A woman with her children at the Masougbo chiefdom primary health unit in Bombali district, Sierra Leone. Photo by: H4+ Partnership / CC BY-NC-ND
When you think of efforts to reduce maternal mortality, it’s natural to look to governments, the United Nations, the World Health Organization and other national and international bodies charged with responding to global health challenges.
And in many ways you would be right; but that’s not the full picture. It turns out that private health providers and local health businesses — an overlooked source of healthcare in much of the developing world — may also be important partners in the global push to end preventable maternal deaths.
During the last U.N. General Assembly in New York, Merck for Mothers teamed up with Population Services International and the World Bank to host a panel discussion focused exclusively on this topic. Entitled “Business as Unusual: Exploring the Potential of Local Health Businesses to Reduce Maternal Mortality,” the event set out to reframe the way the global health community thinks about ending preventable maternal mortality.
With the world off track to meet Millennium Development Goal 5, we need new and potentially “unusual” solutions to help save the nearly 300,000 women who die each year during pregnancy and childbirth. One of those solutions may rest with private providers and local health businesses.
To date, most global resources to improve maternal health care have focused on strengthening public sector institutions. Historically, groups like private doctors, nurses and midwives, drug shops and pharmacies, and private clinics and hospitals have not been leveraged — even though many women often prefer receiving care in these settings because they are close to home, open long hours, and care personalized and perceived to be high quality.
In fact, the divide between the private and public sector is often artificial. Many providers who work in the public sector in the morning actually transition to a private clinic in the afternoon or evening. No health system is wholly public or private, and these health businesses have untapped potential to support our global goals of reducing maternal mortality.
Thanks to new analyses by the London School of Hygiene and Tropical Medicine — previewed during our event and set to be published later this year — we now have data demonstrating that the local private sector delivers a substantial percentage of maternal health services across the developing world. So shouldn’t private health providers and businesses factor prominently in discussions about reducing maternal deaths?
The “Business as Unusual” panel discussion brought together leaders with deep experience in and understanding of the local private health sector to explore the implications and challenges associated with the LSHTM findings.
Fielding questions from Devex President and Editor-in-Chief Raj Kumar, panelists grappled with issues like financing private care, regulating it to ensure quality, protecting equity and creating systems that are conducive to complementary relationships between the public and private sectors. The conversation was both informative and provocative, and I was personally encouraged to see it steer toward one major theme echoed during UNGA: health coverage for all. This means that a woman has the right to affordable, quality care wherever she seeks it.
Each of the panelists agreed that efforts to reach all women necessitate reaching all the health workers serving those women. As former Botswana Health Minister Joy Phumaphi acknowledged: “Women want respect … they want dignity … they want equity … they want social solidarity … they want universal coverage. Experience has shown that in our developing economies, it has to be a combination of both public and private models to [achieve those goals].”
Dr. Ariel Pablos-Mendez, assistant administrator for global health at the U.S. Agency for International Development, reiterated Phumaphi’s point.
“The solutions to [realize] the bold vision of ending preventable maternal and child deaths require the engagement of the [local] private sector because it’s huge, because it reaches many communities and because there’s a tradition of innovation,” he said.
Likewise, Tim Evans, the World Bank’s senior director for health, nutrition and population, discussed the need to integrate the public and private health sectors, and that, despite their differences and complexities, “all health systems should be driving toward shared outcomes that are commonly owned across whole populations: access, affordability and quality.”
These three goals — access, affordability and quality — are paramount in maternal health. I was pleased to shed light on Merck for Mothers’ work to achieve them, joining with Zacch Akinyemi from PACE to talk about our partnership to strengthen private maternal healthcare in Uganda through social franchises.
As the world rallies around new targets for the Sustainable Development Goals — with our bars set higher, our sights farther and our timelines faster — it is clear that we need new approaches to bring about the world we all envision. For me, that world is one where no woman dies giving life, and to get there, I hope we’re willing to explore business as unusual.
Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.
Photo: Midwives for Haiti
Women need skilled care before, during, and after delivery. In developing countries like Haiti, postnatal care programs are often the weakest of all reproductive and child health programs. Lack of postnatal care contributes up to half of all preventable maternal and newborn deaths.
Hospital Ste. Therese is the public referral hospital in the Central Plateau. About two hundred women give birth here every month and in 2013, only 1% received postnatal care. Without the resources or funding to provide this care, many mothers and newborns died needlessly.
In July 2014, in partnership with Hospital Ste. Therese, Midwives for Haiti launched the Postnatal Care Program. Two skilled birth attendants were selected and thoroughly trained, patient sheets were drafted, and logbooks were created. From the first day, data was collected.
Six days a week, the midwives work from 8am-4pm. They see as many patients as they can in the hospital and at an out-patient clinic two days a week.
Within three months, these two midwives have provided care to 894 women and infants, increasing access to postnatal care at the hospital from 1% to 65%.
If you ask Juslene or Illa, the Postnatal Care Team, they will tell you countless stories of women who narrowly avoided dying from preeclampsia or who were kept several days longer in the hospital because of anemia or an infection. They will tell you how much time they spend with mothers to dispel the cultural belief that mothers cannot nurse well in the first few days after delivery. They make sure mothers are educated about the benefits of colostrum for their newborn babies, and how important it is to nurse frequently. They will tell you about the newborns they have referred for special care or treated for infection. They will tell you how many mothers come back before their one-week follow-up appointment because they now know that a high temperature of their baby or themselves is a danger sign.
They will not only tell you these stories with pride but will also show you. Follow them on their rounds and they will introduce you to the woman who they discovered hemorrhaging alone on her bed hours after she delivered. They will show you the mom and baby who are finally nursing well. They will show you the free prescriptions they are writing for vitamins and pain medication. They will show you the logbook, 63 pages long, filled top to bottom with the patients they have seen in the past few months.
The success of Postnatal Care Program has deepened our conviction and inspired us so greatly that we have dedicated a fundraising campaign to expand it. We want all mothers and newborns at Hospital Ste. Therese to receive postnatal care. We are determined to end preventable maternal and infant deaths in Haiti. And we appreciate your support.
This year 15 million babies will be born prematurely, with 1 million a year – or 3000 a day – dying as a result of premature birth. And for the first time in history, preterm birth has overtaken pneumonia as the leading cause of death in young children.
Today marks the 4th World Prematurity Day, a global effort to raise awareness of preterm birth and its prevention, involving over 200 countries, NGOs and relevant organizations.
What are the problems?
Preterm birth is now the leading global killer of young children with more than 3,000 children dying daily from preterm birth complications as outlined in a recent Lancet special issue.
Across the world, the top 5 countries with the highest numbers of babies dying from preterm birth complications each year are: India (361,600), Nigeria (98,300), Pakistan (75,000), Democratic Republic of the Congo (40,600) and China (37,200). West Africa is currently seeing some of the highest rates, which will no doubt be on the increase in those countries suffering from the Ebola outbreak.
What is being done about it?
According to this press release, out today, $250 million has been provided to carry out revolutionary research into the cause of preterm birth and prevention/delay and will involve more than 200 researchers. Key messages this year
This press release, released at 0:00 GMT today provides vital information and statistics on the causes and effects of preterm birth. Key messages are outlined below.
There are many known preventions to reduce the risk of preterm birth and complications, including family planning, decreasing embryo transfer numbers when using assisted reproductive techniques, and eliminating C-sections that are elective before 39 weeks.
Since 2000, we have seen an annual reduction of 3.9% in under-five deaths. This can, at least in part, be put down to the great advances made against deaths from pneumonia, diarrhea, measles and HIV. In comparison, preterm births have seen an annual reduction of 2.0%.
Dr José M. Belizán, who is Editor-in-Chief of Reproductive Health and also the chosen spokesperson of the press release for South America, reflects on how the journal is contributing to the effort to reduce pretem births:
“Through the journal Reproductive Health we have made many relevant contributions. Initially with the Born Too Soon supplement and the corresponding infographic and consequently with three further supplements giving the basis for interventions that could ameliorate the problem of preterm births.”
How is research contributing to these advancements?
Research is fundamental to ensuring the continued reduction of preterm births. Reproductive Health has published several important supplements in 2014 as part of this work as well as the Born Too Soon supplement published last World Prematurity Day in 2013.
Our first supplement on Essential interventions for Maternal, Newborn and Child Health addressed essential key steps to take in order to improve maternal, newborn and child health and survival in a series of freely available review articles. This includes family planning, corticosteroid use and management of preterm, premature rupture of membranes, kangaroo mother care for preterm babies as well as continuous positive airway pressure to manage preterm babies with respiratory distress syndrome.
We then looked at Quality of Care for Maternal and Child Health in a series of five papers that assessed and summarized information from relevant systematic reviews on the impact of various approaches to improve the quality of care for women and newborns. This included outreach services for women at a high risk for preterm birth.
Most recently, we looked at Preconception interventions addressing pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences, including factors associated with preterm birth and proposed interventions.
It has potential to further reduce global maternal and child mortality and morbidity, particularly in low-income countries where the highest burden of pregnancy-related deaths and disability occurs. You can also see a visual summary of these supplements in our infographic.
What can you do to participate?
- Visit facebook.com/worldprematurityday to read stories from around the world
- Show your support on Twitter using the hashtag #worldprematurityday
- Share this blog/these infographics and the information within them
Dr José M. Belizán is a medical doctor, with a PhD in Reproductive Health Sciences, Superior Researcher of his country’s National Board of Science and Technology and the Editor-in-Chief of Reproductive Health
Natasha Salaria is the Journal Development Editor of Reproductive Health at BioMed Central
A nurse helps a new mother breastfeed her newborn at a clinic in Accra, Ghana. © Bill & Melinda Gates Foundation/Olivier Asselin
The global burden of preterm birth represents a large and complex public health challenge that no single intervention or organization can solve alone. Each year, 15 million infants are born preterm, and more than one million will not survive their first month of life, making preterm birth the leading cause of death for all children up to age 5 worldwide. To tackle a health problem of that magnitude, a new coalition of leading health institutions is banding together to find new solutions for the prevention and care of preterm birth and its associated morbidity and mortality worldwide.
The Global Coalition to Advance Preterm birth Research (GCAPR) is a partnership initiated by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the March of Dimes Foundation, the Bill & Melinda Gates Foundation, and the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), an initiative of Seattle Children’s.
Sixteen organizations from around the world have already signed on as members of the organization, expressing their desire to increase collaboration, efficiency, and funding of preterm birth research.
Infants who are born preterm face the risk of death or potentially lifelong complications including respiratory and vision disorders and developmental delays, affecting families and increasing demands on resources for health care, education, and social services. The Institute of Medicine estimated in 2007 that the costs associated with preterm birth were $26.2 billion each year in the U.S. alone. While organizations exist to fund research to decrease risks of preterm birth, GCAPR was formed to coordinate those efforts, accelerate discovery of new solutions, and leverage new and existing investments to achieve global change.
The Coalition has outlined some priority activities, which include:
- Improve coordination, comparability, and harmonization of research. A subcommittee will review materials from several existing research programs and recommend steps to make methods and definitions more compatible. Materials will include questionnaires, standard operating procedures, protocols and definitions. When pregnancy researchers use similar definitions and methods across research projects, results can be compared, evaluated, and analyzed more effectively.
- Evaluate evidence-based strategies to improve survival and health. One area of implementation research that is ripe for attention is the evaluation of interventions and treatments that are delivered in combination. It is common for individual interventions to be evaluated separately, but delivered in conjunction with others. Careful analysis of outcomes will allow researchers to identify the role that each intervention plays in improving infant survival.
- Accelerate moving discoveries into practice. New scientific advancements need a more rapid path from discovery to development of diagnostic or therapeutic products to improve health outcomes. GCAPR members will share expertise to advance strategies and research needed to move results down the pipeline to the mothers and infants who need them.
- Ensure global applicability of products. Through collaboration and partnership, GCAPR will seek opportunities to conduct clinical trials across populations so that the resulting products and interventions can have broad applicability around the world.
Preterm birth is not a problem that will be solved easily, as there are many pathways and causes. We know that uniting organizations with similar goals will give us the best opportunities to make measurable progress toward reducing the global burden. We are very excited about the momentum that has been building around preterm birth funding and research. We hope that additional organizations and agencies from both the public and private sector will continue to join this effort as we focus attention on preterm birth and strive to find solutions.
Photo: Mark Tuschman
Nigeria, one of the richest countries in Africa, also boasts one of the world’s highest rates of maternal, newborn, and child death. One in 13 Nigerian women dies during pregnancy or childbirth, and one in 8 Nigerian children dies before their fifth birthday.
And Nigeria is not alone. The global realities are equally devastating – nearly three million newborn babies die annually, and 800 women die in childbirth every single day. That means that two women will die by the time you finish reading this article – assuming you read fast.
While the numbers are shocking, it’s even more horrifying to realize that nearly 90% of these deaths are avoidable: women, newborns, and young children die from preventable conditions like hemorrhage, premature birth, malnutrition, and malaria.
Simply put, here’s what these statistics mean – Aisha didn’t have to bleed to death during childbirth. Baby Efe didn’t have to asphyxiate in his first minutes of life. Two year old Tosin didn’t have to die from diarrhea.
All of these lives could have been saved – easily and inexpensively. But in an age of unprecedented medical innovation, we are still failing to save the lives of poor women and their children.
The challenges may appear intractable, but the solution is simpler than you think.
The international community needs to invest in the country-based leaders who have the power to transform the health of their own communities. We need to invest in the civil society leaders and organizations who fight every day to save the lives of women and children.
This strategy lies at the core of Champions for Change, a new initiative supported by the Bill and Melinda Gates Foundation in Nigeria. Champions for Change empowers strong local leaders and organizations to advocate for the laws, policies, programs, and funding needed to improve reproductive, maternal, newborn, and child health (RMNCH) outcomes in Nigeria.
Champions for Change invests in the talent, vision, and potential of the Nigerian civil society leaders. These Champions ensure that Nigeria’s policies, systems, and services advance the health and rights of women and children. Champions for Change leverages the tested model of its sister initiative, Let Girls Lead, which has contributed to improved health, education, livelihoods, and rights for more than 3 million girls globally, as demonstrated by an external evaluation commissioned by the UN Foundation.
Following a highly competitive process, Champions for Change selected Nigeria’s best and brightest civil society leaders working across sectors – reproductive health, child nutrition, family planning, girls’ education, women’s rights, poverty reduction, HIV/AIDS prevention, media, and youth development – to scale up their innovative approaches to reduce maternal and child deaths in Nigeria.
The civil society leaders participating in Champions for Change know best the challenges facing their communities, and how to create scalable impact. These Champions bring the experience, cultural fluency, and vision needed to ensure that policies, programs, services, and funding respond to the realities of women and their children across Nigeria.
This week in Lagos, we are hosting the inaugural Champions for Change convening, launching a two-year process that integrates state of the art leadership development and organizational strengthening. An elite cohort of 24 leaders from 12 Nigerian organizations will participate in intensive advocacy capacity building, executive coaching, and organizational development.
These leaders will learn strategies to engage policymakers, traditional and religious leaders, and medical providers to create sustainable change, and how to empower women and communities to raise their voices for their own priorities.These Champions will also receive grant funding and technical assistance to develop scalable new strategies that sustainably improve the health and wellbeing of Nigerian women and children.
Saving the lives of women and children takes financial resources, political will, and savvy advocates who are undaunted by the enormity of the challenges they face. Investing in visionary local leaders and organizations is the most promising strategy to ensure that policies, systems, and services improve health outcomes. Nigeria’s women and children deserve no less.
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