Placing Women at the Center: Rethinking the RMNCH Continuum of Care
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. 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.