
thre
e m
oder
n m
etho
ds o
f co
ntra
cept
ion
Nat
iona
l out
put i
ndic
ator
s
•N
atio
nal c
omm
unic
atio
n an
d ad
voca
cy s
trat
egy
deve
lope
d
•C
oord
inat
ion
team
in p
lace
, led
by
MoH
, with
UN
FPA
, WH
O, U
NIC
EF,
the
Wor
ld B
ank,
Re-
gion
al D
evel
opm
ent
Ban
k, k
ey b
ilate
rals
, ci
vil
soci
ety
and
othe
r pa
rtne
rs
•C
ensu
s, D
HS,
MIC
S, o
ther
MM
pop
ulat
ion-
base
d st
udie
s
•H
MIS
, DH
S, M
ICS
•D
HS
, MIC
S
•D
HS
, C
ensu
s
•H
MIS
•D
HS
, MIC
S
•M
OH
bud
gets
and
fin
anci
alre
port
s
•H
MIS
, DH
S, M
ICS
•H
MIS
•E
xist
ence
of
docu
men
t
•M
inut
es o
f m
eetin
gs o
fco
ordi
natio
n te
am
Eve
ry 3
- 10
yea
rs
Eve
ry 1
- 5
yea
rs i
n-cr
easi
ng to
yea
rly
Eve
ry 3
- 5
year
s
Eve
ry 5
yea
rs
Eve
ry y
ear
Eve
ry 3
- 5
year
s
Year
ly
Eve
ry 1
- 5
yea
rs i
n-cr
easi
ng to
yea
rly
Year
ly
Onc
e be
fore
201
1
Year
ly
37
•D
istr
ict
heal
th m
anag
emen
t te
ams
(DH
MT)
conv
ened
reg
ular
ly b
y M
oH to
pla
n an
d m
onito
rqu
ality
MN
H s
cale
-up
•U
p-to
-dat
e ne
eds
asse
ssm
ents
for
MN
H a
s pa
rtof
nat
iona
l hea
lth p
lan
incl
udin
g FP
/RH
CS
,hu
man
res
ourc
es f
or M
NH
and
Em
ON
C
•U
p-to
-dat
e co
sted
nat
iona
l pla
ns f
or F
P/R
HC
San
d E
mO
NC
•P
ropo
rtio
n of
ser
vice
del
iver
y po
ints
whe
rew
omen
at
tend
ing
ante
nata
l car
e re
ceiv
e V
CT
and
PM
TCT
•N
atio
nal
MN
H h
uman
res
ourc
e ne
eds
asse
ss-
men
ts u
p-to
-dat
e
•N
atio
nal
MN
H h
uman
res
ourc
e pl
an d
evel
oped
•N
umbe
r an
d pr
opor
tion
of m
idw
ifery
tra
inin
gin
stitu
tions
, in
all
part
icip
atin
g co
untr
ies,
with
revi
sed
and
cultu
rally
app
ropr
iate
cur
ricul
a–ba
sed
on I
CM
ess
entia
l co
mpe
tenc
ies
adop
ted
and
impl
emen
ted
•A
nnua
l num
ber
of m
idw
ifery
gra
duat
es f
rom
natio
nal
mid
wife
ry t
rain
ing
inst
itutio
ns i
n al
lpa
rtic
ipat
ing
coun
trie
s be
ing
depl
oyed
at
basi
cE
mO
NC
and
com
preh
ensi
ve E
mO
NC
fac
ilitie
s
•N
umbe
r an
d pr
opor
tion
of m
idw
ives
, in
all
the
part
icip
atin
g co
untr
ies,
who
are
aut
horiz
ed a
ndem
pow
ered
to
adm
inis
ter
the
core
set
of
life-
savi
ng in
terv
entio
ns (
the
seve
n ba
sic
Em
ON
Cfu
nctio
ns)
•P
ropo
rtio
n of
mid
wiv
es,
in t
he p
artic
ipat
ing
coun
trie
s, w
ho b
enef
it fr
om s
yste
ms
for
com
pul-
sory
sup
port
ive
supe
rvis
ion
and
cont
inue
ded
ucat
ion
for
mid
wiv
es
•P
ropo
rtion
of
parti
cipa
ting
coun
tries
with
a n
atio
nal
mid
wife
ry c
ounc
il/bo
ard,
with
inte
rnat
iona
l sta
ndar
ds
•M
eetin
g re
port
s
•E
xist
ence
of
docu
men
t
•E
xist
ence
of
docu
men
ts
•H
MIS
•E
xist
ence
of
docu
men
ts
•E
xist
ence
of
docu
men
ts
•Fr
om U
NFP
A C
O, b
yve
rific
atio
n of
doc
umen
tsfr
om e
ach
scho
ol
•Fr
om U
NFP
A C
O, b
yve
rific
atio
n of
doc
umen
tsfr
om e
ach
scho
ol
•Fr
om M
oH d
ocum
ents
•Fr
om m
idw
ifery
asso
ciat
ion’
s do
cum
ents
•D
irect
ver
ifica
tion
by IC
Man
d U
NFP
A re
gion
al o
ffice
s
Year
ly
Less
tha
n 5
year
s ol
d
Less
tha
n 5
year
s ol
d
Year
ly
Less
tha
n 5
year
s ol
d
Less
tha
n 5
year
s ol
d
Year
ly
Year
ly
Eve
ry 1
- 5
year
s
Eve
ry 1
- 5
year
s
Eve
ry 1
- 5
year
s
38
•P
ropo
rtio
n of
ser
vice
del
iver
y po
ints
offe
ring
at le
ast
thre
e m
oder
n m
etho
dsof
con
trac
eptio
n
Uni
ted
Nat
ions
Em
ON
C In
dica
tors
•C
ase
fata
lity
rate
for
dire
ct o
bste
tric
caus
es i
n fa
cilit
ies
•A
vaila
bilit
y of
em
erge
ncy
obst
etric
and
new
born
car
e: b
asic
and
com
preh
ensi
veE
mO
NC
fac
ilitie
s
•P
ropo
rtio
n of
all
birt
hs in
Em
ON
Cfa
cilit
ies
•M
et n
eed
for
Em
ON
C
•P
ropo
rtio
n of
cou
ntry
com
mod
ity r
e-qu
ests
sat
isfie
d
•In
tern
atio
nally
-agr
eed
MN
H i
ndic
ator
s in
tegr
ated
in n
atio
nal H
MIS
•Sp
ecifi
c no
tific
atio
n of
mat
erna
l dea
ths
•A
nnua
l num
ber
of m
ater
nal d
eath
aud
its in
-cr
ease
d
•P
ropo
rtio
n of
dis
tric
ts r
epor
ting
year
ly o
n na
tion-
ally
-agr
eed
MN
H i
ndic
ator
s
•Fr
om H
MIS
(not
e U
NFP
Ast
rate
gic
plan
ind
icat
or a
ndal
so p
art o
f GP
RH
CS
M&
Efr
amew
ork)
See
: The
Indi
cato
rs fo
rM
onito
ring
The
Ava
ilabi
lity
and
Use
of O
bste
tric
Ser
-vi
ces.
WH
O, U
NFP
A, U
NIC
EF.
Col
umbi
a U
nive
rsity
. Su
b-m
itted
for p
ublic
atio
n 20
09.
(Not
e: u
pdat
ed e
ditio
n fr
om19
97 d
ocum
ent)
•F
rom
Em
ON
C n
eeds
as-
sess
men
ts a
nd H
MIS
•Fr
om H
MIS
•Fr
om H
MIS
•Fr
om H
MIS
•Fr
om n
atio
nal
requ
ests
re-
ceiv
ed
•Fr
om H
MIS
(inc
lude
s M
DG
5,FP
in S
DP
s, U
nite
d N
atio
nsE
mO
NC
ind
icat
ors)
•Fr
om H
MIS
•Fr
om H
MIS
•Fr
om H
MIS
Year
ly
Eve
ry 1
- 5
year
s in
-cr
easi
ng to
yea
rly
Eve
ry 1
- 5
year
s in
-cr
easi
ng to
yea
rly
Eve
ry 1
- 5
year
s in
-cr
easi
ng to
yea
rly
Eve
ry 1
- 5
year
s in
-cr
easi
ng to
yea
rlyE
very
1 -
5 ye
ars
in-
crea
sing
to y
early
Eve
ry 1
- 5
year
s
Year
ly
Year
ly
Year
ly
39
•S
hare
of g
over
nmen
t exp
endi
ture
for
hea
lth (
aspe
r an
nual
gov
ernm
ent
fig
ures
)
•N
atio
nal b
udge
t for
MN
H o
vera
ll an
d pe
r ca
pita
(incl
udin
g al
l flo
ws:
dom
estic
and
ext
erna
l), a
sm
easu
red
thro
ugh
natio
nal
heal
th a
ccou
nts
whe
re th
ey e
xist
Oth
er c
ount
ry-s
peci
fic o
utpu
ts(P
leas
e re
fer
to c
ount
ry-s
peci
fic p
ropo
sals
toth
e M
HTF
and
cou
ntry
AW
Ps fo
r eac
h M
HTF
supp
orte
d co
untr
y)•
Oth
er in
dica
tor
…•
Oth
er in
dica
tor
…
Reg
iona
l out
put i
ndic
ator
s
•N
umbe
r of
reg
iona
l m
eetin
gs o
n M
NH
•A
nnua
l num
ber
of S
outh
-Sou
th M
NH
cap
acity
build
ing
mis
sion
s /
exch
ange
s in
volv
ing
MH
TF-
supp
orte
d co
untr
ies
•P
rese
nce
of r
egio
nal e
ffort
s to
sta
ndar
dize
mid
wife
ry c
urric
ula
with
in r
egio
ns b
ased
on
inte
rnat
iona
l st
anda
rds
•N
umbe
r of
MH
TF-s
uppo
rted
cou
ntrie
s in
eac
hre
gion
with
a n
atio
nal
mid
wife
ry c
ounc
il/bo
ard
esta
blis
hed
and
func
tioni
ng
Glo
bal o
utpu
t ind
icat
ors
•Le
vel o
f fin
anci
ng fo
r M
NH
for
high
mat
erna
lm
orta
lity
coun
trie
s
•N
umbe
r of
cou
ntrie
s re
ceiv
ing
join
t U
N-M
NH
supp
ort
•N
umbe
r of
inst
itutio
ns a
ctiv
ely
part
icip
atin
g in
the
tech
nica
l as
sist
ance
net
wor
k
•Fr
om g
over
nmen
t an
nual
finan
cial
rep
orts
•Fr
om M
oH r
epor
ts
•Fr
om U
NFP
A R
O
•Fr
om U
NFP
A R
O
•Fr
om IC
M a
nd U
NFP
A R
O
•Fr
om U
NFP
A C
Os
•Fr
om g
loba
l st
udie
s (e
.g.
WH
O, U
NFP
A, U
NIC
EF,
Wor
ld B
ank
cost
ing)
•Fr
om U
N-M
NH
wor
king
grou
p
•Fr
om U
NFP
A M
HTF
coor
dina
tion
team
Year
ly
Year
ly
Year
ly
Year
ly
Year
ly
Year
ly
Eve
ry 3
- 5
year
s
Year
ly
Year
ly
40
ANNEX 2.
A. JOINT STATEMENT ON MATERNAL AND NEWBORN HEALTH
B. WHO-UNFPA-UNICEF-WORLD BANK JOINT COUNTRY SUPPORT FOR
ACCELERATED IMPLEMENTATION OF MATERNAL AND NEWBORN CONTINUUM OF
CARE
C. PROPOSED LIST OF PRIORITY COUNTRIES FOR UN MNH JOINT WORK
41
Today, 25 September 2008, as world leaders gather for the High-Level Event on the Millennium Development Goals (MDGs), we jointly pledge to intensify our support to countries to achieve Millennium Development Goal 5 To Improve Maternal Health — the MDG showing the least progress.
During the next five years, we will enhance support to the countries with the highest maternal mortality. We will support countries in strengthening their health systems to achieve the two MDG 5 targets of reducing the maternal mortality ratio by 75 per cent and achieving universal access to reproductive health by 2015. Our joint efforts will also contribute to achieving MDG 4 To Reduce Child Mortality.
Every minute a woman dies in pregnancy or childbirth, over 500,000 every year. And every year over one million newborns die within their first 24 hours of life for lack of quality care. Maternal mortality is the largest health inequity in the world; 99 per cent of maternal deaths occur in developing countries — half of them in Africa. A woman in Niger faces a 1 in 7 chance during her lifetime of dying of pregnancy–related causes, while a woman in Sweden has 1 chance in 17,400.
Fortunately, the vast majority of maternal and newborn deaths can be prevented with proven interventions to ensure that every pregnancy is wanted and every birth is safe.
We will work with governments and civil society to strengthen national capacity to:
• Conduct needs assessments and ensure that health plans are MDG–driven and performance–based;
• Cost national plans and rapidly mobilize required resources;
• Scale-up quality health services to ensure universal access to reproductive health, especially for family planning, skilled attendance at delivery and emergency obstetric and newborn care, ensuring linkages with HIV prevention and treatment;
• Address the urgent need for skilled health workers, particularly midwives;
• Address financial barriers to access, especially for the poorest;
• Tackle the root causes of maternal mortality and morbidity, including gender inequality, low access to education — especially for girls — child marriage and adolescent pregnancy;
• Strengthen monitoring and evaluation systems.
In the countdown to 2015, we call on Member States to accelerate efforts for achieving reproductive, maternal and newborn health. Together we can achieve Millennium Development Goals 4 and 5.
JOINT STATEMENT ON MATERNAL AND NEWBORN HEALTH
Margaret Chan Director General, WHO
Ann M. Veneman Executive Director, UNICEF
Joy Phumaphi Vice President Human Development, World Bank
Thoraya Ahmed Obaid Executive Director, UNFPA
Accelerating Efforts to Save the Lives of Women and Newborns
WHO-UNFPA-UNICEF-World Bank Joint Country Support for Accelerated
Implementation of Maternal and Newborn Continuum of Care 22 July 2008
Objective To harmonize approaches by UN agencies towards improving maternal and newborn health (MNH) at country level and jointly raise the necessary resources. Background The year 2007 represented the mid-point for the Millennium Development Goals (MDGs). While there has been some progress in the health-related MDGs, MDG 5 is the one with the least progress.1,2 It represents the greatest inequality in health and one that affects women, with a life-time risk of maternal death of one thousand times greater in parts of sub-Saharan Africa and Asia (as high as 1 in 7) than in some industrialized countries. Complications of pregnancy and childbirth leave 10-20 million women with physical and mental disabilities every year. Maternal mortality has root causes in gender inequality, low access to education, especially for girls, early marriage, adolescent pregnancy, low access to sexual and reproductive health, including for adolescents, and other social determinants. Maternal mortality can be effectively reduced by addressing the above determinants and by ensuring universal access to a) family planning, b) skilled attendance at birth and c) basic and comprehensive emergency obstetric care. Maternal and newborn health is also intrinsically related to health programmes such as HIV and AIDS, in particular primary prevention and prevention of mother-to-child transmission, malaria prevention and treatment, nutrition and immunization. Taking into consideration the comparative advantage, core expertise/experience, and collective strengths in MNH, WHO, UNFPA, UNICEF and The World Bank undertake to accelerate our joint support to countries to improve maternal and newborn survival by strengthening the continuum of care. The agencies will coordinate their support at country level guided by the national health plan and according to each agency’s respective country-specific strengths and capacities. Support to these activities will be embedded within the strengthening of national health systems. The agencies will jointly contribute to national capacity strengthening, building of sustainable national health systems and costing and financing of MNH national plans whilst ensuring national and global advocacy. 1 Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and The World Bank. October 2007. Geneva. WHO.
Africa and the Millennium Development Goals. United Nations. 2007 Update. http://www.un.org/millenniumgoals/docs/MDGafrica07.pdf
2 The Millennium Development Goals Report. United Nations. 2007. http://millenniumindicators.un.org/unsd/mdg/Resources/Static/Products/Progress2007/UNSD_MDG_Report_2007e.pdf
2
Core functions of the UN agencies based on their comparative advantage:
• WHO: policy, normative, research, monitoring & evaluation • UNFPA: reproductive health commodity security, support to implementation, human resources for sexual and reproductive health including MNH, technical assistance on building M&E capacity • UNICEF: financing, support to implementation, logistics & supplies, monitoring &
evaluation • The World Bank: health financing, inclusion of MNCH in national development frameworks, strategic planning, investment in inputs for health systems, including fid- ciary systems and governance, taking successful programmes to scale
Focal agencies Focal agencies – (or shared focal agencies) – have been identified for each component of the MNH continuum of care and related functions to ensure and facilitate coordinated, optimal support to countries and clear accountability (Table 1). While these provide global guidance, the work of each agency at country level will be determined by existing situations in countries where agency strengths and experience differ as well as by arrangements such as sector-wide approaches (SWAps), or other sector plans, within the context of support to the national health plan/compacts. Being a focal agency would imply accountability at global and national level for facilitating and ensuring coordinated optimal support to countries for scale-up of the agreed programme components including:
ensuring knowledge of the situation, inventory (mapping) of existing activities and resources, including human resources;
ensuring support for the inclusion of MNH continuum of care concept in the development of detailed national plans/compacts and district plans;
ensuring availability of technical support (tools and people); identifying relevant partners and supporting government coordination; supporting resource mobilization; and ensuring that a strong monitoring and evaluation system and the required skills are in place
and used.
Being a focal agency does not mean that other agencies are not involved; on the contrary, the focal agency should help coordinate a strong UN response in support of the national health plan and national leadership, and foster the involvement of other key partners. The government should always lead and coordinate the process. Table 1 Proposed focal agency per building blocks, i.e. core areas within the continuum of care
Area Focal agency Partners Family Planning UNFPA, WHO UNICEF, WB Antenatal Care UNICEF, WHO UNFPA, WB Skilled Attendance at Birth WHO, UNFPA UNICEF, WB B-EmONC3 UNFPA, UNICEF WHO, WB C-EmONC4 WHO, UNFPA UNICEF, WB Post-partum WHO, UNFPA UNICEF, WB Newborn care WHO, UNICEF UNFPA, WB Maternal and Neonatal Nutrition UNICEF, WHO,WB ( for
maternal nutrition) UNFPA
3 B-EmONC Basic Emergency Obstetric and Newborn Care 4 C-EmONC Comprehensive Emergency Obstetric and Newborn Care
3
Table 2 lists additional issues and functions to be considered for maternal and newborn health programming. Table 2: Focal and partner UN agencies in additional areas of MNH work
Area Focal Agency Partners Girls education UNICEF UNFPA, WB Gender/culture/male involvement UNFPA, UNICEF WHO, WB Gender-based violence UNFPA, UNICEF WHO Adolescent sexual reproductive health - young people
UNFPA, UNICEF, WHO WB
Communication for development UNFPA, UNICEF WHO, WB Obstetric fistula UNFPA WHO Prevention of unsafe abortion/ post-abortion care
WHO UNFPA
Female genital mutilation UNFPA, UNICEF, WHO WB MNH in humanitarian situations UNFPA, UNICEF, WHO WB Sexually transmitted infections WHO UNFPA, UNICEF HIV/AIDS and integration with family planning
As per UNAIDS Technical Support Division of Labour
Pre- and in-service training of human resources for MNH
WHO, UNFPA UNICEF, WB
Regulation/legislation for human resources for health
WHO UNFPA, UNICEF, WB
Essential drug list WHO UNFPA, UNICEF Road maps' development and implementation
WHO, UNFPA, WB UNICEF
Proposed list of Priority Countries for UN MNH Joint Work
Country MMR
Lifetime risk of maternal death. 1 in IHP Catalytic EU Gates Norway
CIDA-PMTCT
UNFPA-MHTF
WB-Norway SPP*
GF-MNH Joint UN-MNH
Afghanistan 1800 8 1 1 1 1Angola 1400 12 1 1Bangladesh 570 51 1Benin 840 20 1 1 1 1 1Burkina Faso 700 22 1 1 1 1 1 1 1Burundi 1100 16 1 1 1Cambodia 540 48 1 1 1 1Cote d'Ivoire 810 27 1Djibouti 650 35 1DRC 1100 13 1 1Eritrea 450 44 1Ethiopia 720 27 1 1 1 1 1 1Ghana 560 45 1 1 1 1Guyana 470 90 1 1Haiti 670 44 1 1 1India (very high MMR states) 450 70 1 1 1Kenya 560 39 1 1 1Lesotho 960 45 1Liberia 1200 12 1 1Madagascar 510 38 1 1 1Malawi 1100 18 1 1 1 1 1 1Mali 970 15 1 1 1Mozambique 520 45 1 1 1 1 1Nepal 830 31 1 1Niger 1800 7 1 1 1 1Nigeria 1100 18 1 1 1Pakistan 320 74 1 1 1 1Rwanda 1300 16 1 1Senegal 980 21Sierra Leone 2100 8 1Sudan 450 53 1Swaziland 390 120 1 1Tanzania 950 24 1 1 1 1 1 1Uganda 550 25 1Vietnam 150 280 1 1Zambia 830 27 1 1 1 1Zimbabwe 1 1 1
Total 11 14 8 3 4 4 11 9 14 4 25Selection criteria
Sub-set of 68 Countdown countries
Very high MMR > 550
Committed Country Teams (governement and partners)
Potential for scale-up including availability of financial resources