Economic and Political determinants

of Safemotherhood

Dr Olive Sentumbwe-Mugisa
Family Health and Population Advisor
WHO

Intention of presentation

Present and discuss the dimensions and

determinants of Safe motherhood

Dimensions imply

Health is something tangible

Health can be measured
Health can change
Change = increase or decrease
Health status is unlikely to remain the
same

Understanding the dimensions,

determinants

What
What
What
What

is health?
increases health?
decreases health?
keeps health the same?

Grouping of Determinants of
Health

WHO Definition of Health

Health
A state
A state of mind everything that changes
the mind, changes health
A state of body everything that changes
the body changes health
A state of life everything that changes
life changes health

Determinants of Health
Health status is influenced by:
Biology- Biologic and genetic endowment
Health care( Availability and Quality )
But to a much larger extent by what has
been termed as the broader
determinants of health called social
determinants

Determinants of Health
Genes (race)
Environment biological factors,
physical factors and chemical factors
(GEOGRAPHY WEATHER - ALTITUDE)
Nutrition (QUALITY, QUANTITY OF FOOD
AND WATER)
Lifestyle pleasure, leisure, vices,
occupation
Socio-economic status
Time (Age)

Social determinants

Income and social status

Social support networks
Education/Time
Employment/working conditions
Social environments/politics
Housing
Personal health practices and coping
skills

Social determinants cont--

Healthy child development

Access to health services
Gender issues
Powerlessness
Culture and ethnicity
Immigration/refugee status

How can we measure health?

Degree of morbidity

(physical+mental)

Degree of disability
(physical+mental)
Degree of mortality
Death = zero health

Some of the factors that can

change the mind, body and life?
Stress,
Abuse (physical, emotional, sexual)
Deprivation (food, liberty, sex,)
Accidents

Deprivation
Imprisonment

Economic
Family Planning:
High Fertility and Low use of FP
leading to large unaffordable families
in terms of shelter, food and
schooling
Environmental degradation leading to
women walking and working harder
to find food and firewood

Poor living conditions result into:

Excessive workload and no rest
Poor shelter therefore exposed to
diseases such as malaria
Poor sanitation at times leading to
worm infestations and diarrhoea
Poor cooking methods with firewood
and charcoal stoves therefore smoke
leading to chronic lung diseases
starting with bronchitis

Fire Outbreaks

Poverty and women

Smoked food -direct flame has also been
associated with liver, pancreas disease as
well as pharyngeal carcinoma
For some women in Kenya who have had to
carry heavy loads on their backs tied
around the forehead some bone disorders
of the vertebrae have been recorded
(KEMWA) and chronic osteoathritis

HIV and Poverty

Some women are forced into sex for
food and clothing
Some students trade sex for basic
needs such as school fees ,
underwear and sanitary pads
Poor shelter of slum dwellers force
children to be exposed early to sexual
activity of their parents so they also
start experimenting

Overall HIV Prevalence in

Uganda by Sex and Age

Sex for something concept

Leads to unwanted pregnancy as well
in many young women and older
Unsafe Abortion and the possible
related complications such as
infection, chronic pelvic pain,
infertility in the long run,excessive
bleeding, death etc
Uganda has a very high prevalence of
abortion at 54/1000

Maternal Health
The Rural poor have high fertility because
of poor access to FP services but also rural
poor men desire large families
Rural poor women in this way have higher
increased lifetime risk to pregnancy
complications
Yet poor access to maternal health services
due to poverty and longer distances

Why Women Die in Pregnancy & Childbirth:

The Three Delays
1st Delay
Delay in the Home

3rd Delay

2nd Delay
Delay in
Accessing the
Health Facility

Delay in
receiving care
at the health
facility

Delivery by skilled attendant and fertility:

differences according to poverty-wealth index

Newborn Health
Overworked and poorly nourished
women are likely to produce small
children
Underweight babies will not do well
Data shows that underweight is a risk
to newborn survival

Adolescent Pregnancy
High amongst the rural poor for
dowry (exchange of money for the
girl) and cultural norms
Low information about sexuality and
no services
Poor use of FP services amongst this
age group-DHS 2000

Issues Relating to the health

of Adolescents
High Proportion of Unintended
Pregnancy
Less than 20% have access to
Services
High Secondary School Drop
Out Rate- double tragedy
High STI/HIV Infection Rate
Lack of life and livelihood Skills

Average number of births per 1000 females

age 1519 in various regions (UNICEF, 1998)

Adolescent contribution to
maternal mortality

40 44%
* Data from Mulago National Referral
Hospital, 2005.
* Maternal death review reports:
Soroti, Hoima and Iganga, 2003.

Cancer of the cervix

High prevalence of HPV
Low knowledge
No vaccine as it is unaffordable
Scanty cancer cervix screening
services
Most common cancer amongst
women in Uganda

Infertility
Management of Infertility is out of
reach for many of the poor people in
Uganda so therefore a double tragedy
7% of couples known to be infertile in
Uganda

Gender Issues in RH
Vesicle vaginal and Rectal Vaginal
Fistula
High prevalence amongst the rural poor
because they cannot access services
easily therefore when they get
obstructed labour they cannot easily be
assisted

Therefore this remains largely a

disease of poverty

Male Support for Womens Health

When women are economically empowered
they can afford and access health services
when they need them other than depending
on handouts from their male spouses who
may also be equally economically
challenged
Similarly poor men take long to seek
services because they cannot afford them
usually therefore present with late signs
difficult/expensive/too late to manage

Politics and womens health

There is an apparent political good will to
address the poor SRHR indicators in the
region but also a blessing and sense of
social responsibility from the international
community

We could take it from the ICPD

The Abuja declaration-15% for health
The Road Map for MNH
The Maputo Plan of Action
The First Ladies Forum and activities for Safe
motherhood-White Ribbons Alliance

Launch of CARMMA
24 countries so far have launched
Uganda launched its forum on 5th May
2010
The main purpose here is to engage the
communities to play their parts in
protecting and promoting womens
health and ensure Safe motherhood
It also aims at advocating to
stakeholders to address service provision

Uganda
The Road Map has been signed by the
President
Making Pregnancy Safer is district evidence
on how political will can make a difference
Some of the politicians involved used the
interventions-Ambulances to gain further
support
While the specialist in the refferral hospital
could not be voted into politics because he
was more valued as a health worker saving
womens and childrens lives

Local Government Political support

Work plans addressed the local needs of
women in their various villages as there
was grassroot planning capturing issues
which were affecting production in Soroti
district
One of these was health of women in
relation to pregnancy- need for more health
units and midwives and for sometime these
two interventions were priotised in the local
development fund

Political Support and Resource

Allocation
Political will important for Budget allocation
to maternal health programmes at all levels
as you have seen
We have involved the parliament to
appreciate what the Road Map for
accelerating the reduction of maternal and
newborn deaths is and why more resources
need to be put in health and for what
interventions

Political Support and Legislation

Issues of Safe Abortion Access for
RAPE and Defilement

War, Civil Strife and maternal

Health
High risk environment for women-RAPE
No access to organised health services such
as FP, ANC, delivery and Skilled care
However when war, natural disasters are
on, the first packages rarely include
Reproductive Health needs yet the greatest
at risk are women and children

SAMPLE OF MCH SERVICE DELIVERY POINT

WITH IN A CAMP SETTING
Partitioning
using papyrus
Reeds.

High Population and Hunger

High Population density and therefore hunger is a common problem in the refugee camps.

Health Challenges of refugee/migrant

women

During Displacement
H/Workers migrate to safer places
People engage more in sexual
activities voluntarily or forced for food
or even as a case of direct violence
against young girls and women
HIV is likely to be on the rise
The traditional system for caring for
pregnant women usually take over

Politics continued
Political stability is key for the desired
multi-sectoral support to accelerate
reduction
Coordination and accountability is
required at a very high level in order
for health programmes to receive the
inputs they need from Ministries of
finance and other related service
ministries

What about Global politics?

Do we have examples in countries
outside AFRICA where politics has
influenced peoples Reproductive
health?

Slow Progress of RH Indicators;

Persistent Inequalities
Coverage Gap for key proven
evidence based interventions

TRENDS OF THE REPRODUCTIVE

HEALTH INDICATORS IN UGANDA
1987
1995
2000
2006
TFR
UNMET
FP
CPR
DELIVERIES
(skilled)

ADOL
PREG.
MMR
IMR
Neonata

7.3

6.9

6.9

6.7

33%

29%

35%

42

5%

15%

23%

24%

37%

38%

44%

43%

38%

42%
25

32%
527

506

122

81

435
505

77
32

Coverage of Maternal/ Neonatal interventions

along the continuum of care in Africa

Source: Opportunities for Africas Newborns based on State of the Worlds Children 2006, and DHS
released since

Inequities in the coverage of some neonatal

interventions among African countries

Source: Opportunities for Africas Newborns - base en 32 EDS

Reference materials
MDGs
ICPD plan of action
The Road Map for Accelerated
Reduction of maternal and newborn
mortality
The Maputo Plan of Action
The MPS

How?
Empowering communities to willingly
make health protecting, health
restoring and health promoting choices

Evidence
Strong advocacy skills
Resources
Multifaceted approach

Conclusions
Health has many dimensions
It is important to understand the
different dimensions as they relate to
the community one is serving
Empowering communities to make
informed choices willingly to protect,
promote and restore their own health
is a major goal of all health systems.

Thank You