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NEW THIS WEEK: A STRATEGY FOR REDUCING MATERNAL AND NEWBORN DEATHS BY 2015 AND BEYOND

Tuesday, 10th of December 2013

A STRATEGY FOR REDUCING MATERNAL AND NEWBORN DEATHS BY 2015 AND BEYOND

Gary L Darmstadt1*

* Corresponding author

Email: gary.darmstadt@gatesfoundation.org

Tanya Marchant2

Email: tanya.marchant@lshtm.ac.uk

Mariam Claeson1

Email: mariam.claeson@gatesfoundation.rog

Win Brown1

Email: win.brown@gatesfoundation.org

Saul Morris1

Email: Saul.morris@gatesfoundation.org

France Donnay1

Email: France.donnay@gatesfoundation.org

Mary Taylor1

Email: mary.taylor@gatesfoundation.org

Rebecca Ferguson1

Email: becky.ferguson@gatesfoundation.org

Shirine Voller2

Email: shirine.voller@lshtm.ac.uk

Katherine C Teela1

Email: kate.teela@gatesfoundation.org

Krystyna Makowiecka3

Email: krystyna.mackowiecka@lshtm.ac.uk

Zelee Hill4

Email: z.hill@ich.ucl.ac.uk

Lindsay Mangham-Jefferies5

Email: lindsay.mangham-jefferies@lshtm.ac.uk

Bilal Avan2

Email: bilal.avan@lshtm.ac.uk

Neil Spicer5

Email: neil.spicer@lshtm.ac.uk

Cyril Engmann1

Email: cyril.engmann@gatesfoundation.org

Nana Twum-Danso1

Email: nana.twum-danso@gatesfoundation.org

Kate Somers1

Email: kate.somers@gatesfoundation.org

Dan Kraushaar6

Email: DKraushaar@msh.org

Joanna Schellenberg2

Email: Joanna.Schellenberg@lshtm.ac.uk

1 Global Development Division, Bill & Melinda Gates Foundation, PO Box

23350, Seattle, WA 98102, USA

2 IDEAS project, Faculty of Infectious and Tropical Disease, London School of

Hygiene and Tropical Medicine, Keppel St, London, UK

3 IDEAS project, Faculty of Epidemiology and Population Health, London School

of Hygiene and Tropical Medicine, Keppel St, London, UK

4 Centre for International Health and Development, Institute of Child Health,

University College London, London, UK

5 IDEAS project, Faculty of Public Health and Policy, London School of Hygiene

and Tropical Medicine, Keppel St, London, UK

6 Management Sciences for Health, Boston, MA, USA

 

Also at http://www.biomedcentral.com/1471-2393/13/216/abstract

 

Abstract

Background

Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030.

 

Discussion

The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact.

 

Summary

Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.

 

Background

Knowledge of what is needed to improve maternal and newborn survival in low-income

settings has advanced substantially since the Millennium Development Goals (MDGs) were

set in 2000. Evidence to date suggests, however, that only a few of the high-mortality

countries will reduce child mortality by two-thirds between 1990 and 2015 (MDG4) and

reduce maternal mortality by three-quarters during the same time period (MDG5) [1].

While maternal survival has improved substantially worldwide since 1990, with a 1.9%

annual decline in mortality between 1990 and 2011, deaths continue to be concentrated in

sub-Saharan African and South Asian countries where the lifetime risk of a woman dying

from pregnancy-related causes is about 100 times higher than that of a woman in a high

income country [2]. During the same period, child survival (to 5 years of age) also improved

markedly, although progress has varied dramatically across income groups and geographies

[3]. Newborn survival (to 28 days after childbirth) has improved more slowly in all regions of

the world, and globally in 2012 44% of all under-five deaths occurred during the neonatal

period [4], up from 37% in 1990. Each year, an estimated 6.6 million children under five

years of age die, which includes an estimated 2.9 million newborn infants [3]. Additionally,

an estimated 2.6 million babies are stillborn annually [5], primarily in settings where vital

registration and cause-of-death statistics are often lacking and maternal and neonatal

mortality remain high.

Maternal death can have catastrophic consequence for the whole family [6] and child deaths

are linked to maternal health via perinatal causes (stillbirths and early neonatal deaths) [7,8],

and via suboptimal care and nutrition in pregnancy and early infancy [9]. Better maternal

health and nutrition can improve intrauterine growth and reduce the chance of a low birth

weight baby; and subsequently, reduce the risk of stunting, infectious diseases,

neurodevelopmental impairments and death [10-13]. Newborns and mothers are both at the

highest risk of dying around childbirth: about one-third of neonatal deaths occur in the first

24 hours after birth [14], and the risk of maternal death is highest within 48 hours of delivery,

not accounting for the estimated 13% of maternal deaths related to abortion [15,16].

To address this unfinished agenda, we present a strategy for accelerating progress on MDG 4

and 5 leading up to the 2015 target date, sustaining the gains beyond 2015, and further

bringing down maternal, neonatal and child mortality by two thirds by 2030. This provides a

frame work for measuring and evaluating progress towards these ambitious but feasible

goals. The Maternal Newborn and Child Health (MNCH) strategy takes into account current

trends in coverage and cause-specific mortality, builds on implementation lessons learned of

what works to date, and will help to reach out to those who do not yet access services.

Discussion

Towards an MNCH strategy for scale up

A limited number of conditions account for the majority of maternal deaths [6] (haemorrhage,

hypertensive disorders, sepsis/infections, and obstructed labour), which also contribute to the

highest burden of newborn conditions [17] (preterm birth, severe infections (sepsis,

meningitis), and intrapartum-related complications also known as “birth asphyxia”). Lifesaving

interventions that can be delivered at community level up to first referral level of the

health system are well understood but coverage of these interventions remains unacceptably

low [18,19]. Global reviews of evidence on the impact and coverage of interventions have

been compiled [20,21], informing this strategy for scale up which aims to complement and

fill gaps in global action for women and newborns, and proposes a pathway towards

sustained health impact.

Trained frontline workers, including qualified or unqualified medical practitioners, private

drug sellers, community health workers (CHWs), traditional birth attendants, and trained

midwives and other skilled birth attendants (e.g., nurses) together provide a critical link to

address the problem of low coverage of interventions [21]. In linking cadres of frontline

workers who are primarily community-based with those who work in primary health

facilities, a larger number of families can be supported through combined counselling, health

education and negotiation at home, pregnancy care, skilled care at birth, and postnatal

healthcare in communities and primary health facilities (Figure 1) [22]. By connecting

communities with the health system [23], for example by mobilizing and empowering

families to seek health care with birth preparedness planning or through communication and

referral systems, life-saving interventions can be brought closer to those who need them [24],

particularly the poorest, who continue to experience the highest burden of mortality [25]. For

example in Bangladesh, CHWs demonstrated effective prevention and management of

serious neonatal illnesses using interventions such as clean cord care, thermal care, and sepsis

management in the home, leading to a 34% reduction in neonatal mortality [26].

Figure 1 Examples of interventions that can be delivered through interactions between

families and frontline workers to reduce neonatal and maternal mortality.

Building on this evidence base, this MNCH strategy focuses on behaviour change both at

home and in primary health facilities where childbirth services are available, by families and

health providers, and strengthens the interconnections between maternal and newborn health,

and between frontline workers and families, ensuring that they are well connected to

accessible, good quality, clinical services. Demand for facility births is increasing [20],

resulting in changes in the rates of facility births globally. To respond to this demand and to

other enhanced care seeking practices, attention to the quality of services provided to

pregnant women, their newborn babies and to sick children at first level facilities is critical

for achieving impact on maternal, newborn and child deaths [27].

The theory of change

The MNCH strategy is based on a theory of change (Figure 2) which charts a pathway

towards impact on maternal and neonatal survival. Both supply and demand are critical, as is

a policy environment which supports program effectiveness. The theory includes initiatives

which work across the continuum from discovery and development of tools and technologies

to the implementation of delivery strategies that lead to high, equitable, and cost-effective

coverage of key interventions.

Figure 2 Theory of change.

Enhancing interactions between families and frontline workers is at the heart of this theory of

change. For more life-saving interventions to be adopted and spread, more families need to

have frequent contacts with skilled and motivated frontline workers who provide good quality

care (both from the technical content and user perspectives) in an equitable and pro-poor way

(see Additional file 1: Web annex 1 for a list of indicators for enhanced interactions).

Demand and supply side innovations which aim to enhance interactions and which are

designed for scale-up are currently being tested in the states of Bihar and Uttar Pradesh in

India, Ethiopia, and northern Nigeria (see Additional file 1: Web annex 2 for a list of current

investments in this strategy by the Bill and Melinda Gates Foundation (BMGF). These

geographies account for approximately six percent of the global population and ten percent of

global births, but as much as 16 percent of global maternal and neonatal mortality [19]. The

BMGF is also investing in the achievement of impact at scale in 8 countries of Mesoamerica,

through performance-based financing.

Each country has many potential large-scale delivery vehicles for scale-up and spread—

through government programs, private sector, and networks of individuals, communities and

organizations. In addition, other non-health sector determinants of maternal and neonatal

health are important for accelerated progress, including secondary education of girls, the

nutritional status of adolescent girls and access to, and use of clean water and sanitation

facilities. Overcoming gender barriers within households and at the community level to

accessing health and other services are essential to reach the 2015 MDG targets, and to

accelerate progress among the poorest communities that are lagging behind -- beyond 2015.

A framework for measurement, learning and evaluation of the MNCH

strategy

Measurement can generate evidence about what works and what doesnt work or has

unintended consequences. It is an important component in any program strategy in order to

enable course correction for program improvement, and to maximize the benefits of local and

global action. The measurement framework for this MNCH strategy, developed by the

BMGF MNCH strategy team and the IDEAS project (Informed Decisions for Actions in

Maternal and Newborn Health, http://ideas.lshtm.ac.uk/), aims to monitor implementation

progress and to find out whether the policies and actions proposed in the theory of change are

effective in achieving program impact, in different geographic locations.

Specifically, the measurement, learning and evaluation answer the following questions:

(1) What community-based maternal and newborn health innovations are being implemented

in Ethiopia, northern Nigeria and northern India, and through what pathways and processes

are they expected to increase “effective coverage” of key interventions (effective coverage

being the fraction of the potential health gain of an intervention that is being delivered to a

population)?

(2) To what degree do these innovations enhance interactions between families and frontline

workers, and increase intervention coverage, in program areas? Are they cost-effective?

Through what mechanisms do enhanced interactions affect coverage of key interventions?

(3) What helps and what hinders scale-up of innovations, both within and beyond project

areas, and how can scale-up be catalysed and leveraged for impact beyond program bounds?

(4) Where innovations have been implemented on a large scale beyond program areas

(through government programs, markets and networks), what is the effect on coverage of key

interventions and how does this depend on implementation strength? What survival impact

can be expected?

The evaluations are multi-disciplinary and include both qualitative and quantitative

approaches. For the latter, IDEAS , BMGF and program implementers and partners are using

quasi-experimental plausibility designs [28], with emphasis on data quality and use of

monitoring as well as evaluation results. Taken as a whole, the approach uses data collected

in support of all components of the theory of change in order to track implementation

progress by foundation grantees and by other partners when innovations spread through

catalytic effects. Data is used to make evidence-based decisions about program improvement

for enhanced efficiency, effectiveness and equity, and to generate evidence of impact and

learning for future investments.

Implications for research and policy

In developing the measurement framework, several key principles for effective monitoring

and evaluation were applied. First, it is important that efforts have country ownership and are

aligned with country models and measurement efforts. Involving in-country researchers and

policymakers during evaluation design is of central importance. This MNCH strategy and

measurement framework aims to complement existing structures at the country level, and not

lead to parallel data collection systems or processes. Primary data is collected only to fill

gaps. Since the measurement is applied to the “real world” of field implementation,

evaluation design is often constrained by lack of valid comparison areas: defining the scale

and context in which innovations are implemented is therefore an essential component.

Results of measurement efforts must be fed back to program implementers in a timely way so

that the maximum possible use of data is made for course correction. Results must also be

shared widely, particularly with decision and policy makers who can make policy and

program changes to improve health services for women and children. Beyond the countrylevel,

the new evidence that will be generated from these evaluation activities is anticipated

to show the extent to which large-scale delivery strategies maximize frontline worker

potential to increase coverage of life-saving interventions; this evidence will be relevant for

others striving to improve the survival of mothers and newborns.

Contribution to global efforts

Since the launch of the MNCH strategy by the BMGF, adjustments are being made to reflect

changes in the global landscape and lessons learned through implementation. For example, as

mortality rates decline and the cause structure of mortality changes [29], with preterm birth

now being the second-leading cause of under-five deaths, increased emphasis is given by

global partners to the prevention and management of prematurity. As frontline health worker

programs are rolled out, for example in India and Ethiopia, the focus on quality and equity is

increasing, in addition to the number of interactions with families. Similarly, as demand is

generated for facility services and births increasingly take place in health facilities, greater

emphasis is placed on quality improvement activities for care, as well as more comprehensive

care at childbirth [30]. Finally, the importance and role of partners working together towards

common outcomes will be critical for achieving the post 2015 MDGs. We estimate based on

solid trends analysis by the Child Health Epidemiology Reference Group, USAID and

UNICEF that two thirds of maternal and childhood deaths could be averted by 2030 and that

we collectively should be held accountable for achieving those ambitious but realistic goals

[31].

Summary

In conclusion, this MNCH strategy provides an effective framework for priorities and actions,

measurement and evaluation, and can guide decisions about the scope of investments along

the pathway towards impact. It is based on a theory of change that is oriented towards

addressing the highest risks of dying for mothers and newborns. The strategy proposes

innovative potential solutions (Additional file 1: Web annex 2) to mitigate those risks, with a

focus on enhancing interactions between frontline workers and mothers and families as a

critical lever in increasing the effective coverage of .life-saving interventions. When new

innovations are introduced to health services, measurement must be incorporated in order to

monitor progress along the way [32]. Strategy and measurement are intertwined: identifying

the link between action and impact can validate strategies, identify the most effective

innovations to take forward, and inform course correction in strategy, investments and

implementation. To take forward innovative local solutions to achieve impact at scale,

strategic and catalytic partnerships are essential, and increasingly such partnerships are

formed with governments providing the leadership and with other development partners

engaged, for example, in the states of Bihar and UP in India, and in Nigeria, Malawi and

Ethiopia. This strategy, strengthened by its measurement framework, should contribute to the

overall global efforts to improve maternal and newborn survival, reducing deaths by two

thirds by 2030. Evidence for this hypothesis is being gathered and will be synthesized and

disseminated, in order to advance global learning and to maximise the potential to improve

maternal and neonatal survival.

 

Competing interest

The authors declare that they have no competing interests.

 

Authors contribution

JS, GLD, TM and MC conceived of the concept for the article. TM and GLD wrote the first

draft. All authors contributed to the intellectual content and writing process of the paper.

GLD is the overall guarantor. All authors read and approved the final manuscript.

 

Acknowledgement

 

Financial disclosure

The IDEAS project at London School of Hygiene and Tropical Medicine is a Measurement

Learning and Evaluation grant awarded by the Bill & Melinda Gates Foundation.

 

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Additional file

Additional_file_1 as DOCX

Additional file 1 Web Annex 1. Indicators for enhanced interactions (more and better)

between families and frontline workers across the continuum of care. Web annex 2. Current

investments by the Bill & Melinda Gates Foundation in innovations to enhance interactions

between families and frontline workers (initiatives 2 and 3) in Ethiopia, Northern Nigeria,

and Uttar Pradesh, India.