INTERNATIONALBANK FOR WORLD BANK R E T C N O E N STRUCTION PM AND DEVELO May 2004 No. 47 A regular series of notes highlighting recent lessons emerging from the operational and analytical program of the World Bank`s Latin America and Caribbean Region INTEGRATED SERVICES TO FIGHT MATERNAL MORTALITY IN NICARAGUA Maria Elena Ruiz Abril and Jesus María Fernández Díaz 1 Introduction health in remote areas of Nicaragua through Women's Reducing Nicaragua's high maternal mortality rate of 150 Centers (WC), which provide care to high-risk pregnant maternal deaths per 100,000 live births is a priority in the women before and after delivery; and "Extension of Government's Health Plan and Poverty Reduction Strat- Coverage" initiatives that sub-contract health operators to egy.2 Efforts to improve repro- provide basic health care to iso- ductive health face many chal- lated communities. Since 2001, lenges. Adolescent pregnancy nine WCs (Table 1) have served rates are among the highest in 2,927 women--6 percent of all the region (130 per 1,000 15- expected births in the 887 com- 19 year olds). Fertility in rural munities in 23 municipalities they areas (5.4 children per cover.3 "Extension of Coverage" woman) and among poor projects in Siuna and San Carlos women (6.6) is significantly cover 4-6 percent of the popula- higher than the Latin Ameri- tion of these districts, serving ap- can average of 2.8 children proximately 11,000 people per per woman. Poverty, limited year. educational and employment opportunities, traditional gen- Women in isolated rural commu- der roles and disempowerment nities with high risk pregnancies of women, and poor access to are referred to the WC by health distant health services across personnel (health volunteers in difficult terrain in remote ru- communities, midwives, and doc- ral areas are significant barri- tors and nurses in intermediary ers. Maternal complications health points). These women tend need immediate attention, are to be poor or extremely poor, with difficult to manage and often little or no education. Nearly one lead to the death of the woman (and/or child). third are teenagers. They usually spend two weeks before delivery and one week after delivery at the center. In addition to food and lodging, they receive daily medical Women's Centers and Extending Health visits from health center doctors, and education on sexual and reproductive health including family planning (FP) Care Services to Remote Areas and child care. WCs have extended their services beyond those planned, offering advice and counseling on issues as Since 1998, the health sector reform project has contrib- diverse as domestic violence, child support claims, and uted to improving maternal mortality and reproductive how to obtain identity cards or land titles. 1 Under "extension of coverage" initiatives, the MoH hires Box 1. Women's Centers in figures a local health operator (usually a CSO) to visit remote rural communities periodically to monitor health and From 2001-2003, 2927 women gave birth to 2930 provide basic health services. Using an incentive-based babies in WCs-80 percent of the women were poor or contract, the MoH reimburses the local health operator extremely poor - 30 percent of the women were according to agreed-upon health indicators. The CSOs younger than 19 years, 30 percent were older than 35- tend to be grass root organization which work closely with 60 percent had little or no education - Their average the community health network of midwives and volun- number of children was 4.6 - half the women had teers. The integration of this network with the formal previously delivered a baby at home - In the North health care system has produced excellent results for basic Atlantic Zone, 90 percent of the women were of and reproductive health care. Miskito origin - The average travel time to the WC is between 3 and 8 hours on foot or by boat Results Following an initial visit by the Ministry of Health Preliminary data suggest sharply reduced maternal (MoH), local communities promote the idea of a WC and mortality since WCs became operational. Many women identify a local community service organization (CSO, are using WCs, most of whom are receiving professional e.g. a local NGO) to manage and operate it. These CSOs care during a birth for the first time. Their unprecedented tend to be small grass-roots organizations with a strong access to regular checkups, medical visits and ultrasounds local base. WCs are governed by a committee that in- has significantly reduced maternal mortality in all health cludes representatives from the health center, local gov- districts with a WC, except for Rio Blanco (Table 1). In ernment, the leading CSO and sometimes a local Ministry San Carlos, the WC has increased births attended by of Education representative. The CSO usually contributes health professionals by 48 percent, and maternal mortality one full time staff to manage the center, and the MoH has decreased from 16.7 to 6.2 per 100,000 live births. provides (decreasing) funding for operating costs, and health staff to visit the centers regularly. Local govern- Coordinated action by WCs and community health net- ments sometimes provide land for a building and part of works has increased family planning (FP). FP education the operating costs. Networks of friends have arisen has intensified through household visits, community around most WCs to provide additional resources. meetings and talks in WCs. Results are encouraging, Community health net- works--health volunteers and midwives--play an es- Box 2. "Extension of coverage" initiatives funded under the Health Sector sential role in the successful Reform ProjectSan Carlos' Basic Health Team operations of WCs. Volun- teers and midwives, trained The Community Health Association provides basic health services to 8 isolated by the MoH (or international communities in the municipality of San Carlos. The association comprises over 300 NGOs) to recognize common local men and women, 10 technical and 4 administrative staff. Their basic health health problems, live in re- team includes a doctor and three nurses who usually spend 4 to 5 days in each mote communities. They community every 8 weeks.The association coordinates its work with the MoH and monitor the health of the presents bi-monthly reports on their progress toward agreed-upon health targets. community and alert health They vividly remember working through the Easter holiday week to achieve targets personnel when emergencies on time. Achievement of the targets carries with it a significant reward: a 15 percent arise, coordinating with inter- premium to invest in equipment for the association. The association has always met mediary health points staffed their targets. Furthermore, their contract with the Health Sector Reform Project is a by nurses and/or doctors and source of pride, representing institutional recognition and support for the work they with health centers or hospi- have been doing for years.Siuna's integrated reproductive health servicesThe tals. They are responsible for Women's Movement Paula Mendoza provides a broad range of reproductive health family planning and repro- services for poor isolated rural communities in Siuna, including a reproductive ductive health training in health clinic, a Women's Centre, and nutrition and training programs. They use communities. They identify innovative approaches in reproductive health and family planning education to try to and refer high risk pregnan- involve men. These include periodic workshops with community leaders (men), cies to the health point or offering reproductive health counselling to couples, and talking with fathers to WC. promote responsible parenthood. 2 although considerable obstacles remain, especially men's WC management committee. Unlike earlier efforts, WCs reluctance to use and/or let their wives use FP methods. In are totally integrated into the health system. MoH support San Carlos and Siuna, sites of extension of coverage at central level has helped legitimize the model and initiatives, FP coverage among the fertile population has generate additional external support. Weak local level more than doubled from 21 to 43 and 47 percent respec- MoH capacity, however, undermines the WC and whole tively. system. For example, high staff turnover (3 health center directors and 2 maternal health doctors in two years) in Women have said in interviews that their WC stay pro- Bluefields has delayed the WC project. vided physical and psychological rest that would have been impossible given the large, continuous demands on WCs complement services already provided by health them in their communities. They value highly the care centers, which avoids competition and keeps costs as low received from WC staff, doctors, and other women in the as U.S. $66.6 per woman for 15 days of services. Centers, and have come to regard health care as their right, not charitable assistance. Gender training for project, WC and MoH staff has built knowledge of the realities women face, raised awareness of how gender inequalities can worsen women's reproduc- Factors contributing to tive health, and improved the ability of the WCs to the success of Women's meet their clients' needs. Centers Community participation is es- Challenges sential to the success of WCs. Learning from similar, less suc- cessful initiatives, the project There are four main future assessed communities' institu- challenges: tional capacity, and involved ·i. transmitting reproduc- communities fully. The leading tive health messages to role of CSOs in establishing and men in ways that they will operating the WCs, as well as accept; the support of local hospitals, ·ii.harmonizing reproduc- have also been essential. tive health training pro- grams run by MoH, Minis- Community ownership of WCs try of Education, and local strengthens sustainability. and international NGOs, MOH's strategy of decreasing and ensuring quality con- financing, coupled with helping trol of these training initia- WCs develop long-term tives; sustainability plans have ·iii. setting service spurred fundraising activites standards and creating a and resulted in various alliances. Federation of WCs as WCs For example, Matiguas WC is proliferate across Nicara- seeking support from a Parlia- gua; and mentarian and network of mi- ·iv. building capac- grants in Los Angeles. In Siuna, ity to operate WCs prop- donations from friends in the U.S. fund equipment, and erly in more communities, several international NGOs contribute to operating costs. particularly where no solid social base exists. El Castillo and San Carlos' WCs are supported by grass root organizations and international NGOs. WC managers are unanimous that after the project closes, they "will not Conclusion let the project fall (in)to the cracks because of lack of Preliminary findings indicate encouraging success and funds, we will search for funds wherever necessary". cost effectiveness of Women's Centres and Extension of Coverage initiatives in improving maternal mortality and The MoH plays an essential role at the local level, setting other reproductive health indicators in isolated areas of strategy, coordinating different health operators (the WC, Nicaragua. Their expansion in Nicaragua and replication CSO and community health network), and sitting on the elsewhere is highly recommended. Investing in building 3 communities' capacities to operate the centres and bring- has the lowest military spending among developing regions, ing the local branch of the MoH on board are fundamental 1.3 percent of GDP. But the region suffers from a relatively to efficient implementation and sustainability. low overall rates of savings (19 per cent of GDP). The region has the potential to reach many of the MDGs. It is the only developing region where girls have a higher literacy rate Millennium Development Goals than boys. The region also has the highest life expectancy at birth, 71 years. Yet there are still significant gender Latin American Overview differences in labor market opportunities. Child malnutrition remains a problem in the low-income countries and in poorer The Latin America and the Caribbean region has the highest regions of some middle-income countries. Although it is a gross national income (GNI) per capita of all developing comparatively wealthy region, it is also the most unequal country regions. The number of poor in the region would fall from Box 3. Men and reproductive health decision making 57 million in 1999 to 47 million by 2015, if it Reproductive health decisions, ranging from whether to use contraceptive methods to whether can maintain a per to spend household resources on transporting pregnant women to a health center, are usually capita growth rate of made by husbands. Men's opposition to family planning or disregard for their pregnant wives' 2.6 percent. But GDP care can stem from ignorance of the consequences of poor or little care, or from long-standing per capita has grown by cultural practices that are difficult to change. Women's limited ability to challenge the authority only 1.5 percent a year of men can have pernicious consequences. WC personnel note that maternal deaths not since 1990 in the uncommonly result from husbands refusing to allow their wives to go to the health center. region, with many Women often obtain contraceptives surreptitiously, getting injected contraception when taking countries affected by their children to the health point, or choosing caesarean delivery to be able to have tubal economic crises in the ligations without telling their husbands. WCs and health personnel have tried many approaches second half of the to get men on board. For example, health personnel in Matiguas get men to observe and support decade. Latin America their wives during the delivery, which can also raise awareness of pregnancy risks. They recall continues to attract the father of a large family telling his wife during delivery: "(giving birth) is horrible, we have more private capital, to (family) plan". Midwives often talk to men of the economic difficulties of raising large $72 billion in 2001, families. This was a powerful argument for one man whose reason for undergoing a vasectomy than any other was the high cost to his family (about $1000) when his wife had an emergency during a developing country pregnancy. region. The region also ____________________ 1 This note summarizes a case study produced under the `Gender Mainstreaming in Latin America and the Carib- region in the world. Inequalities are high both across and bean' component of the Bank-Netherlands Partnership within countries. The region includes two very poor Program. Information was gathered in Nicaragua in countries (Haiti and Nicaragua), and regional averages for September 2003, in interviews with project staff, local country indicators mask wide disparities in social indicators health personnel and Women's Center staff; visits to 3 by income, ethnicity, gender and geographic location. Centres (Matiguas, Siuna and San Carlos); and focus groups with WC clients and community health network About the Authors members. The authors gratefully acknowledge Josefina Medrano's (Health Sector Reform Project) help during fieldwork. For additional information: Jesus María Fernández Díaz is Sr.Public Health Specialist at mruizabril@worldbank.org or the World Bank Human Developement Department for Latin jfernandezdiaz@worldbank.org America and the Caribbean Region. María Elena Ruiz Abril in consultant at the Economic Policy Sector at the Poverty 2 Improving maternal health is a Millennium Develop- Reduction and Economic Management Department ment Goal; the target is reducing maternal mortality by three quarters, between 1990 and 2015. About "en breve" 3 The average number of communities served by each WC is 99; in Siuna, where communities are especially dis- Subscribe to "en breve" by sending an email to persed, the WC serves 190 communities. en_breve@worldbank.org 4 The increase in maternal deaths in 2001 reflects better recording after the WC opened 4