Amy Boldosser-Boesch is the Interim President and CEO at Family Care International. This article originally appeared on the Maternal Health Task Force blog as part of a series for the Global Maternal and Newborn Health Conference, October 2015 in Mexico City.
The year 2015 has been one of dramatic movement for global maternal and newborn health—from the end of the Millennium Development Goals to the beginning of a universal and even more ambitious global agenda. The Global Maternal and Newborn Health Conference is a key moment to examine how the Sustainable Development Goals will help ensure and improve quality of care, integration and equity. I’m pleased to see on the conference program a focus on midwives, a key partner in turning the conference themes and focus into a reality for women and their families everywhere.
At this crossroads moment in global development, it’s a travesty that the countries burdened with 92% of the world’s maternal and newborn deaths have only 42% of the world’s midwives, nurses and doctors. Even though we have the medicines and the technology to make sure no woman or newborn dies from preventable causes, a person’s place of residence often still determines whether–and how–she will live or die. This is simply unacceptable. Fortunately, skilled midwives can prevent up to two-thirds of maternal and newborn deaths, and in doing so can turn around health care in their communities, according to UNFPA’s State of the World’s Midwifery Report 2014.
This new video looks at the past and to the future of Countdown to 2015, a global movement of academics, governments, international agencies, health-care professional associations, donors, and nongovernmental organizations to stimulate and support country progress towards achieving the health-related Millennium Development Goals (MDGs).
Zulfiqar Bhutta, of the Centre for Global Child Health, Hospital for Sick Children (Canada) and Aga Khan University (Pakistan), and Mickey Chopra, of The World Bank, are co-chairs of Countdown to 2015. This article originally appeared on the Maternal Health Task Force blog as part of a series for the Global Maternal and Newborn Health Conference, October 2015 in Mexico City.
‘Ten years from now, in 2015,’ said the opening line of the first Countdown to 2015 report, published in 2005, ‘the governments of the world will meet to assess if we have achieved the Millennium Development Goals (MDGs), the most widely ratified set of development goals ever, signed onto by every country in the world.’
Today, at the London School of Hygiene and Tropical Medicine, The Lancet launched its newest series Midwifery. This series provides concrete actions for stopping preventable maternal and newborn death and ensuring perinatal health. The knowledge that midwives are key to preventing perinatal death is not new. However, scaling up the utilization of midwives on a systems level is lacking, which has prevented this solution from becoming a reality.
The Midwifery Series was created to provide concrete guidance and frameworks on how to utilize midwives and a new standard of care for Quality Maternal and Newborn Care (QMNC). At the center of this model of care are the needs of women and their newborn infants. Even though the needs of women across the world seem to differ greatly, this series clarifies that no matter where a woman lives, care led by a midwife is the answer to ensuring health. The series comprises four separate papers which were created by a multidisciplinary group, including academics, researchers, advocates for women and children, clinicians, and policy-makers. This multidisciplinary approach is necessary for addressing current gaps in perinatal care.
The current maternal and newborn health landscape often offers fragmented solutions and interventions to address the needs of women and their newborns. This fragmentation is a barrier to adequate perinatal care. These gaps in care lead to 98% of the annual 289,000 maternal deaths, 2.6 million stillbirths, and 2.9 million neonatal deaths. In order to mitigate these preventable deaths, improvements in the quality throughout the continuum of care and emergency services are imperative. The series supports a whole-system approach to improving perinatal care by ensuring skilled care for all.
The Lives Saved Tool (LiST) was used in the series to model different levels of scale-up of essential interventions for reproductive, maternal, and newborn health (RMNH) which are within the scope of practice of a midwife. In low-resource settings even a 10% increase in the interventions covered by midwifery would decrease maternal mortality by 27%. Therefore, more rigorous scale-up could have an incredible impact on reducing maternal mortality.
The standard for QMNC presented in the series is globally applicable as it not only focuses on the scale-up of essential interventions, but also the harmful effects and necessary mitigation of over-medicalization of birth and perinatal care. Professor Petra ten Hoope-Bender, of the Instituto do Cooperación Social Integrare, Barcelona, Spain, said, “Although the level and type of risks related to pregnancy, birth, postpartum and the early weeks of life differ between countries and settings, the need to implement effective, sustainable, and affordable improvements in the quality of care is common to all, and midwifery is pivotal to this approach. However, it is important to understand that to be most effective, a midwife must have access to a functioning health-care service, and for her work to be respected, and integrated with other health-care professionals; the provision of health care and midwifery services must be effectively connected across communities and health—care facilities.”
In order to assist the development of health systems and their integration of midwives, the series provides three new tools:
The Framework for Quality Maternal and Newborn Care is applicable to all countries on not only what needs to be implemented, but how to implement strategies to reduce maternal, neonatal, and infant mortality and morbidity, improve quality of care, and increase efficiency of health systems.
Country diagrams can be used to identify the most important elements required to strengthen a country’s health systems to provide quality midwifery services.
Pragmatic steps provide a guide to initiate or further develop their midwifery services.
Midwives not only provide care at the time of birth, but work with women from before their pregnancy through their newborns infancy to prevent death and ensure health. This life course approach is essential for having a large impact on the needless numbers of deaths and morbidities. Check out The Lancet’s Midwifery Series for more details on how midwives will make a large difference in the lives of women and their children in the coming years as the post-2015 agenda is implemented.
Martha Murdock is FCI’s vice president for regional programs.
Last week in Nairobi, a range of partners — from the Kenyan government, UN agencies, donor countries, and many NGOs and research organizations from the national and county levels — came together for a presentation of new research that has the potential to increase the momentum of efforts to save the lives of nearly 300,000 women who die each year (5,500 of them in Kenya) from causes related to pregnancy and childbirth.
Each of these avoidable, premature deaths is a tragedy in its own right, and a terrible injustice. Each of these women — some of them barely more than girls — has a right to life and health, and to a standard of health care that protects her from preventable illness, injury, and death.
But we who work to improve maternal health have argued for years that each of these deaths also brings countless additional layers of loss, pain, and destruction. The tragic, sudden death of a woman in the prime of life — in many cases already a mother and often the most economically productive member of the family — begins a cascade of loss and pain that upends the lives of those around her: her newborn baby (if it survives) and her older children, husband, parents, and other members of her family and community.
Up until now, however, we haven’t had the hard data to support our case, to help us persuade governments, donors, and policy makers that investments in maternal health are also investments in children, in stable families, in education and community development, and ultimately in stronger national economies. Now, thanks to a study conducted in Kenya by FCI, the International Center for Research on Women (ICRW), and the KEMRI-CDC Research and Public Health Collaboration, we know that the data behind that argument is very powerful indeed.
Based on interviews and focus group discussions with every family, across a poor rural area in Siaya County in western Kenya, that had lost a family member to maternal death over a two-year period, we found that:
When a mother dies in or around childbirth, her newborn baby is unlikely to survive.
Of 59 maternal deaths in the study, only 15 babies survived their first two months of life.
A mother’s death harms the educational and life opportunities of her surviving children.
Many children had to leave school because the loss of a mother’s income meant that they couldn’t pay tuition fees, needed to work for a living, or had to take up essential household chores.
The cost of emergency care (even when unsuccessful), combined with high funeral costs, puts families under a crushing economic burden.
Families spent more on funerals than their total annual expenditure on food, housing, and other household costs, after having already spent 1/3 of their annual consumption expenditure on medical costs.
Loss of income and high, unexpected costs send many families into a spiral of debt, poverty, and instability.
Many families, under desperate financial pressure, had to sell household property, borrow from moneylenders, or move children out of the family home.
When this moving and compelling report was launched in Nairobi last Friday, I was proud to stand at the dais and introduce eminent leaders of efforts to improve women’s and children’s health in Kenya, including the U.K. High Commissioner for Kenya, Dr. Christian Turner (representing the U.K. Government, which funded this important research together with the John D. and Catherine T. MacArthur Foundation and the Partnership for Maternal, Newborn & Child Health). Dr. Turner, in turn, introduced Kenya’s Cabinet Secretary for Health, Hon. James Macharia. With us in the room were important policy makers from the Ministry of Health, national parliamentarians, and high-level representatives from UNICEF, WHO, UNFPA, USAID, and a range of other agencies and organizations.
We came together that morning, I said, “because we are all resolved, together with so many colleagues and partners here in Kenya and around the world, to work together to finally put an end to a tragic toll of maternal and newborn death that goes back to the beginnings of human history.” We have long known that far too many women were dying. What we lacked, until now, was hard data to help us fully understand the financial and social impact of a mother’s death — the costs to the health and well-being of thousands of surviving children, families, and communities. We and our partners undertook this study because we saw that filling this critical knowledge gap will offer advocates and policy makers a powerful tool for bringing further attention and investment to maternal health.
The messages that emerge from this research were expressed clearly and succinctly by Hon. James Macharia as he presided over the official launch of the report:
A mother’s death ignites a chain of disruption, economic loss, and emotional pain that often leads to the death of her baby, diminished educational and life opportunities for her surviving children, and a deepening cycle of poverty for her family.
“Women and their families,” she says, “have to be active, they have to understand what their rights are in terms of access to health care, in terms of access to information, and they have to demand that their political leaders, locally and nationally, make these services available and make these services high quality. If you don’t have that kind of demand and that kind of momentum in place, then any changes that get implemented are not going to be sustainable.”
During the third week of May, I was in Geneva — together with an impressive collection of global health leaders from governments, UN agencies, and civil society — for the 66th session of the World Health Assembly (WHA). I am in Geneva fairly often, for meetings with WHO, the Partnership for Maternal, Newborn & Child Health (PMNCH) and other partners, but the annual World Health Assembly meeting is unique. The WHA is the governing body of the World Health Organization, and so it is attended by high-level delegations – usually led by the Minister of Health – from WHO’s member states. That makes WHA a great opportunity for networking and strategizing: finding an available seat, much less a table, in the famous (but oddly named) Serpent Bar at the Palais de Nations is always a challenge, as many conference participants spend virtually all of their time huddled there in intense discussion.
Perhaps most importantly, this year’s WHA considered, and ultimately passed, a resolution to implement the recommendations of the UN Commission on Life-Saving Commodities for Women and Children. The resolution commits countries to improving the quality, supply, and delivery of underutilized and essential commodities for RMNCH, and tasks WHO with reporting back to WHA each year through 2015 on progress in implementing the Commodity Commission recommendations as well as those of Commission on Information and Accountability for Women’s and Children’s Health. The WHA resolution is a clear, global endorsement of the Commodity Commission recommendations, and represents a commitment by the world’s nations to ensure that life-saving medicines and technologies get to the women and children who need them. It is a significant achievement for our community, and it provides an important mechanism for ongoing advocacy, and for holding governments and development partners accountable for keeping their promises.
Notably, the Commodity Commission’s list of 13 priority commodities includes two that are advocacy priorities for FCI: misoprostol, a drug that is highly effective for preventing and treating postpartum hemorrhage (PPH), the leading cause of maternal death; and emergency contraceptives, which help women prevent unintended pregnancy after unprotected sex. (FCI is host organization for the International Consortium for Emergency Contraception—ICEC.) At a very well-attended side event during the WHA, hosted by the delegations from Nigeria, Norway, and the U.S., along with World Vision International and PATH, speakers focused on the importance of innovation in overcoming barriers to access to essential health commodities. Presentations highlighted the substantial achievements that have already been made, and the important step forward represented by the Commodity Commission’s recommendations. Representatives from various countries also noted the significant challenges that remain, including those related to health commodity distribution systems, manufacturing, and supply. Several countries expressed a preference for purchasing and distributing locally-manufactured commodities, although this approach can sometimes raise concerns about quality assurance; further study, and advocacy, will be needed to address this challenge.
Only a few days later, and half a world away, I was one of a dozen FCI staff members who attended Women Deliver 2013, in Kuala Lumpur, Malaysia. This week was even busier – in fact, much crazier – than the previous week in Geneva; there were meetings and events starting at 7 in the morning, and organized social events went until 8 or 9 pm every night. The conference was amazing, bringing together 4,500 leaders, clinicians, program managers, and advocates representing over 2,200 organizations and 149 countries. I could not take full advantage (or anywhere near it) of everything the conference had to offer; there was an endless variety of stimulating plenary and concurrent sessions (including six sessions presenting the latest findings from Countdown to 2015, in which FCI is a leading advocacy partner), as well as Speaker’s Corner (where FCI and WHO presented new tools for strengthening countries’ policies on adolescent sexual and reproductive health). There was a youth corner and a cinema corner, a busy and bustling exhibition hall, and many, many other activities going on at all times. The cumulative value of all the connections made, facts and ideas conveyed, materials disseminated, and plans and strategies developed was immeasurable but immense.
Here, too, essential health commodities were on the agenda. On the Monday morning just before the conference officially started, FCI co-sponsored a side event called “In Our Hands: Successful Strategies to Prioritize Essential Maternal Health Supplies,” at which the Maternal Health Supplies Working Group and the Maternal Health Supplies Caucus of the Reproductive Health Supplies Coalition brought together global and national advocates and program implementers in an interactive forum – including advocacy case studies from Africa, Asia and Latin America – to network, strategize, and exchange ideas for elevating maternal health supplies onto global and national health agendas. At the same time, ICEC co-sponsored a session on “Emergency Contraception: New Research Findings, Programmatic Updates, and Advocacy Strategies,” at which advocates, researchers, pharmaceutical representatives, and other leaders in the field discussed efforts to ensure access to EC globally, with a focus on developing countries.
That afternoon, FIGO and Gynuity Health Projects (our partners in misoprostol advocacy) co-hosted a discussion of misoprostol for PPH: “New Evidence and the Way Forward.” Presenters offered the latest information on ways that the current evidence can help inform and develop effective policies and service delivery programs across varying levels of the health system, and on lessons learned from innovative programs in Afghanistan and Nepal. I concluded the session with a presentation on advocacy opportunities and challenges for “Making Misoprostol an Operational Reality.”
At these and related sessions the level of discussion, the enthusiastic participation by advocates and health workers, and the clear attention that these issues are getting from policy makers, made for an inspiring and energizing two weeks. “Making sure that women and children have the medicines and other supplies they need is critical for our push to achieve the MDGs,” said Secretary-General Ban Ki-moon when he launched the Commodities Commission 15 months ago. Progress is being made, and we, together with our advocacy partners, are working hard to make sure that essential commodities are available to all who need them.
by Gary L. Darmstadt, France Donnay, and Ann Starrs
Gary Darmstadt and France Donnay are, respectively, Director of Family Health and Senior Program Officer, Maternal, Neonatal and Child Health, at the Bill & Melinda Gates Foundation. Ann Starrs is president of FCI. This post first appeared on Impatient Optimists, the blog of the Bill & Melinda Gates Foundation, on June 3, 2013.
That interconnections exist between maternal and newborn health is well known. Most maternal deaths are caused by the woman’s poor health before or during pregnancy, or by inadequate care in the critical hours and days during and just after childbirth; the same is true for most newborn deaths. And when a woman dies after giving birth, her death is far too often followed by the death of her newborn baby. And we know, based on substantial evidence, which interventions are best for improving maternal health and saving women’s lives, and which are effective for improving newborn survival.
What we didn’t sufficiently understand, until now, was the range of interventions that bring health and survival benefits to both mother and newborn. In this new study, a research team from Aga Khan University in Pakistan, working in collaboration with Family Care International and with support from the Bill & Melinda Gates Foundation, looked at more than 150 interventions, assessing them for impact on both maternal and neonatal outcomes. They then grouped the interventions into “packages of care” that can be effectively delivered at each of the key levels of care: community, health center, and hospital.
This study advances our knowledge in important ways. It reinforces the widely-recognized benefits, for women and their babies, of high-quality antenatal care, skilled birth attendance, and postpartum care, which are still too often insufficiently, ineffectively, or inequitably delivered. It highlights the crucial role of family planning, which can be used to delay and space pregnancies. It identifies a number of areas — including management of preconception diabetes, treatment of maternal depression, and community-based approaches for improving birth preparedness and care-seeking — which are currently neglected but could significantly improve maternal and newborn outcomes.
Most importantly, the findings send a clear message: that greater integration of maternal and newborn care — and, more broadly, of services across the reproductive, maternal, newborn, and child health (RMNCH) continuum of care — is one of our most promising strategies for strengthening efforts to save women’s and children’s lives.
This kind of integration may sound like an obvious step, but it is not always easy. Integration of services is critical if countries are to make substantial progress towards national health goals. It forces policy makers, donors, program managers, and health workers to find common ground among their varying constituencies, goals, and agendas; to understand the needs of women and their babies in new and different ways; and to design services that respond to these needs. It requires that the physical, financial, and human architecture of the health system be designed and constructed to efficiently and equitably deliver high-quality services across the continuum of care.
And yet, Progress on reducing maternal and newborn deaths has been too slow, and far too many women and babies die every day. Recognizing and acting on the crucial interconnections between maternal and newborn health revealed by this study, and the broader linkages that tie together the RMNCH continuum, can help save the lives of millions of women and children. The time to take action is now.