annual rEporT 2009 THE MaTErnal HEalTH THEMaTic fund Accelerating Progress towards Millennium Development Goal 5 The Maternal Health Thematic Fund Annual Report 2009 i THE MiSSiON OF UNFPA unfpa, the united nations population fund, is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. unfpa supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HiV, and every girl and woman is treated with dignity and respect. UNFPA - because everyone counts. Cover photo by Lynsey Addario/Vii A pregnant Congolese woman seen at her home in the neighborhood of Birere, Goma, North Kivu province, Democratic Republic of the Congo. April 10, 2008. Table of Contents photo by GMB Akash/Panos Picture A husband visits his wife and child at the Fistula Repair Centre at Dhaka Medical College Hospital in Bangladesh. 2005. TABLE OF CONTENTS Acknowledgements 02 Foreword by Werner Haug – Director, Technical Division, UNFPA 05 Executive Summary 07 introduction 17 Maternal Health Thematic Fund Overall Results 19 Strengthening Midwifery: UNFPA-iCM Midwifery Programme 39 Campaign to End Fistula 53 Way Forward 73 Financial information 75 ACKNOWLEDGMENTS UNFPA wishes to acknowledge its partnerships with national governments and donors. We would also like to acknowledge the leadership of the African Union for launching the Campaign to Accelerate Maternal Mortality Reduction in Africa (CARMMA) as a specific follow-up to the Maputo Plan of Action. UNFPA acknowledges with gratitude the multi-donor support generated to strengthen Maternal and Newborn Health (MNH) since 2003. In particular, we wish to thank the governments of Australia, Austria, Canada, Finland, Iceland, Ireland, Luxembourg, The Netherlands, New Zealand, Norway, Poland, Republic of Korea, Spain, Sweden and Switzerland. Special thanks also go to donor funds, private corporations and NGOs for their contributions, among them: Americans for UNFPA, the Bill and Melinda Gates Foundation/EngenderHealth, European Voice, Johnson and Johnson, Virgin Unite, Women’s Missionary Society of the African Methodist Episcopal Church, United Nations Foundation, the UN Trust Fund for Human Security, Zonta International and our many individual donors. We express our sincere thanks to country, regional and global colleagues in the World Health Organization (WHO), UNICEF and the World Bank for their invaluable teamwork and for jointly supporting countries in the spirit of Delivering as One. Sincere gratitude also goes to our development partners for their collaboration and sup- port in championing MNH issues and for their technical contributions: Columbia University’s Averting Maternal Death and Disability (AMDD) Program, EngenderHealth, Family Care International (FCI), the International Federation of Gynecology and Obstetrics (FIGO), the International Confederation of Midwives (ICM), Immpact (Aberdeen University), Johns Hopkins University (JHPIEGO), the many partners of the Partnership for Maternal, Newborn and Child Health (PMNCH), the PMNCH Secretariat, and national and regional institutions. Finally, we thank the hardworking team of the UNFPA Sexual and Reproductive Health Branch, Commodity Security Branch, our colleagues in the Technical Division, colleagues in the Resource Mobilization Branch and in the Media and Communication Branch, and members of the Maternal Health Inter-Divisional Working Group for their commitment, solidarity and teamwork in promoting maternal and newborn health. We thank you all and look forward to further collaboration and active participation in the future. 2 The Maternal Health Thematic Fund Annual Report 2009 LiST OF ABBREViATiONS AND ACRONyMS aMdd Averting Maternal Death and Disability Program – Columbia University dHS Demographic and Health Surveys Emoc Emergency obstetric care Emonc Emergency obstetric and newborn care HMiS Health management information system icM International Confederation of Midwives iHp+ International Health Partnership iMMpacT Initiative for Maternal Mortality Programme Assessment – University of Aberdeen H4 WHO, UNICEF, UNFPA and The World Bank GprHcS Global Programme on Reproductive Health Commodity Security 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 Mpoa Maputo Plan of Action npc Non-physician clinician of Obstetric Fistula (Global Campaign to End Fistula) SrH Sexual and reproductive health unfpa United Nations Population Fund unicEf United Nations Children’s Fund undp United Nations Development Programme WHo World Health Organization The Maternal Health Thematic Fund Annual Report 2009 3 A Masai woman in the RIft Valley province, Kenya. Photo by Seamus Murphy/VII. 4 The Maternal Health Thematic Fund Annual Report 2009 FOREWORD Werner Haug, Director Technical Division, UNFPA We, as, a global community have committed to improving maternal health. More concretely, as mapped out in Millennium Development Goal (MDG) 5, we have agreed to reduce, by 2015, the global maternal mortality ratio by three quarters, using 1990 as a baseline. To this overall goal another target was added in 2007 — that of ensuring universal access to reproductive health by 2015. To back up our commitment to maternal health, two UNFPA initiatives — the Global Programme on Reproductive Health Commodity Security and the Maternal Health Thematic Fund — represent a focused effort to accelerate progress towards MDG 5 in the 60 countries that have the highest maternal mortality and are furthest from achieving universal access to reproductive health. Toward this end, UNFPA complements its core resources where the need is greatest to ensure that every pregnancy is wanted and every birth is safe. The Maternal Health Thematic Fund (MHTF) became operational in 2008, and 2009 represents the first full year of operations. As this annual report illustrates, significant progress can be made by adopting proven strategies — including family planning, skilled care during childbirth (particu- larly midwifery services), expanded access and utilization of emergency obstetric and newborn care — combined with partnerships for better coordination under national leadership. To increase the effectiveness and efficiency of country support, reduce administrative and transaction costs, and foster closer alignment with government procedures, the Midwifery Programme (launched in 2008 with generous support from the Swedish government and since supported by other donors as well) and the Campaign to End Fistula (launched in 2003 with multi-donor support) were programmatically integrated into the Maternal Health Thematic Fund in April 2009 and September 2009, respectively. Both initiatives will continue to operate as targeted efforts in programme countries under the umbrella of the Maternal Health Thematic Fund. As such, the 2009 MHTF Annual Report reflects outcomes and achievements of the Maternal Health Thematic Fund activities, including the Midwifery Programme and the Campaign to End Fistula. I would like to take this opportunity to thank countries, donors, WHO, UNICEF, the World Bank, other partner organizations, and all concerned colleagues for this effective collaboration. The Maternal Health Thematic Fund Annual Report 2009 5 Young girls in Afghanistan. Photo by Lynsey Addario/VII. 6 The Maternal Health Thematic Fund Annual Report 2009: Executive Summary 2 0 0 9 ExECUTiVE SUMMARy In early 2008 the United Nations Population Fund (UNFPA) launched the Maternal Health Thematic Fund (MHTF). This effort — UNFPA’s contribution to boost maternal and new- born health — aims to provide support to countries with a high maternal mortality burden to scale up proven interventions needed to save mothers and infants. In synergy with the UNFPA’s Global Programme on Reproductive Health Commodity Security (GPRHCS), technical assistance is provided to develop capacity. In 2009 UNFPA integrated its thematic funds to improve the effectiveness and efficiency of its programmes while reducing transaction costs to countries. As a result, the Maternal Health Thematic Fund now serves as the umbrella under which UNFPA’s Midwifery Programme and Campaign to End Fistula operate. This document highlights MHTF actions taken and results achieved in 2009. This summary identifies bottlenecks to maternal health services in priority countries, strategies available to address these bottlenecks, results achieved in the past year, and, looking ahead, key challenges for 2010. One critical bottleneck to improving maternal health, for example, is the shortage of supply in family planning — a high priority for UNFPA. To learn more about scaling up family planning services, readers are invited to consult the annual report of UNFPA’s Global Programme on Reproductive Health Commodity Security. identifying Bottlenecks in Maternal Health care In order to identify bottlenecks in maternal health care, UNFPA relies upon information from a variety of sources. One such source is the mapping exercise conducted by UNFPA, UNICEF, WHO and the World Bank (known as the H4), which was designed to identify those countries with the greatest need to reduce maternal mortality and set priorities. Other sources of information include: inception missions, country health indicators, emergency obstetric and neonatal care needs assessments, midwifery desk reviews, obstetric fistula needs assessments, and factors underlining high maternal mortality ratios. Among the latter are very low access to and uptake of family plan- ning, and weak health systems (particularly inadequate midwifery skills, poor service delivery and limited financial investment). Strategies to address Bottlenecks The Maternal Health Thematic Fund employed several strategies to address the bottlenecks identified above, namely: `` Raising awareness and political will through public outreach, advocacy and working with the media; The Maternal Health Thematic Fund Annual Report 2009: Executive Summary 7 `` Contributing to the launch of country-led initiatives, such as Malawi’s Campaign to Accelerate Reduction of Maternal Mortality in Africa (CARMMA), which aims to leverage resources and ensure that maternal health is a national priority; `` Strengthening the capacity of UNFPA country offices to better provide technical assistance and support national processes through the recruitment and posting of Technical Advisors for maternal health, midwifery and obstetric fistula. Technical Advisors are at work in Madagascar, Ethiopia, Haiti, Guyana and Benin, and more are under recruitment in Nigeria, Mali and DRC; `` Strengthening monitoring and evaluation through better planning, including: annual work plans; peer review exercises; discussing, amending and finalizing results frameworks; and institutionalizing maternal death reviews to identify cause of death. The peer review process was cited by the UNFPA Division of Oversight Services as a best practice that country offices could implement with core funding to improve efficiency; `` Improving documentation to promote advocacy and information sharing; `` Building partnerships with UN and non-UN organizations to coordinate efforts and maximize results. Key contributions and results In 2009, the Maternal Health Thematic Fund (MHTF) provided support to 15 countries (Benin, Burkina faso, Burundi, cambodia, djibouti, Ethiopia, Guyana, Haiti, Madagascar, Malawi, Sudan, cote d’ivoire, Ghana, uganda and Zambia), among which four were supported only for midwifery (cote d’ivoire, Ghana, uganda and Zambia). The Campaign to End Fistula supported 25 countries (Benin, car, chad, cote d’ivoire, congo, drc, Eritrea, Gabon, Ghana, Guinea, Guinea-Bissau, Kenya, liberia, Malawi, Mauritania, niger, nigeria, Senegal, Zambia, afghanistan, Bangladesh, nepal, pakistan, Somalia and Sudan). In order to deliver support to priority countries, MHTF has strengthened partnerships with scien- tific and academic communities, such as the International Confederation of Midwives, the Interna- tional Society of Fistula Surgeons (ISOFS), Johns Hopkins University, Columbia University and the University of Aberdeen, among others, for evidence-based support to priority countries. Also, dur- ing 2009, joint WHO, UNFPA, UNICEF and World Bank (H4) missions were organized in Ethiopia, Nigeria, and DRC — three of the six countries that account for half of all maternal deaths. These missions embody the “deliver as one’’ principle by fostering collaboration among UN agencies and the efficient use of technical and financial support. 8 The Maternal Health Thematic Fund Annual Report 2009: Executive Summary