The MHTF seeks to generate and disseminate high quality scientific research; surface key issues for critical discussion, consensus building and policy advocacy; support emerging professionals in maternal newborn health; and connect researchers, policy makers, providers and other stakeholders in the global maternal newborn health field.
“We cannot achieve our goals of ending maternal and child deaths without addressing critical health system barriers around the world,” said Grace Chee of the U.S. Agency for International Development (USAID)’s flagship Maternal and Child Survival Program at a recent Wilson Center event. To improve the lives of mothers and children, health workers must address the underlying causes of poor health outcomes, including systemic weaknesses in health care governance, financing and human resources.
“High quality and coverage of these essential services cannot be achieved without trained and motivated health workers, who have the medicines, equipment and technology that they need to deliver these services,” said Chee, which—in turn—depends on strong leadership and greater financing.
Human resources is an essential building block in Liberia, said Dr. Birhanu Getahun: “The health workforce capacity has been built at county, district and national levels, so they do have the soft skills to strengthen the health system.”
Similarly, in Rwanda, the Low-Dose High-Frequency mentorship program deployed traveling mentors to train providers “within their working environment,” said Dr. Stephen Mutwiwa. Since the launch of the program in 2016, the total number of providers in Rwanda trained in basic emergency obstetric and newborn care, child health and family planning has increased three-fold.
Governance and financing: Changing the system from within
Like all international development programs, programs aimed at providing technical assistance to improve maternal and child health should work closely with national and local government leaders, because “only they can really change the system from within,” Chee said.
In Nigeria, the lack of centralized governance has slowed progress in reducing maternal mortality and under-five mortality rates, said Lee Pyne-Mercier of the Bill and Melinda Gates Foundation. The large number of donor and non-governmental partners in Nigeria have “led to significant fragmentation and duplication of effort,” said Pyne-Mercier. The Gates Foundation is working with national leaders to coordinate efforts and develop a single set of long-term goals for the health system.
Official development assistance (ODA), while at a record high, continues to make up only a small sliver of total development assistance worldwide, according to Dr. Mariam Claeson from the Global Financing Facility (GFF). Other sources include foreign direct investment, remittances and domestic financing.
“How can we use, smartly, our ODA to leverage those other sources of finance for women, children and adolescents?” said Dr. Claeson. GFF estimates that an additional $33.3 billion would be needed to cover the global need for reproductive, maternal, newborn, child and adolescent health services—but currently total development assistance worldwide—for all needs—is roughly $36 billion.
The Global Financing Facility seeks to close the funding gap by encouraging country leaders to mobilize domestic resources, providing technical support for health finance reforms and identifying target areas for investment. “We have to put the country…in the driver’s seat,” Dr. Claeson said.
Governments can assess their progress by asking, “Is money going to underserved areas? Are domestic resources increasing over total government resources? Are there more technical health personnel assigned to the primary healthcare level?” said Dr. Claeson. These disbursement-linked indicators, developed by the World Bank, help to bring investments to the frontline by identifying neglected areas, said Dr. Claeson.
Data: Measuring what works
Data—collecting and assessing it—is critical to a well-functioning health system. For example, Dr. Koki Agarwal, the director of USAID’s Maternal and Child Survival Program, noted that while antenatal care is highly utilized by women worldwide, “we still don’t know what services are being provided and how effective they are,” she said.
To be useful, data must be accessible, said Mary Taylor of the Arctic University of Norway. “It is most important that everybody have the capacity to actually understand and use that data at the levels at which they work,” she said.
Dr. Agarwal urged development workers to “think differently about how we invest in our country programs and what outcomes we are interested in.” Along those lines, Saldaña urged us to remember that the Sustainable Development Goals look very different in each country context.
“Only by changing how the system fundamentally operates,” said Chee, “can we have sustainable improvement.”
Sources: Bill and Melinda Gates Foundation, District Health Information Software 2, Global Financing Facility, Jhpiego, United Nations, USAID, USAID’s flagship Maternal and Child Survival Program, World Bank, World Health Organization
Photo Credit: Lindsay Mgbor/UK Department for International Development
The burden of maternal mortality in the United States (U.S.) has recently garnered a great deal of media attention and is now supported by new data from the Building U.S. Capacity to Review and Prevent Maternal Deaths project team. Released earlier this year, their Report from Nine Maternal Mortality Review Committees (MMRCs) provides an evidence-based analysis of why preventable maternal deaths continue to take place in the U.S. Incorporating data from nine states—Colorado, Delaware, Georgia, Hawaii, Illinois, North Carolina, Ohio, South Carolina and Utah—as well as lessons learned from surveying maternal mortality in a total of 20 state and local MMRCs, the report investigates causes, contributors and next steps related to addressing maternal mortality.
According to David Goodman, PhD, team lead, Maternal Health Team in the U.S. Centers for Disease Control and Prevention (CDC) Division of Reproductive Health,
“While maternal deaths are relatively rare in the United States, each one is tragic. We have an opportunity to build on current momentum to turn the tide. A tangible step in that direction is new data and insight we published earlier this year in Report from Nine Maternal Mortality Review Committees. In the report, we confirmed that the majority of these deaths are preventable, provided in-depth insight into causes of death and racial disparities, and highlighted actionable prevention recommendations made by the Nine Committees. Each maternal death is a tear in the community fabric—a child without a mother, parents without a daughter, and partners without their other half. CDC is committed to reducing maternal mortality in the U.S., and welcome additional collaboration as we work together to end preventable deaths.”
Over 60% of pregnancy-related deaths in the U.S. were preventable. The report estimates that 63% of pregnancy-related deaths were preventable while 68% of cardiovascular and coronary deaths and 70% of hemorrhage deaths were preventable.
Both direct and underlying causes led to maternal death—and varied by race. Nearly half of pregnancy-related deaths were caused by hemorrhage, cardiovascular and coronary conditions, cardiomyopathy or infection. Underlying causes such as preeclampsia and eclampsia and embolism were identified as leading causes of death among non-Hispanic black women, while mental health conditions comprised an important cause of maternal deaths, especially among white women.
Patient/family and provider factors were considered largest contributors to maternal death. An average of four contributing factors were identified for every one pregnancy-related death, with the greatest proportion of factors contributing to pregnancy-related death was linked to patient/family factors, such as lack of knowledge on warning signs and the need to seek care. This was followed by provider and systems of care factors, including misdiagnosis/ineffective treatment and poorly-coordinated care, respectively. Facility and community factors were not commonly associated with maternal death. However, the authors caution readers not to “assume that the absence of ‘community-level’ factors in our last report is evidence that community-level factors do not contribute to pregnancy-related death.”
As a health volunteer for the United State Peace Corps, I assist a team of doctors, midwives and nurses in delivering basic health care to a local community in Guyana, South America. Every week at the health center, there are three clinic days dedicated to providing antenatal care, family planning and newborn vaccinations. Approximately 10–30 women come to the antenatal clinic per week and according to the records, the health center saw 184 pregnant women in 2017. The only available statistic that addresses noncommunicable diseases (NCDs) in the context of maternal health for this population is the testing rate for anemia—in 2017, 76 out of 184 women were tested.
Every week, several women at the health center present signs of pregnancy induced hypertension, anemia, obesity and other NCDs, such as depression or anxiety. However, data reports for the health center are limited because our indicators do not target NCDs in the antenatal population. Regular reports are viewed as burdensome and compulsory, rather than as a tool to better understand the population and its health needs, and outdated metrics continue to be used. This contributes to an overall reliance on basic maternal health guidelines—such as the proportion of pregnant women receiving antenatal care—as benchmarks for quality of maternal health care in Guyana. This trend is consistent with research showing a quality-coverage gap in antenatal care on a global scale, particularly where resources are limited and quality data collection remains challenging.
In 2016, the maternal mortality rate in Guyana was 116 per 100,000 live births. Fortunately, there is a high utilization of antenatal care. In 2014 90.7% of women age 15-49 were attended by a skilled health personnel at least once during pregnancy and 92.4% were attended by a skilled birth attendant at their most recent live birth. Access to a health facility to see a skilled birth attendant is typically not a major barrier to care because health care coverage is free and health infrastructure supports this demand. In some regions, Amerindian maternity waiting homes accommodate women planning to deliver in the coastal hospital and after they return to their rural communities.
Filling the data gap to meet local needs
Guyana Ministry of Health officials have identified the need to focus on NCDs in the general population. While this action points Guyana in a positive direction, priority must also be given to adapting monitoring systems within the primary health care system. Quality data surveillance and monitoring is required to best understand multiple, overlapping vulnerable populations, such as individuals with NCDs and women of reproductive age in developing countries. This overlap holds potential to address complex health topics with sustainable solutions, but only if the knowledge gap is filled.
Increasing data collection in primary care
Implementation strategies to improve utilization of evidence-based guidelines and focus on capacity building might include in-service training, supportive supervision, appropriate checklists, accountability processes and financial incentives. Innovations within the field of health technology, such as mHealth, could be used for quality data collection and surveillance to improve health statistics.
High quality maternal health care requires a health workforce and health systems that adequately respond to local needs and can meet emerging challenges, such as those at the intersection of maternal health and NCDs. Guyana’s health system structure has serious potential to evaluate and respond to these complex health issues, but decisions concerning resources and strategies require evidence-based support, highlighting the demand to improve data quality measurement tools and methods.
Further research is required to drive improvements in health system monitoring and appropriate guidelines in countries with limited resources. Investing in strategies that support quality health assessments will help to close the evidence gap in maternal health and enable health care providers to advance sustainable solutions and better health outcomes for the women, their families and communities.
“The contents of this blog post are the author’s and do not reflect any position of the United States government or the Peace Corps.”
In 2017, ProPublica introduced a series of articles titled “Lost Mothers”—which was recently awarded the Goldsmith Prize for Investigative Reporting—to raise awareness about preventable maternal deaths and striking maternal health inequities in the United States (U.S.). The featured article describes an effort to identify the estimated 700 to 900 women who died from pregnancy- or childbirth-related causes in 2016 in the U.S., presenting heart-wrenching stories of women from around the country. Other articles highlight critical maternal health issues in the U.S. with an emphasis on racial inequities, quality of care and monitoring and surveillance of maternal deaths.
Despite the enormity of the burden and the existence of evidence-based solutions to prevent many stillbirths, stillbirths have been long overlooked in global data tracking, social recognition and in investment and programmatic action.
This must change. And signs of progress give hope.
But there are still gaps and we need to do more. Stillbirths count to families and economies; thus they should count to governments, donors, the UN agencies and all stakeholders.
In 2016, only 32 of the 75 Countdown countries regularly tracked stillbirths as part of their national health information systems. With stillbirths now included in the Countdown profiles and as a core indicators in the Global Strategy, the UN needs to respond to the growing demand for regular counting of stillbirths. However, to date, the UN has not produced regular estimates of stillbirths. While they have recently been included within the global burden of disease estimates, the lack of transparency in the estimation progress, absence of a country consultation process and limited dissemination limits their utility for programmes, policymakers or global tracking.
The UN Inter-agency Group for Child Mortality Estimation (IGME) has agreed to undertake regular country-level stillbirth rate estimates, but their ability to deliver on the commitment to regularly count stillbirths will not be possible without further investment from partners.*
Breaking the silence
We thank UN IGME for its willingness to help break the silence around stillbirth by including stillbirth estimates in its maternal and child estimation processes. We call upon the global donor community to commit its resources as well to counting stillbirths so that we may accelerate progress in ending this avoidable tragedy. Richard Horton, editor-in-chief of The Lancet, reflected that “stillbirths are a sensitive indicator of our solidarity, cohesion and inclusiveness.”Will 2018 be the year when the international health community demonstrates their collective commitment to the counting and preventability of stillbirths?
Learn more about what has happened in the two years since The Lancet published their series on ending preventable stillbirths here.
* IGME’s role is to harmonize mortality estimates within the UN and its partners, improve methods for robust, transparent child mortality estimates, report progress towards child survival goals and build country capacity to produce annual estimates of child mortality.
Every woman has the right to be free from harm and ill treatment
Every woman has the right to information, informed consent and refusal and respect for her choices and preferences, including the right to her choice of companionship during maternity care, whenever possible
Every woman has the right to privacy and confidentiality
Every woman has the right to be treated with dignity and respect
Every woman has the right to equality, freedom from discrimination and equitable care
Every woman has the right to health care and to the highest attainable level of health
Every woman has the right to liberty, autonomy, self-determination and freedom from coercion
Continued research, commitment and collaboration among the global community will help safeguard these rights for every woman, everywhere.
Health-seeking behaviors among pregnant women in low-resource settings in India are abysmally low. The latest National Family Health Survey (2016) revealed that only 35% of women in Maharashtra, a high-income and highly urbanized state in India, accessed full antenatal care, (ANC) including at least four antenatal visits, at least one tetanus toxoid injection and iron folic acid tablets or syrup taken for 100 or more days. Having worked with communities living in informal settlements in the megapolis of Mumbai and its suburbs for nearly two decades, the Society for Nutrition, Education and Health Action, (SNEHA) a non-profit organization that works on women and children’s health across the life cycle, aims to strengthen bonds with women and children from marginalized and vulnerable slum communities to influence decision-making in health matters. SNEHA’s Maternal and Newborn Health Program works with communities as well as public health systems to bring about tangible change in indicators, attitudes and health services.
At the community level, one of SNEHA’s many outreach strategies is to conduct events such as baby-showers, or godhbharai. These culturally relevant community events have immense potential in improving the health-seeking behavior of pregnant women while expanding their knowledge of and willingness to use available public health services.
These baby showers are typically conducted at local health posts close to where intended beneficiaries live, giving pregnant women an opportunity to feel welcome at health facilities. Creating a feeling of festivity and celebration is central to the godhbharai, in which women receive garlands and are offered fruits as a take-home souvenir. These events are conducted in collaboration with public systems, with public workers and personnel in attendance. These personnel contribute by giving health and nutrition talks and assuring the gathered women of the system’s commitment to their health and the babies’ wellbeing.
Here are five lessons learned from conducting these events:
Provide a useful platform for sharing critical health information
These baby showers combine celebration of the pregnancy as a life event, while disseminating valuable health information on the importance of seeking ANC, pregnancy registration, birth preparedness as well as newborn care and breastfeeding. They also enable public health staff to talk about relevant programs, such as the Janani Suraksha Yojana, a conditional cash transfer scheme that encourages institutional deliveries. Field workers share stories of second-time mothers who register themselves with a public facility for delivery after hearing about the benefits. The 2016 endline survey of Beyond Boundaries found that average institutional delivery rates among the intervening beneficiaries was around 89.5%. Distributing birth preparedness and complication readiness cards that list information in an easy-to-digest manner helps empower women with information and take charge of pregnancy and birth.
Disseminate practical nutrition education
Organizing stalls at the venues with sample meal plans and food items showcases an optimum pregnancy diet. The stalls have samples of lentil sprouts, boiled eggs, roasted whole-flour snacks and soups to emphasize the importance of maintaining a healthy intake of protein and iron rich foods, while pregnant. Selecting affordable and low-cost food items demonstrates that it is possible to eat a healthy diet on a low budget. This can motivate pregnant women to go back home and start eating and cooking mindfully.
Introduce the local public health facility as a touch-point during pregnancy and labor
Holding these events at the health post—rather than in a community space—has helped lead more women to use public health facilities and services. The events are attended by public health workers and employees, bringing together public health staff and the community. Health post staff arrange for antenatal check-up kits at the event. For many women, it is their first visit to a health facility and an opportunity to learn about the services they offer. When women see motivated and engaged public health personnel, they are often keen to register their pregnancies, come for antenatal check-ups and give birth in a public health facility. This can also give them the confidence to become empowered users of public services. According to the endline survey, on average about 95% of women received four or more antenatal check-ups.
Given that many beneficiary communities are migrants and often have families and social networks hundreds of kilometers away, bringing pregnant women together in an event creates a community of support to share joys and resolve anxiety. Informal social networks have positive effects on knowledge of health practices, during pregnancy, birth and child development. The geographical layouts of slum communities encourage interaction and friendships, thereby having a positive effect on health.
Connect community health volunteers to beneficiaries
A cadre of community health volunteers attends these baby showers. Volunteers are connected to pregnant women and then help women register their pregnancies, take them for antenatal visits, intervene in the case of emergencies and organize transportation during labor. They are trained in basic and emergency obstetric care and to spot danger signs during pregnancy and labor.
Innovations in health care delivery are crucial to improving maternal health worldwide. Introduced in Northern Europe, Canada and the United States in the early 20th century—and now available in many areas around the world—maternity waiting homes (MWHs) provide a place for women at high risk of pregnancy complications to await labor and delivery near a qualified health facility. MWHs seek to reduce the distance to timely, high quality health care, which is often a major obstacle in the decision to seek care—especially for pregnant women living in rural areas. While the evidence on their effectiveness remains mixed, researchers have linked MWHs to reductions in maternal and perinatal mortality throughout Africa. Further research has explored the barriers that prevent use of MWHs as well as the factors that contribute to their uptake and success.
As outlined by the World Health Organization (WHO) more than two decades ago, community and cultural support is a crucial element in the success of MWHs. In Zambia, support from community groups—including Safe Motherhood Action Groups, Neighbourhood Health Committee members and faith-based organizations—played a major role in the development, construction and operation of MWHs, as well as communication between the community and health staff.
Address quality of care issues
As with any service along the continuum of maternal health care, MWHs must meet women’s needs in a dignified, respectful environment. Even when the concept of MWHs is accepted and valued, poor quality of care can deter women from using them. Women and community groups in Zambia expressed the need for better infrastructure, services, food, security, privacy and transportation:
“When I delivered last year, I went home immediately […] it was impossible to keep myself clean without water in the maternity ward and maternity home despite the midwife advising me to stay until the following day.”
–Woman who gave birth at a rural health center
Given that MWHs serve as a point of referral for nearby health facilities, efforts to improve quality of care must extend beyond the MWH itself. According to WHO, MHWs “…cannot function effectively in a vacuum. Rather, they are a link in a larger chain of comprehensive maternity care, all the components of which must be available and of sufficient quality to be effective and linked with the home.”
As Vermeiden and colleagues articulated, it is vital to address the needs of the whole health system:
“If the Ethiopian health care system is incapable of absorbing an influx of women for childbirth, encouraging women to use MWHs could lead to more women receiving substandard care, which may backfire on Ethiopia’s attempts to reduce maternal and neonatal morbidity and mortality.”
Considering the health system structure and capacity is another fundamental element of success. Chibuye and colleagues found that most participants remained skeptical that women would pay for services at MWHs because the health system services for reproductive, maternal, neonatal and child health are free of charge in Zambia. Securing funding from governments and other sources as well as establishing strong partnerships are also key to ensuring sustainability of MWHs.
As Vermeiden and colleagues emphasize, “MWHs alone will not reduce maternal and neonatal mortality and morbidity; they are merely a tool to increase the number of women who are able to access care.” Efforts to gain community support and engagement, improve quality of care and leverage local context can help ensure that MWHs are effective in linking pregnant women to timely, life-saving services.
A recent study conducted in Ethiopia by Management Sciences for Health at one rural and two urban health centers in the Tigray Region of Ethiopia aimed to understand the prevalence of gestational diabetes in Ethiopia and its risk factors and assess the feasibility of integrating low-cost services for gestational diabetes into antenatal care. The study found that relatively simple and low-cost interventions could help manage gestational diabetes for many women—but there were different outcomes among women living with HIV and those without the condition.
According to the study, more than 11% of the 1,242 pregnant women tested positive for gestational diabetes—higher than expected, since previous prevalence estimates of gestational diabetes in Ethiopia were between 4% and 9%. Nearly a quarter of the women living with HIV were diagnosed with gestational diabetes, compared with 11% of HIV-negative women.
HIV treatment and gestational diabetes
Among the HIV-positive pregnant women, 29% of those who were on antiretroviral treatment (ART) tested positive for gestational diabetes. By comparison, 15% of HIV-positive pregnant women who had not started ART prior to their pregnancies were diagnosed with gestational diabetes. This finding is especially important since Ethiopia has adopted the Option B+ treatment, which places all HIV-positive pregnant women on lifelong treatment.
The study also revealed challenges and discrepancies related to treatment for gestational diabetes. Whereas 79% of pregnant women with gestational diabetes brought their blood glucose levels to normal through low-cost behavioral interventions—including dietary changes and increased physical activity—after two weeks, less than half of the women living with HIV did so. Half of the pregnant women on ART responded positively to behavioral changes, compared to about a third of HIV-positive women not yet on ART.
The study results are eye-opening and warrant more attention. First, the prevalence of gestational diabetes among HIV-positive women and the treatment results should be assessed on a larger scale, including the influence of ART. The high prevalence of gestational diabetes among HIV-positive pregnant women highlights the importance of screening all HIV-positive pregnant women for gestational diabetes, especially in light of expanding ART coverage and Ethiopia’s adoption of Option B+ treatment. Furthermore, HIV-positive pregnant women with gestational diabetes may need specialized treatment services. Additional research should develop and test effective new treatment models, especially in low-resource and rural settings, where women frequently have trouble accessing regular care.