Early Human Development, 29 (1992) 397401 Elsevier Scientific Publishers Ireland Ltd.
397
EHD 01310
Ethical considerations in safe motherhood (SM) programs in developing countries V.C.W. Taam Wong Department
of Obstetrics
and Gynecology, Road,
University of Hong Hong Kong (UK)
Kong,
Queen
Mary
Hospital,
Pokfulam
There are still many maternal deaths in the world each year and over 98% are in developing countries. A program of safe motherhood is needed to make certain that every woman has the right of basic maternity care. Key words: safe motherhood;
maternal death
Introduction It is estimated that there are 500 000 maternal deaths each year in the world and that over 98% are in developing countries. The death of these women leads to increased risk of death and ill-health in the children and decreased productivity of the family unit. Those who survive may suffer from reproductive morbidity. The direct causes of maternal deaths are abortion, hemorrhage, hypertension, infection and obstructed labour, all of which can be prevented or treated if optimum facilities and personnel are available. The core ‘safe motherhood’ program falls into three parts: (1) community-based prenatal surveillance and education, appropriate care during labor and delivery, postnatal counselling and support; (2) facilities and trained personnel to handle obstetric emergencies, including innovative means of communication and transport; (3) facilities and expertise at the referral center to provide ‘essential obstetric care’. SM Core Programs need to be planned and executed in conjunction with the development of the three levels of health care with adequate staff and patient management capacity at all levels, in order to provide a ‘team approach’ in training, supervision, monitoring and feedback. Correspondence to: V.C.W. Taati Wong, Department of Obstetrics and Gynecology, University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong.
0378-3782/92/.$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
398
On the other hand, safe motherhood programs include other intervention that may affect maternal health and well-being indirectly. They include: improving the status, education and employment of women, community mobilization and education related to the knowledge, attitude and practice regarding pregnancy and childbirth, strengthening family planning programs and addressing the problem of unsafe abortions. With limited resources, a number of ethical questions need to be answered. Should one direct more effort to areas that are poor and backward or should one target areas that have more potentials for success? Is it ethical to conduct operational research to determine minimum management package for inaccessible and poor areas? Is ‘double standard’ acceptable? Should one concentrate in one component or should one attempt all three aspects partially? Is it ethical to set priorities according to the relative cost-effectiveness or cost-benefit of different programs in saving lives? Should program components be targeted towards saving the live of the mother or that of the baby? Approach to program planning Before the ethical issues are addressed, it is useful to review the main factors that would affect SM programs: (1) target population size, distribution and density; (2) contraceptive prevalence rate and total fertility rate; maternal mortality rates and ratios, causes of maternal deaths and main obstacles to the implementation of maternity care programs; (3) existing network of clinics and health facilities that deal with nutrition, primary health care, family planning, child health, immunization and communicable diseases; (4) socio-economic status of the community and the amount of funding from government and donors. Collection of the basic data on a particular locality is the first step in program planning. The main steps in the planning process is listed as follows: (1) assess the magnitude and characteristics of the problem locally; (2) assess existing health facilities and manpower; (3) define objectives and targets; (4) design custom-made programs through task analysis of priority activities (who, what, where, when and how); (5) choose the appropriate alternatives to the program - cheapest package for all three co’mponents, phased implementation of the core program or vary the contents of the three components according to local needs; (6) start pilot prototypes for areas with different constraints e.g. urban slum, remote mountains, wetland or islands. Ethical considerations With pilot programs, planners and funders would like to demonstrate successful interventions. It is much easier to initiate projects in areas that have more political commitment, higher educational levels, better technical expertise, infrastructure and resources. The probability for success is higher if investment is directed to these areas. This is contrary to basic concepts of need and equity. However, it is logical to start with the easier areas which can be used as models for the less motivated and
399
less well endowed ones to emulate. On the other hand, it may be necessary to tackle the poorest parts with the worst vital statistics by conducting operational research to determine the minimum management package that is achievable, affordable, accessible, available and acceptable. Politicians have to balance the commitment to fair and equitable distribution of public funds against the pressure to produce successful demonstration projects. For the remote and poor areas, the investment per unit of activity is relatively greater. Under such circumstances, the amount of money that can be diverted to these areas may be insufficient for the desired objectives and targets. Program directors may have no choice but to accept a different standard of care. Most studies in maternal mortality in developing countries showed that about half of the mothers died before their arrival at the hospital and the majority of obstetric emergencies are not associated with antenatal risk factors that can be used to select mothers for hospital delivery. Thus improvement in the quality of care at the community level is just as important as that at the hospital level. Hence one should not be forced to choose between upgrading community-based facilities and those within hospitals. If one follows the six steps suggested in the previous section on program planning, one can circumvent the need for setting priorities and choosing between competing components. However, when one component is chosen at the expense of another, it is usually based on the perceived cost-effectiveness of that intervention. Thus the question is shifted to the ethics of using cost-effectiveness and/or costbenefit analysis to set priorities. Cost-effectiveness analysis Cost-effectiveness analysis is an economist’s way to identify the most effective use of limited resources. It attempts to determine which program accomplishes a given objective at the minimum cost. There are live main steps in this exercise: (1) define the program; (2) compute the net costs; (3) compute net health effects; (4) apply decision rules; (5) perform sensitivity analysis. SM programs are hitherto not well defined. The interventions may not have a direct causal relationship to the desired outcome of decreasing maternal deaths. e.g. treatment of anemia with iron in the antenatal period may improve maternal wellbeing but it does not prevent death from postpartum hemorrhage resulting from uterine atony or ruptured uterus. The health effects of SM programs are even more difficult to document. Maternal mortality is grossly under reported in developing countries with poor reporting system for vital statistics. Process indicators such as the percentage of mothers with prenatal care or the percentage of mothers with delivery by trained attendants does not reflect the quality of care and may not be good indicators of outcome. Thus it is necessary to use more specific ones such as incidence of major complications and case fatality rates. The numbers used for computing the net health effect are estimated according to available epidemiological data, expert opinion or controlled trials. Since there is a dearth of reliable data that can be used for these calculations, cost-effectiveness analysis for SM programs, is, at its best, a ‘calculated guesstimate’ and should be interpreted with extreme caution.
400
Cost-benefit analysis Cost-benefit analysis goes a step further by assigning monetary values to health outcomes or benefits. This is often used to compare health projects with those outside the health sector in terms of its effect on human welfare e.g. comparing the effect of an education project against the effects of a health project on productivity of the target population. The effects of the different projects are evaluated in terms of dollar value of those effects-these are known as the ‘benefit’ of that alternative. The ‘net benefit’ is calculated by subtracting the ‘benefits’ from the ‘cost’ of the project. This is also known as the ‘social profit’ because it is an estimate of the value of the project in terms of how much the society may profit from it. There are two approaches to calculate the monetary value of health benefits. The human capital approach focuses on improvement in labor productivity as a result of the health intervention. Thus saving the life of a man produces a benefit equal to the dollar value of that man’s expected future work output. It puts projects for women’s health at a great disadvantage because most work performed by women: at home and in the fields are not usually counted as productive work. The willingness-to-pay approach estimates the amount that the individuals are prepared to pay for these benefits. This approach does not do justice to women’s health programs in developing countries because the uninformed consumers may not value the health care provided as much as they should. Secondly, the total effective demand for a service assesses the willingness-to-pay without adjusting for the resources available to the individual. Maternal fetal conflict SM programs are often organized in conjunction with child health programs. However, most of the activities are targeted towards the infant rather than the mother. Tetanus immunization of the mother prevents neonatal tetanus. Improved nutrition, rest and iron supplementation for the mother may improve perinatal outcome but can hardly affect the major causes of maternal mortality. On the other hand, measures designed to improve maternal outcome from eclampsia, obstructed labour and infection will improve perinatal outcome because of their impact on the incidence and severity of perinatal asphyxia and sepsis. In developed countries, maternal fetal conflict implies that one has to balance the risks and benefits of a particular procedure for the mother and the baby. Decisions on management are taken after consultation with the mother. However, in developing countries, we are faced with a one-sided situation where the baby is the prima donna in ‘maternal and child health’ interventions and benefits for the mother, if present, are incidental. The women have no part to play in the whole process, from planning to execution, If policy makers attempts to use cost-effectiveness and cost benefit analysis to determine future planning for reproductive health, women will suffer, for want of status in this economic arena and the next generation will be poorer for it. To receive basic maternity care is the right of every woman and there is no need to use the ethical argument to endorse it.
401
Reference Over A.M. Jr., Economic & Financial Analysis of the Health Sector in Developing Countries - A Training Manual, The World Bank.
397
EHD 01310
Ethical considerations in safe motherhood (SM) programs in developing countries V.C.W. Taam Wong Department
of Obstetrics
and Gynecology, Road,
University of Hong Hong Kong (UK)
Kong,
Queen
Mary
Hospital,
Pokfulam
There are still many maternal deaths in the world each year and over 98% are in developing countries. A program of safe motherhood is needed to make certain that every woman has the right of basic maternity care. Key words: safe motherhood;
maternal death
Introduction It is estimated that there are 500 000 maternal deaths each year in the world and that over 98% are in developing countries. The death of these women leads to increased risk of death and ill-health in the children and decreased productivity of the family unit. Those who survive may suffer from reproductive morbidity. The direct causes of maternal deaths are abortion, hemorrhage, hypertension, infection and obstructed labour, all of which can be prevented or treated if optimum facilities and personnel are available. The core ‘safe motherhood’ program falls into three parts: (1) community-based prenatal surveillance and education, appropriate care during labor and delivery, postnatal counselling and support; (2) facilities and trained personnel to handle obstetric emergencies, including innovative means of communication and transport; (3) facilities and expertise at the referral center to provide ‘essential obstetric care’. SM Core Programs need to be planned and executed in conjunction with the development of the three levels of health care with adequate staff and patient management capacity at all levels, in order to provide a ‘team approach’ in training, supervision, monitoring and feedback. Correspondence to: V.C.W. Taati Wong, Department of Obstetrics and Gynecology, University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong.
0378-3782/92/.$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
398
On the other hand, safe motherhood programs include other intervention that may affect maternal health and well-being indirectly. They include: improving the status, education and employment of women, community mobilization and education related to the knowledge, attitude and practice regarding pregnancy and childbirth, strengthening family planning programs and addressing the problem of unsafe abortions. With limited resources, a number of ethical questions need to be answered. Should one direct more effort to areas that are poor and backward or should one target areas that have more potentials for success? Is it ethical to conduct operational research to determine minimum management package for inaccessible and poor areas? Is ‘double standard’ acceptable? Should one concentrate in one component or should one attempt all three aspects partially? Is it ethical to set priorities according to the relative cost-effectiveness or cost-benefit of different programs in saving lives? Should program components be targeted towards saving the live of the mother or that of the baby? Approach to program planning Before the ethical issues are addressed, it is useful to review the main factors that would affect SM programs: (1) target population size, distribution and density; (2) contraceptive prevalence rate and total fertility rate; maternal mortality rates and ratios, causes of maternal deaths and main obstacles to the implementation of maternity care programs; (3) existing network of clinics and health facilities that deal with nutrition, primary health care, family planning, child health, immunization and communicable diseases; (4) socio-economic status of the community and the amount of funding from government and donors. Collection of the basic data on a particular locality is the first step in program planning. The main steps in the planning process is listed as follows: (1) assess the magnitude and characteristics of the problem locally; (2) assess existing health facilities and manpower; (3) define objectives and targets; (4) design custom-made programs through task analysis of priority activities (who, what, where, when and how); (5) choose the appropriate alternatives to the program - cheapest package for all three co’mponents, phased implementation of the core program or vary the contents of the three components according to local needs; (6) start pilot prototypes for areas with different constraints e.g. urban slum, remote mountains, wetland or islands. Ethical considerations With pilot programs, planners and funders would like to demonstrate successful interventions. It is much easier to initiate projects in areas that have more political commitment, higher educational levels, better technical expertise, infrastructure and resources. The probability for success is higher if investment is directed to these areas. This is contrary to basic concepts of need and equity. However, it is logical to start with the easier areas which can be used as models for the less motivated and
399
less well endowed ones to emulate. On the other hand, it may be necessary to tackle the poorest parts with the worst vital statistics by conducting operational research to determine the minimum management package that is achievable, affordable, accessible, available and acceptable. Politicians have to balance the commitment to fair and equitable distribution of public funds against the pressure to produce successful demonstration projects. For the remote and poor areas, the investment per unit of activity is relatively greater. Under such circumstances, the amount of money that can be diverted to these areas may be insufficient for the desired objectives and targets. Program directors may have no choice but to accept a different standard of care. Most studies in maternal mortality in developing countries showed that about half of the mothers died before their arrival at the hospital and the majority of obstetric emergencies are not associated with antenatal risk factors that can be used to select mothers for hospital delivery. Thus improvement in the quality of care at the community level is just as important as that at the hospital level. Hence one should not be forced to choose between upgrading community-based facilities and those within hospitals. If one follows the six steps suggested in the previous section on program planning, one can circumvent the need for setting priorities and choosing between competing components. However, when one component is chosen at the expense of another, it is usually based on the perceived cost-effectiveness of that intervention. Thus the question is shifted to the ethics of using cost-effectiveness and/or costbenefit analysis to set priorities. Cost-effectiveness analysis Cost-effectiveness analysis is an economist’s way to identify the most effective use of limited resources. It attempts to determine which program accomplishes a given objective at the minimum cost. There are live main steps in this exercise: (1) define the program; (2) compute the net costs; (3) compute net health effects; (4) apply decision rules; (5) perform sensitivity analysis. SM programs are hitherto not well defined. The interventions may not have a direct causal relationship to the desired outcome of decreasing maternal deaths. e.g. treatment of anemia with iron in the antenatal period may improve maternal wellbeing but it does not prevent death from postpartum hemorrhage resulting from uterine atony or ruptured uterus. The health effects of SM programs are even more difficult to document. Maternal mortality is grossly under reported in developing countries with poor reporting system for vital statistics. Process indicators such as the percentage of mothers with prenatal care or the percentage of mothers with delivery by trained attendants does not reflect the quality of care and may not be good indicators of outcome. Thus it is necessary to use more specific ones such as incidence of major complications and case fatality rates. The numbers used for computing the net health effect are estimated according to available epidemiological data, expert opinion or controlled trials. Since there is a dearth of reliable data that can be used for these calculations, cost-effectiveness analysis for SM programs, is, at its best, a ‘calculated guesstimate’ and should be interpreted with extreme caution.
400
Cost-benefit analysis Cost-benefit analysis goes a step further by assigning monetary values to health outcomes or benefits. This is often used to compare health projects with those outside the health sector in terms of its effect on human welfare e.g. comparing the effect of an education project against the effects of a health project on productivity of the target population. The effects of the different projects are evaluated in terms of dollar value of those effects-these are known as the ‘benefit’ of that alternative. The ‘net benefit’ is calculated by subtracting the ‘benefits’ from the ‘cost’ of the project. This is also known as the ‘social profit’ because it is an estimate of the value of the project in terms of how much the society may profit from it. There are two approaches to calculate the monetary value of health benefits. The human capital approach focuses on improvement in labor productivity as a result of the health intervention. Thus saving the life of a man produces a benefit equal to the dollar value of that man’s expected future work output. It puts projects for women’s health at a great disadvantage because most work performed by women: at home and in the fields are not usually counted as productive work. The willingness-to-pay approach estimates the amount that the individuals are prepared to pay for these benefits. This approach does not do justice to women’s health programs in developing countries because the uninformed consumers may not value the health care provided as much as they should. Secondly, the total effective demand for a service assesses the willingness-to-pay without adjusting for the resources available to the individual. Maternal fetal conflict SM programs are often organized in conjunction with child health programs. However, most of the activities are targeted towards the infant rather than the mother. Tetanus immunization of the mother prevents neonatal tetanus. Improved nutrition, rest and iron supplementation for the mother may improve perinatal outcome but can hardly affect the major causes of maternal mortality. On the other hand, measures designed to improve maternal outcome from eclampsia, obstructed labour and infection will improve perinatal outcome because of their impact on the incidence and severity of perinatal asphyxia and sepsis. In developed countries, maternal fetal conflict implies that one has to balance the risks and benefits of a particular procedure for the mother and the baby. Decisions on management are taken after consultation with the mother. However, in developing countries, we are faced with a one-sided situation where the baby is the prima donna in ‘maternal and child health’ interventions and benefits for the mother, if present, are incidental. The women have no part to play in the whole process, from planning to execution, If policy makers attempts to use cost-effectiveness and cost benefit analysis to determine future planning for reproductive health, women will suffer, for want of status in this economic arena and the next generation will be poorer for it. To receive basic maternity care is the right of every woman and there is no need to use the ethical argument to endorse it.
401
Reference Over A.M. Jr., Economic & Financial Analysis of the Health Sector in Developing Countries - A Training Manual, The World Bank.
