The Lancet Maternal Health Series published in September 2016 contains six papers highlighting the importance of improving access to high quality maternal health care for all women across the globe. In paper 6, “Quality maternity care for every woman, everywhere: A call to action,” Koblinsky and colleagues offer five priority actions for achieving the Sustainable Development Goal (SDG) global target of fewer than 70 maternal deaths per 100,000 live births by 2030 and promoting maternal health equity within and among countries.
Priority 1: Prioritize quality maternal health services that respond to local needs and meet emerging challenges
The first step towards improving maternal health is the prevention of unwanted or poorly timed pregnancies. If every woman around the world had access to contraceptives, an estimated 29% of maternal deaths could be averted. Complications from unsafe abortion are a leading cause of maternal deaths as well.
For women who continue their pregnancies, adapting strategies and interventions to local needs is necessary to improve the quality of maternity care. There is no single universal solution that applies to every setting: Efforts must be tailored to account for the available infrastructure, resources and health workforce, geographic considerations, the particular sociocultural, political and environmental factors affecting women’s health and the local burden of disease. The authors use the obstetric transition framework to recommend specific priority actions based on maternal mortality ratio, emphasizing the importance of integrating maternity care with other health services.
Priority 2: Promote equity through universal health coverage of quality maternal health services, including for the most vulnerable women
Major barriers to maternity care include gender inequality, geography and financial constraints. Gender disparities affect women’s health through a variety of mechanisms: Child marriage, adolescent pregnancy and a lack of access to education, for example, have lasting implications for girls’ sexual and reproductive health. Some evidence indicates that women are at an increased risk of experiencing gender-based violence during pregnancy.
Living in remote settings or areas affected by humanitarian crises also impedes women’s access to health services. High rates of fertility, unwanted pregnancies and sexual violence are typically common during humanitarian crises, and yet sexual, reproductive and maternal health services in those situations are often insufficient or nonexistent.
For low-income women, utilizing maternal health services—especially for obstetric emergencies—represents a catastrophic expenditure. Health insurance promotes maternal health care utilization, which supports the notion that universal health coverage (UHC) is critical to achieve SDG3 (“Ensure healthy lives and promote well-being for all at all ages”) by 2030.
Priority 3: Increase the resilience and strength of health systems by optimizing the health workforce and improving facility capability
Resilient health systems are able to provide essential health services to everyone, even during emergencies such as natural disasters, violent conflicts and infectious disease outbreaks. A fundamental component of resilient health systems is a functional health workforce. Many places do not have enough skilled health workers to care for the entire population; often the health workforce is concentrated in the cities, leaving rural areas without adequate coverage. In sub-Saharan Africa, many countries with the highest birth rates—including the Democratic Republic of the Congo, Tanzania, Kenya and Ethiopia—also have the lowest concentrations of midwives and obstetricians with less than 2 maternal health care providers for every 1,000 pregnancies.
According to the World Health Organization’s Global Strategy on Human Resources for Health: Workforce 2030, more than 18 million additional health workers are needed in order to meet the SDGs and targets for UHC. Expanding the global health workforce will depend on substantial investment in education and training, equitable and efficient resource allocation, management systems, work environments and financial and non-financial incentive schemes. Task shifting to community health workers has the potential to facilitate this process, particularly for family planning services. However, health workers cannot do their jobs without fully-functioning facilities.
Priority 4: Guarantee sustainable finances for maternal-perinatal health
A number of scholars have demonstrated the benefits of investing in women, but ensuring sustainable financing is a challenge. One study estimated that between now and 2035, securing essential health care for women and newborns around the world would cost 72.1 billion USD. High coverage of these maternal and newborn services is expected to substantially reduce stillbirths and maternal and newborn deaths, particularly in high burden countries. As low- and middle-income countries are increasingly transitioning from external donor financing to domestic financing for health, coordinated efforts to support local governments with strategic purchasing and to advocate for prioritization of maternal and newborn health programs are key. In settings with limited financial capacity, continued donor funding will remain crucial as well.
Priority 5: Accelerate progress through evidence, advocacy and accountability
The authors identify two types of research that have the greatest potential to accelerate progress in global maternal health: Measurement of the causes and prevalence of maternal death and disability and implementation research examining the factors that influence the effectiveness of interventions. Currently, many countries do not have the infrastructure necessary to collect comprehensive, high quality data on major maternal and newborn health indicators. Civil vital registration systems that report births and deaths are often weak, missing the most vulnerable populations. Measuring the health of mothers and newborns requires standardizing definitions and methods to allow data systems to capture direct and indirect causes of mortality and morbidity. Implementation research is necessary to ascertain whether or not an intervention is effective and why. In-country researchers are perhaps best positioned to evaluate local programs when trained appropriately.
Translating research into practice is only possible through advocacy and accountability. The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) (Global Strategy) recommends the use of multisector partnerships, community engagement and country-led implementation for achieving the SDGs and focuses on monitoring and reporting as a means of holding stakeholders accountable for results. Together with the Global Strategy and the frameworks from Strategies for Ending Preventable Maternal Mortality and Every Newborn: An Action Plan to End Preventable Deaths, the priority actions put forth by the authors of this paper will help drive improvements in the availability, equity and quality of global maternal and newborn health care.
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Figures: Koblinsky et al. Quality maternity care for every woman, everywhere: A call to action. The Lancet Maternal Health Series, 2016.