At a standing room only event last week at The Forum at Harvard T.H. Chan School of Public Health, global experts gathered to discuss the need for, barriers to, and the way forward for maternal and newborn integration. But what is integration and why is it so desperately needed?
Every year approximately 300,000 women and 5.5 million newborns, including stillborns, die needlessly. The causes of these deaths are often similar since the mother and her newborn are inextricably linked both socially and biologically.
For the panel, Putting Mothers and Babies First: Benefits Across a Lifetime, Ana Langer, Director of the Maternal Health Task Force; Joy Riggs-Perla, Director of Saving Newborn Lives at Save the Children; Alicia Yamin, Policy Director of the François-Xavier Bagnoud Center for Health and Human Rights and Kirsten Gagnaire, Executive Director of the Mobile Alliance for Maternal Action (MAMA), presented the health, rights, and technological advantages to integrating maternal and newborn health financing, policies, training, and service delivery.
Why is integration important?
A woman’s health before conception, during pregnancy, and after her baby is born has a direct impact on the health of her child and the rest of her family. “Biologically the health, the nutritional status, and the well-being of the mother in general strongly influence the chances of survival and well-being of the fetus during pregnancy, the newborn later and even older children,” shared Langer. Since a woman is the primary caretaker of her family, if her health suffers, everyone is affected.
Recent research from Dr. Yamin quantifies this impact. In South Africa, Tanzania, Malawi, and Ethiopia, if a mother dies during pregnancy or childbirth, there is a 50-80% chance that her newborn will die before reaching his first birthday. The impact of the death of the mother also reached far into the future. When a mother dies there are higher rates of family dissolution; early drop out of school, especially for girls; and nutritional deficits.
What are the challenges to integrating?
Although it is easy to see how the health of the mother would directly affect the health of her fetus, newborn and children, integrated care is rarely seen. Maternal health, newborn health, and child health are siloed as separate initiatives across the health care spectrum: from the policy, donor, financing and monitoring levels to the academic, health system, program and NGO levels. But these problems are seen beyond the program and country level. These “challenges also happen at the global level, failing to provide an enabling environment for those changes at the country level to happen. So too often, we see that different initiatives are either targeted to mothers or to babies and don’t make a good enough effort to bring them closer together,” shared Langer.
Divisions in providing maternal and newborn health include separate pre-service training in maternal and newborn health for health care workers, rare HIV-testing and treatment of an infant if the HIV-positive mom dies in childbirth and separate global initiatives, among many others. These persistent separations have created a dearth of evidence of how best to implement integrated maternal and newborn care.
Key areas that remain segregated are ministries of health and data collection systems. Joy Riggs-Perla shared that “there’s often a separation [of maternal and newborn health] organizationally in a Ministry of Health… That can cause problems with program coordination. It can cause problems where one or the other gets more or less emphasis. And so that can actually lead to problems in service delivery.” In addition, Riggs-Perla addressed the crucial need to collect data on both mothers and newborns so that programs and health systems recognize and synchronize their approaches to improve health outcomes along the continuum of care. “I think the bottom line in all of this is that if people think about care from a client-centered perspective, or a client-oriented perspective, you naturally come to the continuum of care. And that helps solve some of these problems. Too many of our health services are organized at the convenience of the providers,” concluded Riggs-Perla.
An additional barrier to integration may be societal discrimination. “Ultimately maternal mortality is the culmination of layers of structural, and discrimination, and exclusion that women face in society. And often women and children face or experience their poverty and marginalization through their context with indifferent and dysfunctional health systems,” shared Yamin.
How to break silos
In order to provide comprehensive care that benefits both the woman and her child, current silos in maternal and newborn health need to dissolve.
MAMA is working to bring integrated information to pregnant women and mothers precisely when they need it. Through mobile technology, both text and voice messages are used to provide timed and targeted information during pregnancy through their child’s third birthday. These messages are specific to the local context and language and include a wide range of information from nutrition during pregnancy and breastfeeding to cognitive development and immunizations for their children.
Another programmatic example is from the TSHIP project in Nigeria, where misoprostol and chlorhexidine are now distributed together by community health workers: misoprostol to prevent postpartum hemorrhage in women and chlorhexidine to prevent umbilical cord infection in newborns.
The panel provided many potential solutions to the chasm in maternal and newborn health:
- Integrated national costed plans of action: “[Integration is] very, very difficult if it doesn’t start at the beginning: once budgets are separated, programs are designed, job descriptions are formed” and integration is nearly impossible – Yamin.
- Integrated pre-service training of health care providers
- Integrated performance and health outcome indicators
- Excluding initiatives that are narrow, categorical and vertical
- Initiatives that strengthen health systems
- Programs that allow for flexibility and learning, both in activities and funding
- Diverse partnerships: “We are increasingly finding ourselves needing to work in a partnership way: in public-private partnerships, bringing in UN agencies, bringing in the host country governments, bringing in bilateral funders, foundations and [the] corporate It takes a tremendous amount of aligning of agendas and understanding how each of these different sectors and entities works, and what their perspectives are. [But,] ultimately I think we get better results from it.” – Gagnaire
While these strategies are promising, there is still a lack of research on integration and so information exchange is key. In order to address this need, Dr. Langer shared news of the upcoming Global Maternal Newborn Health Conference, which will “provide a space for information exchange, for productive debate and for discussion about maternal and newborn health and how to bring it closer together.”
For more details from this event, continue to follow our blog this week to hear more details from Joy Riggs-Perla, Alicia Yamin, Kristen Gagnaire, and Ana Langer. Also, to learn more about integration, check out our MNH Integration Blog Series.