Placing women at the center: Rethinking the RMNCH continuum of care

Ann Starrs is FCI’s president, and is a founding member and former co-chair of the board of the Partnership for Maternal, Newborn & Child Health (PMNCH), of which FCI is  a leading advocacy partner. In this post, cross-posted on the PMNCH website, Ann reports on the Global Maternal Health Conference 2013, which took place in Arusha, Tanzania on January 15th through 17th.

Last week’s Global Maternal Health Conference (GMHC), held in Arusha, Tanzania, was both inspiring and sobering. Twenty-five years after the Safe Motherhood Initiative was launched at an international conference held in neighboring Kenya, maternal mortality has finally begun to decline, and there are many and diverse examples of how countries are addressing the challenge of preventing deaths of women and newborns from complications of pregnancy, childbirth, and the postnatal period. But as the conference highlighted, huge challenges remain — in improving the quality of care, the conference’s core theme; in strengthening the functionality and capacity of health systems; in addressing major inequities in access to care, within and across countries; and in ensuring that maternal and newborn health receives the political support, increased funding, and public attention that it needs.

The majority of the conference’s breakout sessions featured informative and often fascinating presentations on research findings and promising programmatic and technical innovations. One session, however, took a different tack — a debate on “Has the ascendance of the RMNCH continuum of care framework helped or hindered the cause of maternal health?”  I proposed this session to the Maternal Health Task Force, which organized the GMHC, because for me and the organization I head, Family Care International, maternal health has been at the core of our institutional mission since we planned the first Safe Motherhood conference in 1987. For much of the past decade, however, I have been closely involved with the Partnership for Maternal, Newborn and Child Health (PMNCH) and Countdown to 2015, two coalitions that are dedicated to promoting an integrated, comprehensive approach to the reproductive, maternal, newborn and child health (RMNCH) continuum of care. Have our efforts to define and advance the continuum of care framework contributed to progress in improving maternal health? If so, how much? If not, what can be done about it?

These questions were debated by a stellar panel I moderated, which included Wendy Graham, Professor of Obstetric Epidemiology at the University of Aberdeen; Marleen Temmerman, the new head of the Department of Reproductive Health and Research at WHO; Friday Okonofua, Professor of Obstetrics and Gynaecology at the University of Benin, Nigeria; and Richard Horton, Editor in Chief of The Lancet, as well as a fantastic and diverse audience. (You can view a video of the entire discussion here.) To start the discussion I shared the definition of the continuum of care that PMNCH has articulated, based in part on the World Health Report 2005: a constellation of services and interventions for mothers and children from pre-pregnancy/adolescence, through pregnancy, childbirth and the postnatal/postpartum period, until children reach the age of five years. This continuum promotes the integration of services across two dimensions: across the lifespan, and across levels of the health system, from households to health facilities. Key packages of interventions within the continuum include sexuality education, family planning, antenatal care, delivery care, postnatal/postpartum care, and the prevention and management of newborn and childhood illnesses.

It is, of course, impossible to conduct a randomized control trial on the impact of the RMNCH continuum of care on maternal health, so the discussion was based more on perceptions than on hard evidence. Nevertheless, there are a few data points to consider in debating the question. From an advocacy perspective, panelists generally agreed, the adoption of the continuum of care framework has helped the cause by appealing to multiple constituencies related to women’s and children’s health. Attribution is always a challenge; there are many other developments over the past 5-7 years that have also had an impact, such as the two Women Deliver conferences held in 2007 and 2010 (with the third one taking place in May of this year). But participants generally agreed that linking women’s and children’s health, and defining their needs as an integrated whole, has appealed to policy-makers and politicians on an intuitive and practical level, as demonstrated by the engagement of heads of state, celebrities, private corporations, and other influential figures.

Let’s look at the money: during the period 2003-2010 overseas development assistance (ODA) has doubled for MNCH as a whole, according to Countdown to 2015 (Countdown’s analysis did not look at funding for reproductive health, but a new report later in 2013 will incorporate this important element). Maternal and newborn health, which are examined jointly in the analysis, have consistently accounted for one-third of total ODA, with two-thirds going to child health. Given the significant funding that GAVI has mobilized and allocated for immunization over this time period, the fact that maternal and newborn health has maintained its share of total MNCH ODA is noteworthy.

And let’s look at how maternal health has fared within the UN Secretary General’s Every Woman Every Child initiative, launched in September 2010: a recent report summarizes each of the commitments made to Every Woman Every Child in the two years since it was launched. Of the 275 commitments included, 147, or 53%, had specific maternal health content. If we look at the commitments according to constituency group, developing country governments had by far the largest percentage of commitments that had specific maternal health content — 84% — compared to 39% for non-governmental organizations, 24% for donors, and 52% for multilateral agencies and coalitions. Clearly, maternal health has not been marginalized within the continuum from a broad policy, program and funding perspective, despite the fear some had expressed that it would be pushed aside in favor of child health interventions that are perceived as easier and less costly to implement.

Another benefit of the continuum of care framework, as noted by Dr. Okonofua, has been increased collaboration among the communities that represent its different elements. While there were tensions and rivalries when PMNCH and Countdown were first established, especially between the maternal and child health communities, today groups working on advocacy, policy, program implementation, service delivery, and research within the continuum generally work together more frequently, cordially and effectively than they did before, especially at the global level. PMNCH and Countdown, as well as Every Woman Every Child, have brought together key players to define unified messages and strategies that have achieved widespread acceptance.

That was the good news; but panelists and participants at the session also saw a number of problems with the continuum of care concept. The concern articulated by Richard Horton, and echoed by many of the session participants, was that the continuum views women and adolescents primarily as mothers or future mothers. This narrow view contributes to a range of gaps and challenges; it means crucial cultural, social and economic determinants of health and survival, including female education and empowerment, are not given adequate weight. Gender-based violence deserves much more attention, both for its own sake and for its impact on maternal, newborn and child health. Politically sensitive or controversial elements of the continuum, especially abortion but also, in some cases, family planning and services for adolescents, may be neglected in policy, programming, and resource allocation.

The fragmentation inherent in the continuum of care also contributes to what Wendy Graham called the compartmentalization of women. As Countdown’s analysis of coverage has demonstrated, the continuum of care doesn’t guarantee continuity of care; coverage rates are much higher for interventions like antenatal care and child immunization than for delivery or postnatal/postpartum care. Women’s needs for a range of interventions and services, available in a single health facility on any day of the week, are not being met in many countries.

Other concerns that emerged during the discussion were that the RMNCH continuum of care framework does not explicitly or adequately reflect the importance of quality of care, which in turn depends on a range of factors: skilled, compassionate health care workers, functional facilities, adequate supplies and equipment, and an effective health information system that tracks not just whether interventions are being provided, but also whether individual women and their families are receiving the care they need throughout their lives.

Dr. Okonofua, in his comments, focused on how the continuum of care concept has been implemented, or hasn’t, in countries. The implications of the continuum of care for on-the-ground program implementation have not been fully articulated and communicated; more effort, he noted, needs to be invested in making the concept relevant and useful for policy-makers, program managers, and service providers.

Despite these gaps, however, participants in the session – and the panelists themselves – agreed that the continuum of care is a valid and valuable concept, and that the inadequacies identified should be addressed. “Don’t throw the baby out with the bathwater,” said one member of the audience. The continuum of care, as a concept, has already evolved; initially, for example, it did not fully integrate reproductive health elements. As Marleen Temmerman commented, the continuum of care concept is a tool; what is important is what is done with it.

As 2015 approaches, the global health community is struggling to articulate a health goal for the post-2015 development framework that will resonate widely and guide accelerated, strategic action to prevent avoidable deaths and improve health of people around the world. The RMNCH community — or communities — needs a framework that more fully reflects the realities and complexities of the lives of women and children, and that enables us to reach out to other health and non-health communities, including HIV/AIDS, NCDs, and women’s rights and empowerment, for a common cause. To do this, we need to revise the continuum of care framework to maximize its relevance and utility for countries, and to incorporate the following missing elements:

  • Recognition of the importance of quality of care
  • Responsiveness to the needs of girls and women throughout the life cycle, not just in relation to pregnancy and childbirth
  • Links to the cultural, social and economic determinants of women’s and children’s health

Richard Horton’s call for a manifesto to emerge from the GMHC included 10 key points; redefining the RMNCH continuum of care was one of them, inspired by the panel. The challenge has been issued; it is now up to us to meet that challenge.

Countdown to 2015 at FIGO Rome 2012

This item, featuring an interview with FCI president Ann Starrs, is cross-posted from the website of the Partnership for Maternal, Newborn & Child Health.

8 OCTOBER 2012 | ROME – Countdown to 2015 partners hosted a side event at the end of the first day of FIGO 2012 [the World Congress of Gynecology & Obstetrics]: “Reproductive, Maternal and Newborn Health: Are Countries Making Progress?” Participants heard about the newest Countdown to 2015 data on 75 highest-burden countries and received information on why and how countries should work with Countdown to amass data and tools to promote evidence-based policy change.

In her presentation on the Countdown initiative and its value, Dr Joy Lawn, Director of Global Evidence and Policy with Save the Children’s Saving Newborn Lives program, used recent child mortality findings to demonstrate how presenting clear and meaningful data is helpful for hammering home the need to address remaining challenges urgently even if progress is being made.

Among children under five years old, data shows deaths from diarrhea have come down and malaria as well, meanwhile there has been very little progress on neonatal causes of death. If countries were to continue making progress at their current rates (the global annual rate of reduction for neonatal death is 1.8 percent), it would take the following regions quite a long time to meet their Millennium Development Goal targets: the Americas would achieve their target in 2040, Southeast Asia not until 2085 and Africa not until 2165.

“It is so important to present data in a way that is understandable and has an impact,” said Ann Starrs, President of Family Care International, one of the partner organizations behind the Countdown Initiative who also spoke at the event. “Graphs are great, but they can be confusing. It’s helpful when you can look at indicators and they tell you a story — this can lead very directly to policy and funding changes.”

The Countdown country profile

Ms Starrs said it is crucial that health professionals are brought on board when advocating for change.

“If the medical community resists then it’s very, very hard to get a new policy adopted and implemented,” she said, which is why initiatives like Countdown are essential for helping RMNCH champions within government or civil society make the case for adopting or investing in proven solutions to reduce preventable deaths.

Healthy Mother, Healthy Newborn

There is ample evidence illustrating that the health of a woman and her newborn baby are intimately connected. We know that:

  • most maternal and newborn deaths are caused by the mother’s poor health before or during pregnancy or due to inadequate care in the critical hours, days, and weeks after birth
  • when a woman dies in childbirth, her newborn baby is less likely to survive

Recent research conducted by Dr. Zulfiqar Bhutta and colleagues at the Aga Khan University in Karachi, Pakistan confirms what we already know, and goes one step further: it identifies which maternal and newborn health interventions benefit both mother and newborn. These include:

  • Family planning/birth spacing: Family planning, including counseling on and provision of contraceptive methods, prevents unwanted pregnancies and unsafe abortion, and increases spacing between births. Adequate birth spacing (between 18-23 months) reduces the risk of maternal and newborn-related deaths.
  • High-quality antenatal care: Antenatal care provides a critical window to address a range of health care needs, such as treating HIV and sexually transmitted diseases (STDs), and providing counseling and educational support. Well-designed, good quality ANC reduces the risk of preterm birth, perinatal mortality, and low-birth-weight infants
  • Detection and management of maternal diabetes: Treating maternal diabetes (through dietary advice, glucose monitoring, and insulin) reduces maternal and perinatal morbidity, specifically antenatal high blood pressure and neonatal convulsions.
  • Exclusive breastfeeding during the first six months of life: The benefits of breastfeeding for the mother are both short- and long-term. In the short term, she is likely to recover more rapidly from the birthing process. It also has a significant impact on reducing the risk of breast cancer. For the newborn, exclusive breastfeeding for the first six months of life is recommended for optimal growth, development, and health.

This research is a critical step in better understanding just how deeply interconnected are the health of a woman and that of her newborn baby. It also underscores how vital it is to interconnect health care for women and their newborns — to promote greater efficiency, reduce costs, limit duplication of resources, and achieve greater impact.

As part of efforts to promote investment in and implementation of health interventions that can save the lives of both women and their newborn babies, FCI developed two publications summarizing the findings from this research and its impact on advocacy, policy, research, and programming:

  • A pocket card for non-technical audiences including policy makers, health officials, and civil society groups.
  • An Executive Summary for program managers and implementers working in low-resource settings.

With only three years remaining until the 2015 deadline for achievement of the Millennium Development Goals (MDGs), this year will be a critical moment for efforts to improve global health. Because the health-related MDGs — and particularly MDG 4 (Reduce child mortality) and MDG 5 (Improve maternal health) — are furthest off-track, advocates, researchers, programmers, and policy makers must work together to develop, support, and implement effective, integrated policies and programs.

Commission on Life-Saving Commodities to expand access to medicines including misoprostol, EC

Basic medicines, contraceptives, and other health commodities can save millions of lives, but only if people can access them.

A thousand women die needlessly every day from preventable or treatable complications of pregnancy and childbirth. Every year more than 7.6 million children die before reaching their fifth birthday, from preventable and treatable conditions like diarrhea and pneumonia: a child who lives in a poor country is about 18 times more likely to die than one who lives in a wealthier country. And the family planning needs of 215 million women who want to prevent or delay pregnancy remain unmet — meeting this need would prevent 53 million unintended pregnancies and 100,000 maternal deaths every year. Too often, affordable, effective medicines and health supplies do not reach the women and children who need them most.

To address these gaps, UNICEF and UNFPA today launched the Commission on Life-saving Commodities for Women and Children, with a mandate to improve access to essential but overlooked health supplies. President Goodluck Jonathan of Nigeria and Prime Minister Jens Stoltenberg of Norway will serve as founding co-chairs of the Commission, with UNICEF Executive
Director Anthony Lake and UNFPA Executive Director Dr. Babatunde Osotimehin serving as its vice-chairs. The launch announcement said that the Commission will “focus on high-impact health supplies that can reduce the main causes of child and maternal deaths, as well as innovations that can be scaled up, including mechanisms for price reduction and supplies stability.”

Much of FCI’s work focuses on “building the evidence base” on reproductive, maternal, and newborn health, in order to expand access to lifesaving medicines, commodities, and services.  Included on the initial list of 12 essential, overlooked medicines and health supplies identified for consideration by the Commission are two medicines that have been focuses of FCI’s advocacy work:

  • Misoprostol for post-partum hemorrhage (PPH): The Commission aims to ensure that all women, at the time of delivery, have access to medicines that cause the uterus to contract — or uterotonics — in order to prevent or treat the post-partum bleeding that is the leading cause of maternal death in the developed world. The most commonly-used uterotonics are oxytocin and misoprostol, both of which are on the Commission list. In collaboration with Gynuity Health Projects, FCI has been working on a multi-year project that aims to increase understanding, use, and acceptance of misoprostol for PPH in low-resource settings. Research has shown that misoprostol is safe and effective for preventing and treating PPH, and is particularly useful in settings without refrigeration, electricity, IV therapy, and skilled health providers. Unlike oxytocin, misoprostol can be delivered in tablet form, and is temperature stable, so it does not have to be refrigerated or delivered intravenously.
  • Emergency contraception (EC): EC is one of a suite of three particularly overlooked family planning commodities, also including female condoms and contraceptive implants, identified for Commission discussion. FCI serves as host organization for the International Consortium for Emergency Contraception (ICEC), an alliance of non-governmental organizations working to expand access to emergency contraception (EC), with a focus on developing countries. FCI and our colleagues in ICEC and in the broader reproductive health community worked together during the preparatory work prior to the Commission’s launch to ensure that it re-affirms the critical role of family planning in averting maternal and newborn deaths and the importance of ensuring access to EC and other contraceptive methods that are neglected, underutilized, and orphaned.

FCI welcomes the launch of the Commission, and looks forward to working closely with it and with our advocacy and program partners to ensure its effectiveness in improving access to misoprostol, emergency contraception, and other essential health supplies.

New publication fosters country accountability, supports Global Strategy

For the past five years, FCI has been a key partner in Countdown to 2015, a global coalition of academics, governments, international agencies, health-care professional associations, donors, and NGOs that uses country-specific data to stimulate and support country progress towards achieving the health-related MDGs. FCI shares (with the secretariat of the Partnership for Maternal, Newborn & Child Health—PMNCH) overall responsibility for Countdown’s advocacy and communications, working with partners to ensure that Countdown’s data, analysis, and key messages are seen and used by policy makers  to effect real change.

Accountability for Maternal, Newborn & Child Health: An update on progress in priority countriesThis week, Countdown released a new publication, Accountability for Maternal, Newborn & Child Survival: An update on progress in priority countries, which contains updated profiles on high-burden priority countries that account for over 95% of the world’s maternal and child deaths.  The report will be launched at the 126th Assembly of the Inter-Parliamentary Union, which takes place in Kampala, Uganda next week. These profiles highlight how well each country is doing in increasing coverage of high-impact interventions — key elements of the reproductive, maternal, newborn, and child health (RMNCH) continuum of care — that can save the lives of millions of women and children. The charts and graphs in each country profile provide an easy-to-read, attractive, and succinct portrait of whether these high-burden countries are making progress (or not) in increasing women’s and children’s access to essential services like antenatal care, skilled attendance during childbirth, immunization, and prevention of mother-to-child transmission of HIV.

This publication is one of the significant contributions that Countdown is making to the global accountability agenda around the Global Strategy for Women’s and Children’s Health, an unprecedented plan to save the lives of 16 million women and children by 2015, which was launched by UN Secretary-General Ban Ki-moon in September 2010. The country profiles in this publication, customized to showcase the core indicators selected by the Commission on Information and Accountability for Women’s and Children’s Health, are adapted from the full, two-page Countdown country profile, which Countdown produces on a roughly two-year cycle. Full country profiles will be included in Countdown’s 2012 Report, which will be published in June 2012.

Sample country profile from Countdown Accountability report: Burkina Faso
A Countdown country profile, from the Accountability report

FCI is also working on a number of other Countdown initiatives, including the launch of a new Countdown website and the development of a toolkit to assist high-burden countries in developing their own country-level Countdown conferences and publications.

Healthy Families, Healthy World: The Global Strategy for Women’s and Children’s Health and the MDGs

Ann Starrs is FCI’s president. The remarks below were delivered by Ann at the United Nations Association of the USA’s Members’ Day, at the UN on February 10, 2012.

I’m going to start this talk with a story. It’s the story of a family in Afghanistan, several years ago. The wife was pregnant for the seventh time; she died of postpartum hemorrhage, the most common cause of maternal death in poor countries. Because her husband couldn’t cope with the responsibilities and cost of caring for a large family on his own, one of their daughters, aged 13, was married off, to a much older man. At the age of 15, she gave birth to twins. One of the infants died right after birth, and the young mother developed fistula, a horrifying complication in which a woman develops a hole between her urethra and vagina, and leaks urine for the rest of her life unless the hole is surgically Ann Starrs at the UN (Photo: Arnold Gallardo/UNA-USA)repaired. Because of her smell, her husband sent her back to her father, with the weak and ailing surviving infant. They had to spend what was, for them, a significant amount of money trying to get care for the baby.

This is just one family’s story, but it is representative of millions more. Around the world, a woman dies from preventable causes related to pregnancy and childbirth a thousand times every day. A child dies, of similarly preventable causes, every 3 seconds. Add these stories up, and the annual death toll is staggering: 350,000 maternal deaths a year, each one leaving grieving parents, husbands, or children, and 7.6 million children dying before the age of 5. Forty percent of these children are lost in their first month of life, and again, nearly all of these deaths are preventable.

The tragedy of this Afghan family is representative in another way. It portrays, in a nutshell, the multiple reasons why the world must invest in women’s and children’s health. There is a clear moral imperative to prevent these needless deaths, but no less clearly there is an economic imperative. A healthy woman — who is able to decide on the number and spacing of her children, who can deliver them safely, who can see them through childhood in good health — is someone who can contribute to the economic productivity, and to the social and cultural stability, of her family, her community, her nation, and the world. A family destroyed by the loss of a mother or daughter, made desperate by the loss of a breadwinner, or burdened by the tragedy of a lost child, is far too often a family that finds itself trapped in an inescapable cycle of poverty.

This is a challenge that advocates, NGOs, and UN agencies have been working on tirelessly, for decades. My organization, Family Care International, has been working in partnership with governments, other NGOs, donors, academics, and others to raise attention and mobilize commitment — and funding — to address the multiple causes and prevent the horrifying consequences of maternal death. Much of our work is done through and with the Partnership for Maternal, Newborn, & Child Health (known as PMNCH), which has worked to great effect to focus the world’s attention on the powerful and crucial concept of the continuum of care.

The Global Strategy for Women’s and Children’s Health was launched by UN Secretary-General Ban Ki-moon at the General Assembly in September 2010.  The Global Strategy was an expression of the Secretary-General’s recognition that the health MDGs — and particularly MDG 4 (Reduce child mortality) and MDG 5 (Improve maternal health) ­— were headed for failure, and that this dire circumstance presented the world with an urgent moral imperative. The Global Strategy, and the Every Woman Every Child effort that aims to generate commitments to the Global Strategy, represents the compelling moral power of the UN and its Secretary-General to mobilize the world into focused action. Its stated goal was to save 16 million lives between 2010 and 2015.

The Global Strategy has, so far, provided a much-needed jumpstart to international efforts to bring about real progress on women’s and children’s health. It has bought together key UN and other multilateral agencies (including WHO, UNICEF, UNFPA, UNAIDS, and the World Bank) around a coherent, comprehensive vision of what needs to be done to save lives. The Global Strategy set clear, measurable targets, and mechanisms have been established to keep track of whether targets are being met and to ensure accountability. It has mobilized a broad range of stakeholders — from civil society organizations to corporations, from all of the most important international donors to the governments of dozens of developing countries — to commit themselves to take specific, concrete, and significant actions. Many of these commitments have been pledges of money, which is desperately needed, but many have also been commitments in kind: pledges to build new midwifery schools, to achieve specific increases in national skilled childbirth attendance or immunization rates, to institute free emergency obstetric and child health care, or to increase access to and use of contraceptives.

UN Association members' day, February 2012 (Photo: Arnold Gallardo/UNA-USA)This is a multi-year effort, and one whose goals are both ambitious and urgently necessary, and much more still needs to be done. In this time of limited and constrained resources, we must bring about greater efficiency and effectiveness in the ways that aid is allocated and programs are implemented, with a particular focus on the integration of services, so that women and families can meet their health care needs at a single health center offering high-quality, comprehensive services across the continuum of care. We must work in a targeted way, focusing our resources and efforts on key countries, where the burden is highest, and on key, proven interventions. We must ensure that governments, donors, and all other stakeholders are held to account for fulfillment of their commitments: the Global Strategy only becomes truly meaningful when its promises are kept, and advocates (including my organization) are working hard to make sure that they are. And we must have sustained, vocal, visible, high-level leadership — from the Secretary-General himself, from heads of state, and from celebrities; but also from dedicated and often unsung individuals in ministries of health, in civil society organizations like the United Nations Association, in hospitals and clinics, and in the villages and communities where so many women and children are still dying.

So what am I —an advocate from an NGO, and not a representative of the UN — doing here, in front of the United Nations Association, describing an initiative of the UN Secretary-General? I’m here because a great part of the power of this initiative is the way it focuses on the value of partnership to get things done. An engaged, empowered civil society — both here at the global level, and at the grass roots in every country with a high burden of maternal and child death — must play, and is playing, a central role in that partnership. The voice of civil society is key to making change happen, in every corner of the world.

In 2000, the world committed itself in the Millennium Declaration to bring about momentous change by the year 2015, to address the historic challenges of poverty, hunger, disease, inequality, and environmental degradation that deform or end so many lives in the developing world. Much progress has been made, but it is clear that the goals related to health will not be fulfilled. And MDG 5 is the furthest from success. As we begin to talk about an international framework for continued, and accelerated, progress beyond 2015, that framework must include special attention to the health, well-being, and education of children and women. The United Nations, under the leadership of Ban Ki-moon, has set a visionary, progressive agenda. It is our obligation to build on that legacy, to build a world where no woman and no child dies a preventable death, simply because they were born in the wrong place, because they are poor, because we pretend we can’t afford to save them. The Global Strategy has been an essential first step, and its urgent, essential work will continue until it is done.

Getting to Zero: World AIDS Day advocacy

Today, on World AIDS Day 2011, Family Care International has partnered with Save the Children to help policymakers across Africa understand and act on the urgent need to eliminate new HIV infections among children, and to provide comprehensive HIV services for their mothers.

Three decades into the AIDS pandemic, new HIV infections among children are virtually zero in high income countries. Yet in middle and low-income countries, an estimated 370,000 children were born with the HIV virus in 2009, while 60,000 pregnant women died because of HIV. “This is unacceptable. Urgent and exceptional efforts should be made to eliminate new infections among children and to keep their mothers alive,” said Thomas J. McCormack and Fatimata Kané, Country Directors in Mali for Save the Children and FCI, respectively, in a joint statement supporting the Getting to Zero campaign to eliminate new HIV infections. “Save the Children and FCI agree: Getting to zero is possible in Mali and in countries across Africa.”

Photo: UNAIDS/Getting to Zero

With over 2.5 million children and 1.4 million pregnant women living with HIV, action must be taken to ensure the survival of children and mothers. Weak health systems, insufficient numbers of health workers, limited health financing, and inadequate focus on health issues within national development frameworks all must be addressed urgently in order to save women’s lives, protect their health, and help them avoid passing on the virus to their children. This requires action by governments, in partnership with the private sector and development partners.

FCI and Save the Children are joining UNAIDS and a global coalition of NGOs in supporting the Global Plan Towards Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive.  The Global Plan has two important targets:

  • Reduce the number of new HIV infections among children by 90%
  • Reduce the number of AIDS-related maternal deaths by 50%.

African leaders have made a number of commitments to address HIV/AIDS among women and children, most recently at the United Nations High Level Meeting on AIDS in June, 2011, when the Global Plan was launched.

In Mali, Burkina Faso, and Kenya, FCI is working, in collaboration with many partners, to hold policymakers accountable for keeping these promises.  Increased efforts to eliminate new infections for children and keep their mothers alive are crucial to improving child survival and maternal health, and to achieving Millennium Development Goals 4, 5 and 6. FCI is proud to partner with Save the Children and other advocates around the world on World AIDS Day to urge policy makers and donors to help us “get to zero.”

Why are so many newborns still dying?

Shafia Rashid is a senior program officer in FCI’s Global Advocacy program.

Photo: Joey O'LoughlinEstimates released earlier this month, based on research by WHO, Save the Children, and the London School of Hygiene and Tropical Medicine, indicate  that 3.3 million newborn babies died in 2009. This reflects a substantial reduction over the past two decades: the authors estimate that 4.6 million newborns died in 1990, so newborn mortality has declined by 1.7% per year. While this is good news, the fact remains that maternal and child mortality have both been falling more rapidly, at 2.1% and 2.3%, respectively. (The child mortality figure includes newborns, meaning that mortality rates for children more than one month old can be assumed to have declined at an even higher rate.) As our colleague Flavia Bustreo, WHO’s Assistant Secretary-General for Family, Women’s and Children’s Health, has noted, “Newborn survival is being left behind despite well-documented, cost-effective solutions to prevent these deaths.”

At present, 41% of all children who don’t make it to their fifth birthday die during their first four weeks of life. This percentage has been rising, and will keep rising as long as child survival improves faster than newborn survival. Most newborn deaths, of course, occur in developing countries; Africa has shown the slowest progress, with newborn mortality falling by only 1% per year. Clearly, the world needs to more effectively address the continuing epidemic of newborn death — this is an essential key to meeting MDG 4’s goals for overall child survival.

Addressing these challenges requires concerted effort to improve both maternal and newborn health and survival. We know that the health of a woman and that of her newborn are closely linked: most maternal and newborn deaths are caused by the mother’s poor health before or during pregnancy or due to inadequate care in the critical hours, days, and weeks after birth. Improved, more accessible, and integrated services for both mother and baby can efficiently and effectively save both of their lives.

Photo: Joey O'LoughlinLast year, FCI collaborated with Dr. Zulfiqar Bhutta and a research team from Aga Khan University in Pakistan to review the research available on the impact of potential interventions on maternal and newborn outcomes, with a particular emphasis on linkages between the two. Initial results were presented at the Women Deliver conference and the Global Maternal Health Conference in 2010, and the final report will be published in BioMedCentral in January 2012.

The findings from this review highlight how health care for women and newborns is an interconnected continuum — many of the same clinical interventions benefit both mother and baby. It is therefore vital to interconnect care for women and for their newborn children — to promote greater efficiency and lower costs, and to reduce duplication of resources. Perhaps most importantly, integrating interventions can maximize impact on the health and survival of women and their newborns.

This research  will be a helpful first step in better understanding why newborn survival is lagging, and — more importantly — in FCI’s efforts to promote investment in and implementation of health interventions that can save the lives of both women and their newborn babies.

New focus on stillbirths

Each year, there are more than 2.6 million stillbirths — over 7,000 every day. About 98%of  them occur in developing countries, and two-thirds to families living in rural communities. What this means is that many of the same factors causing maternal deaths also lead to stillbirths — and that the solutions to both problems are largely the same. Every pregnant woman needs accessible, high-quality antenatal care, skilled childbirth care, and emergency obstetric care. These basic, essential services are crucial to preventing stillbirths, saving women’s lives, and preventing childbirth injuries like obstetric fistula, as well as vastly improving survival statistics for newborns. Once again, we see that it’s all about the continuum of care.

This week, The Lancet published its Stillbirth Series, which highlights the rates and causes of stillbirth, explores cost-effective interventions to prevent them (as well as maternal and neonatal deaths), and lays out the critical actions needed to cut stillbirth rates in half within 10 years. It also features comments from parents, illustrating “the unique tragedy for families of the birth of a baby bearing no signs of life.”