Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?

Despite progress in lowering death rates in children younger than 5 years, progress in reducing newborn deaths has been slower and should focus on effective interventions, intentional investment, and implementation. This report offers an update of the evidence for interventions, the potential for lives saved, and running costs of implementation. Specific interventions across the continuum of pregnancy care were evaluated along with delivery platforms for these interventions and methods to improve care. All major databases were searched to identify quality systematic reviews in various domains using standardized methodology. Interventions before and between pregnancies include delaying the age at the first pregnancy, family planning, optimal interpregnancy intervals, and enhancement of prepregnancy nutrition. Antenatal interventions include maternal immunization, management of infections and preexisting chronic diseases or pregnancy-induced disorders, detection and management of significant in utero growth retardation, prevention of RhD alloimmunization, improvements in nutrition and psychosocial health, and treatment of drug misuse. Interventions during or close to labor include obstetric care with labor monitoring, skilled delivery and provision of emergency obstetric care as needed, and management of preterm labor and postterm pregnancy, as well as clean/sterile birth practices to reduce neonatal sepsis and tetanus deaths and use of antenatal steroids. Interventions at birth for every newborn include immediate drying and stimulation, provision of warmth, delaying of cord clamping, hygienic care, support for immediate breast-feeding, and administration of vitamin K. Neonatal resuscitation is crucial for babies who do not breathe immediately and could include prevention and management of meconium aspiration. Beginning breast-feeding within 1 hour of birth, exclusive breast-feeding of infants until age 6 months, and continuation of breast-feeding until age 2 years are strongly recommended. Interventions for small and ill newborn babies include prevention of hypothermia; management of respiratory distress syndrome, neonatal pneumonia, sepsis, and hyperbilirubinemia; and skin care with emollient and massage therapy. Kangaroo mother care involves early and continuous skin-to-skin contact, breast-feeding support, early discharge from hospital, and supportive care in stable neonates. Use of continuous positive airway pressure, anticonvulsants, and animal-derived surfactant can reduce neonatal morbidity and mortality. Care of neonates in intensive care units has become increasingly sophisticated in high-income countries, and creation of neonatal intensive care units is being implemented in low- and middle-income countries. Delivery platforms and strategies to reach mothers and neonates are important for delivery of high-quality care to underserved populations. Community-based delivery platforms, especially if linked to local health facilities, can increase coverage of essential interventions and reduce inequities. Changes in household behaviors and practices, tetanus immunization, use of clean birth kits, facility births, early initiation of breast-feeding, and seeking of health care for neonatal illnesses are all factors in reaching mothers and neonates. Community mobilization and antenatal and postnatal home visits by health workers can complement facility-based care and promote family contact with the health system at crucial times. Community-based packages of preventive and basic care, promoted by outreach workers and women’s groups, empower women to facilitate these vital changes. One method to enhance these improvements is to create financial incentives as strategies to ease poverty, reduce financial barriers, and improve health outcomes in poor populations. To determine the financial aspects of these major changes to health care delivery in underserved populations, the Lives Saved Tool was used to model the effects of these interventions within the health systems of 75 countries that account for more than 95% of maternal, neonatal, and child deaths worldwide. The Lives Saved Tool estimates the country-by-country cause-specific effects of increasing coverage of individual interventions from baseline levels of 2012 on stillbirth and neonatal and maternal mortality. With high coverage by 2025, 71% (56%–76%) of neonatal mortality, 33% (23%–38%) of stillbirths, and 51% (44%–53%) of maternal deaths could be averted. If 90% of all women giving birth in facilities in 2020 received highly effective interventions, an estimated 113,000 maternal deaths (84% of the total deaths averted by 2020), 531,000 stillbirths (76%), and 1.325 million neonatal deaths (77%), including 300,000 preterm deaths, would be prevented. The incremental annual costs (in US dollars) of providing these care packages would be ∼$4.5 billion ($0.91/person) by 2020, rising to $5.65 billion ($1.15/person) in 2025 (or $1928 for each maternal and infant life saved). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1.9 million [1.6–2.1 million]), 33% of stillbirths (0.82 million [0.60–0.93 million]), and 54% of maternal deaths (0.16 million [0.14–0.17 million]) annually. Available interventions can reduce preterm, intrapartum, and infection-related deaths by 58%, 79%, and 84%, respectively. Closing the quality gap for facility births is imperative. Many of the current differentials in quality relate to ethnicity, geography, and other forms of social marginalization. Strategies to overcome these obstacles are required to create and maintain health systems to benefit women, babies, development outcomes, and economic capital.

BackgroundBy spacing births and preventing unintended pregnancies, family planning is a crucial technique strategy for controlling the fast expansion of the human population. It also improves maternal and child health. women who are thought to be sexually active but who do not use modern contraception methods, who either do not want to have any more children (Limiting) or who want to delay having children for at least two years are considered to have an unmet need for family planning (Spacing).ObjectiveThis study carried out to determine which socio-demographic factors are the key contributors to the discrepancies in the unmet need for family planning among women of reproductive age between surveys years 2005 and 2016.MethodsThe data for this study arrived from the Ethiopia Demographic Health Surveys in 2005, 2011, and 2016 to investigate trends and Predictors of change of unmet need for family planning among reproductive age women in Ethiopia. Pooled weighted sample of 26,230 (7761 in 2005, 9136 in 2011 and 9,333 in 2016 Ethiopian demographic health surveys) reproductive-age women were used for this study. For the overall trend (2005–2016) multivariable decomposition analysis for non-linear response outcome was calibrated to identify the factors that contributed to the change of unmet need for family planning. The Logit based multivariable decomposition analysis utilizes the output from the logistic regression model to assign the observed change in unmet need for family planning over time into two components. Stata version 16.0 was used to analyze the data.ResultThe percentage of Ethiopian women of reproductive age who still lack access (unmet need) for family planning declined from 39.6% in 2005 to 23.6 percent in 2016. The decomposition analysis revealed that the change of unmet need for family planning was due to change in characteristics and coefficients. The difference in coefficients accounted for around nine out of 10 variations in unmet family planning need. Education level, birth order, and desired number of children were all factors that changed over the course of the last 11 years in relation to the unmet need for family planning.ConclusionBetween 2005 and 2016, there were remarkable changes in unmet need for family planning. Women with birth orders of five and up, women with secondary education, and women who wanted fewer children overall were the main causes of the change in unmet need for family planning.

By spacing births and preventing unintended pregnancies, family planning is a crucial technique strategy for controlling the fast expansion of the human population. It also improves maternal and child health. women who are thought to be sexually active but who do not use modern contraception methods, who either do not want to have any more children (Limiting) or who want to delay having children for at least two years are considered to have an unmet need for family planning (Spacing). This study carried out to determine which socio-demographic factors are the key contributors to the discrepancies in the unmet need for family planning among women of reproductive age between surveys years 2005 and 2016. The data for this study arrived from the Ethiopia Demographic Health Surveys in 2005, 2011, and 2016 to investigate trends and Predictors of change of unmet need for family planning among reproductive age women in Ethiopia. Pooled weighted sample of 26,230 (7761 in 2005, 9136 in 2011 and 9,333 in 2016 Ethiopian demographic health surveys) reproductive-age women were used for this study. For the overall trend (2005-2016) multivariable decomposition analysis for non-linear response outcome was calibrated to identify the factors that contributed to the change of unmet need for family planning. The Logit based multivariable decomposition analysis utilizes the output from the logistic regression model to assign the observed change in unmet need for family planning over time into two components. Stata version 16.0 was used to analyze the data. The percentage of Ethiopian women of reproductive age who still lack access (unmet need) for family planning declined from 39.6% in 2005 to 23.6 percent in 2016. The decomposition analysis revealed that the change of unmet need for family planning was due to change in characteristics and coefficients. The difference in coefficients accounted for around nine out of 10 variations in unmet family planning need. Education level, birth order, and desired number of children were all factors that changed over the course of the last 11 years in relation to the unmet need for family planning. Between 2005 and 2016, there were remarkable changes in unmet need for family planning. Women with birth orders of five and up, women with secondary education, and women who wanted fewer children overall were the main causes of the change in unmet need for family planning.

Preeclampsia and eclampsia are severe complications of pregnancy that significantly contribute to maternal and fetal mortality. A comprehensive understanding of the predictors of these conditions is essential for developing effective interventions. Despite preeclampsia and eclampsia being among the leading contributors to maternal and fetal mortality in resource-limited areas in Kenya, especially the arid and semi-arid regions such as Garissa, limited studies have specifically examined the predictors of maternal and perinatal mortality among women with preeclampsia and eclampsia. Therefore, this study aimed to investigate the predictors of perinatal and maternal mortality among pregnant women with preeclampsia and eclampsia at Garissa County Referral Hospital. A retrospective cohort study was used to evaluate the records of 138 eligible pregnant women diagnosed with preeclampsia and eclampsia from 1st January 2019 to 31st December 2023. The study aimed to determine the predictors of maternal and perinatal mortality among pregnant women diagnosed with preeclampsia and eclampsia. A data abstraction tool capturing sociodemographic, clinical, treatment modalities, and outcome variables was used to collect data. Descriptive analysis was used to present mortality rates and management modalities, while binary logistic regression was used to determine the predictors of mortality among preeclampsia and eclampsia patients. The mean age of the participants in this study was 26.86 ± 7.6 years. There were higher cases of preeclampsia (63.0%) than eclampsia (37.0%) observed. Maternal mortality was 13.0%, while the perinatal mortality was 42.7%. The findings indicated that 34.1% of patients had a postpartum haemorrhage and 14.5% had a placental abruption. Neonatal complications were observed in 26.0% of the fetuses, with respiratory distress being the most prevalent (20.0%). Diabetes mellitus (AOR = 8.9, 95% CI = 2.1-41.4, p = 0.003) and multigravida status (AOR 3.6, 95% CI = 1.6-8.5, p = 0.002) were the significant predictors of maternal and perinatal mortality, respectively. The maternal and perinatal mortality among mothers with preeclampsia and eclampsia was comparable to the rates reported in similar settings. The significant predictors of maternal and perinatal mortalities were diabetes and multigravida status, respectively, highlighting the need for timely antenatal care and close monitoring for multigravida women and those with pre-existing conditions like diabetes.

To investigate causes of and contributors to newborn deaths in eastern Uganda using a three delays audit approach. Methods Data collected on 64 neonatal deaths from a demographic surveillance site were coded for causes of deaths using a hierarchical model and analysed using a modified three delays model to determine contributing delays. A survey was conducted in 16 health facilities to determine capacity for newborn care. Of the newborn babies, 33% died in a hospital/health centre, 13% in a private clinic and 54% died away from a health facility. 47% of the deaths occurred on the day of birth and 78% in the first week. Major contributing delays to newborn death were caretaker delay in problem recognition or in deciding to seek care (50%, 32/64); delay to receive quality care at a health facility (30%; 19/64); and transport delay (20%; 13/64). The median time to seeking care outside the home was 3 days from onset of illness (IQR 1-6). The leading causes of death were sepsis or pneumonia (31%), birth asphyxia (30%) and preterm birth (25%). Health facilities did not have capacity for newborn care, and health workers had correct knowledge on only 31% of the survey questions related to newborn care. Household and health facility-related delays were the major contributors to newborn deaths, and efforts to improve newborn survival need to address both concurrently. Understanding why newborn babies die can be improved by using the three delays model, originally developed for understanding maternal death.

In an era of Sustainable Development Goals, maternal, newborn, and child health still require improvement. Continuum of care is considered key to improving the health status of these populations. The continuum of care is a series of care strategies starting from pre-pregnancy to motherhood-childhood. The effectiveness of such linkage between the pregnancy, birth, and postnatal periods has been demonstrated. However, almost no study has assessed the impact of linkage that starts from pre-pregnancy to pregnancy care on maternal and child health. The present study attempts to fill this gap by assessing the effectiveness of the care linkage between pre-pregnancy and pregnancy care for reducing neonatal, perinatal, and maternal mortality in low- and middle-income countries. We performed a systematic review and meta-analysis of randomized and quasi-randomized controlled trials in low- and middle-income countries. The outcome variables were neonatal, perinatal, and maternal mortality. We searched databases such as PubMed/Medline, POPLINE, EBSCO/CINAHL, and ISI Web of Science for the period 2000–2014, using broad search terms (e.g., pre-pregnancy OR adolescent OR mother), combined with search terms specific for interventions, (e.g., family planning OR contraception OR spacing). From the 1,325 retrieved articles, five studies were finally analyzed. The meta-analysis showed that interventions linking pre-pregnancy and pregnancy care effectively reduced neonatal mortality (risk ratio [RR]: 0.79; 95% confidence interval [CI]: 0.71–0.89, I2 = 62%) and perinatal mortality (RR: 0.84; 95% CI: 0.75–0.94, I2 = 73%), but did not show an effect on maternal mortality. Neonatal and perinatal mortality could be reduced by linking pre-pregnancy and pregnancy care. This linkage of pre-pregnancy and pregnancy cares is an essential component of continuum of care to improve newborn health.Review RegistrationPROSPERO International prospective register of systematic reviews (CRD42015023424).

BackgroundReliable and timely data on maternal and neonatal mortality is required to implement health interventions, monitor progress, and evaluate health programs at national and sub-national levels. In most South Asian countries, including Pakistan, vital civil registration and health information systems are inadequate. The aim of this study is to determine accurate maternal and perinatal mortality through enhanced surveillance of births and deaths, compared with prior routinely collected data.MethodsAn enhanced surveillance system was established that measured maternal, perinatal and neonatal mortality rates through more complete enumeration of births and deaths in a rural district of Pakistan. Data were collected over a period of 1 year (2015/16) from augmentation of the existing health information system covering public healthcare facilities (n = 19), and the community through 273 existing Lady Health Workers; and with the addition of private healthcare facilities (n = 10), and 73 additional Community Health Workers to cover a total study population of 368,454 consisting of 51,690 eligible women aged 18 to 49 years with 7580 pregnancies and 7273 live births over 1 year. Maternal, neonatal, perinatal and stillbirth rates and ratios were calculated, with comparisons to routine reporting from the previous period (2014–15).ResultsHigher maternal mortality, perinatal mortality and neonatal mortality rates were observed through enhanced surveillance compared to mortality rates in the previous 1.5 years from the routine monitoring system from increased completeness and coverage. Maternal mortality was 247 compared to 180 per 100, 000 live births (p = 0.36), neonatal mortality 40 compared to 20 per 1, 000 live births (p < 0.001), and perinatal mortality 60 compared to 47 per 1000 live births (p < 0.001). All the mortality rates were higher than provincial and national estimates proffered by international agencies based on successive Pakistan Demographic and Health Surveys and projections.ConclusionExtension of coverage and improvement in completeness through reconciliation of data from health information systems is possible and required to obtain accurate maternal, perinatal and neonatal mortality for assessment of health service interventions at a local level.

Reducing Maternal and Perinatal Mortality Through a Community Collaborative Approach: Introduction to a Special Issue on the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP)

Nearly 10 years ago, The Lancet published a landmark Series of papers on a widespread mortality burden that had, until then, received virtually no recognition on the global health agenda. The six-part collection drew attention to the 2 million fetal deaths after 28 weeks’ gestation—stillbirths—that take place globally every year, and to the fact that a third of them occur in healthy pregnancies during labour, meaning that they are almost certainly avoidable with skilled delivery care. Stillbirths were not included in the global monitoring processes of the time—the Millennium Development Goals, the Countdown to 2015 initiative, or the Global Burden of Disease project—and country-level surveillance exercises for stillbirths were variable or non-existent.

Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions. SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities. Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country. MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths.

Poor-quality maternal and newborn care is associated with maternal mortality, stillbirths, and infant deaths and contributes to acute and chronic clinical and psychological morbidity for women who survive. Midwifery care can make an essential contribution to high-quality maternal and newborn services. The participation of educated, trained, motivated, and respected licensed midwives, working effectively with medical and public health colleagues, is associated with a rapid and sustained decrease in maternal and newborn mortality and an improvement in quality of care. A multimethod approach was used to assess the key concepts of quality in maternal and newborn care including safe, effective, accessible, appropriate, affordable, equitable, efficient, and woman-centered care. A framework for quality maternal and newborn care was devised, using the best evidence for effective care practices. This evidence was used to assess the potential effect of midwifery and the workforce groups best able to provide midwifery care. Essential interlinked components of the framework were effective practices, organization of care, philosophy, and values of the care providers working in the health system and characteristics of care providers. Interdisciplinary teamwork and collaboration are inherent in implementing the framework. Women’s views and experiences show the interrelationship between the different components of quality care. Information and education are essential to allow them to learn for themselves. They need to know and understand the organization of services so they can access them in a timely fashion, services need to be provided in a respectful way by staff who generate trust and who are not abusive or cruel, and care should be personalized to their individual needs and offered by empathic and kind providers. Women want health professionals who combine clinical knowledge and skills with interpersonal and cultural competence. Two sources within the Cochrane Library identified high-quality, current evidence on effectiveness of specific practices in maternal/newborn care. Effective practices related to categories of the framework found that 46 (38%) of the 122 effective practices were relevant for all childbearing women and infants, with 26 (21%) being first-line management for women and infants with complications. Fifty practices (41%) required the input of a medical practitioner with advanced skills in obstetrics, neonatology, or medicine. The practice categories of (1) education, information, health promotion; (2) assessment, screening care planning; (3) promotion of normal processes and preventing complications; and (4) first-line management of complications were identified as being within the scope of midwifery. Seventy-two (59%) of the 122 effective practices were within this scope. Outcomes improved by effective practices by midwives include reduced maternal and neonatal mortality and fetal loss, reduced maternal and neonatal morbidity including preterm birth, reduced use of interventions, improved psychosocial outcomes, improved public health outcomes, and improved organizational outcomes. The 72 effective practices were examined to determine whether they portrayed the cross-cutting components of the framework. Ten (14%) of the 72 practices for all childbearing women were intended to support women’s own capabilities with information or advice that they could act on themselves. Sixty-one (85%) of the effective practices related to only 1 phase of maternal and newborn care, usually pregnancy or labor. Only 20 practices (28%) examined any aspect of care after the birth for the mother or newborn. Only midwife-led continuity models of care and community-based packages of care applied across the whole continuum. Sixty-six (92%) of the effective practices related to care of either the woman or fetus, or both; 4 examined the mother and newborn infant, and only 1 examined care of the infant. When the characteristics and effect of midwives providing some or all components of care were examined in various studies, women who had midwife-led care were less likely to have regional analgesia, episiotomy, and instrumental birth and were more likely to have no intrapartum analgesia or anesthesia, spontaneous vaginal birth, attendance at birth by a known midwife, and a longer mean length of labor. No differences were noted between groups for cesarean births. Women receiving midwifery care were less likely to have a preterm birth and fetal loss at less than 24 weeks’ gestation. Most studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. A cost-saving effect was noted for midwifery care compared with other models. In 3 case studies of large countries that account for 35% of all births globally, and in which midwives are marginalized or excluded from the health system, the focus on facility-based and emergency care reduced maternal and perinatal mortality. Without the balancing effect of the full spectrum of midwifery care, this strategy led to rapidly growing numbers of unnecessary and expensive interventions and potentially iatrogenic complications and inequalities in the provision of care and outcomes. The new evidence-based framework for high-quality maternal and newborn care incorporates the need to balance community-based preventive and supportive services for all childbearing women and newborns with the elective and emergency services needed by those with complications. The framework differentiates among what and how care is provided and who should provide it. This framework might be used to structure analyses of health system provision, plan new services, or develop an education curriculum. Future planning for maternal and newborn care systems can benefit from incorporating the quality framework into workforce development and resource allocation.

From MDGs to SDGs: Implications for Maternal Newborn Health in Africa.

Family planning has both health and social benefits for women. A lack of access can lead to unwanted pregnancies, unsafe abortion, high maternal and infant mortality, and loss of economic opportunities. The global unmet need for family planning was 15.6% in 2019, while the unmet need for modern family planning among women aged 15-49 years in low- and middle-income countries was unacceptably high at 24%. In Kenya, it was 20% in 2022 despite SDG target 3.7.1 guaranteeing universal coverage. Most studies on unmet needs focus on the prevalence and factors associated with the uptake of family planning, but assessments of socioeconomic inequality within low-utilization groups are rarely given much attention. This is despite socioeconomic inequality being a central theme in achieving the SDGs. This study assessed socioeconomic inequality in the unmet need for family planning measured by the household wealth index and used putative determinants to explain the inequality. The study used data from the KDHS (2022). Associations between individual factors and unmet needs for family planning were determined using logistic regression models, whereas socioeconomic inequality was assessed using concentration curves and concentration indices. The prevalence rate of unmet needs was 14%; 7.6% for spacing and 6.4% for limiting. And among the poorest women was 21.6% compared to 10.1% among the richest. Being poor (OR: 1.788, 95% CI: 1.324-2.414), young (OR: 1.569, 95% CI: 1.212-2.030), having more than one living child (OR: 1.393, 95% CI: 1.157-1.676), not employed (OR: 1.561, 95% CI: 1.375-1.772), having no education (OR: 1.456, 95% CI: 1.022-2.074) and lacking media exposure (OR: 1.249, 95% CI: 1.027-1.519) increased the odds of unmet needs. The socioeconomic inequality in unmet needs was pro-poor (CIX < 0) and was substantially high (CIX<-0.4) among women with more than three children (CIX=-0.41), with no education (CIX=-0.46) or partners have no education (CIX=-0.68) or lack media exposure (CIX=-0.49). The study recommends youth friendly - highly subsidized family planning services and commodities, and family planning information and education for women of low socioeconomic status.

Introduction Maternal and perinatal mortality is still a major public health challenge in Tanzania, despite the ongoing government efforts to improve maternal and newborn care. Among the contributors to these problems is the high magnitude of severe maternal outcomes (maternal near-miss). The current study, therefore, aimed to identify the magnitude and predictors of maternal and perinatal mortality among women with severe maternal outcomes admitted to Dodoma Regional Referral Hospital. Methods A retrospective cross-sectional study was conducted from October 2015 to January 2016 at Dodoma Regional Referral Hospital in Dodoma City. All maternal deaths and maternal near-misses based on WHO criteria were included in this study. Three outcome variables have been identified: maternal mortality, perinatal mortality, and neonatal complications. To examine the predictors for the three predetermined outcome variables, the three logit models each containing unadjusted and adjusted findings were fitted. A P-value less than 0.05 was considered indicative of statistically significant. Results A total of 3600 pregnant women were admitted for obstetric reasons during the mentioned period. 140 of them were diagnosed with severe maternal outcomes; hence, they were included in this study. The severe maternal outcome incidence ratio was 40.23 per 1000 live births, the institutional maternal mortality ratio was 459.77 per 100000 live births, and the perinatal mortality rate was 10.83 per 1000 total births. Most of the maternal morbidity and mortality were due to direct causes in which postpartum hemorrhage and hypertensive disorders were the leading causes. In adjusted analysis, per-protocol management, maternal age, and mode of birth were predictors of maternal mortality, perinatal mortality, and neonatal complications, respectively. Conclusion Establishing and strengthening obstetric ICUs will help reduce maternal mortality as the response time from the onset of obstetric complications, while the provision of high-quality care will be substantially reduced. Furthermore, the study recommends regular provision of in-service refresher training to emphasize the practice and compliance of per-protocol case management through a team approach in order to reduce the burden of maternal and perinatal mortality in Tanzania.

I am pleased that the theme of this maiden conference of the Association of Feto-Maternal Medicine Specialists of Nigeria (AFEMSON) is the reduction of maternal and perinatal mortality. Practising in our setting can be particularly challenging due to the weak health system which leads to frustrating outcomes, with high rates of avoidable maternal and perinatal morbidity and mortality. For practitioners of fetomaternal medicine to deal with this as a major public health concern, the focus should not just be some cold statistics, but rather it must be addressed as a true everyday human story and societal tragedy. In a recent publication1, Elliot Main, a Stanford Professor of Obstetrics and Gynaecology, and founder of California Maternal Quality Care Collaborative was reported as saying: ―When you‘ve had a maternal death, you remember it for the rest of your life - all the details‖ Perhaps, practicing in our setting (like in most low and middle income countries) you may not remember ―all the details‖ because of regularity of occurrence. However, I am sure that each of you, frontline practitioners here gathered, has had a few unfortunate human angle stories - details of which get imprinted in your memory for the rest of your life. In my practice, I also had my own experiences, which were part of the reasons that I decided to temporarily set aside the practice of clinical medicine to get involved in top policy formulation for health and overall societal development. As reported by Olu Obafemi2 in his recent publication of my experiences: “Those days I will tell people that I could never forget the cry of a woman when she loses her child at night, because at a stage, I was living within my clinic. It was harrowing, especially at night, between 1-2am.” As Governor of Ondo State, southwest Nigeria for 8 years (2009-2017), working with other stakeholders, we proved that even in resource-restricted settings like Nigeria, it is possible to achieve positive outcomes in terms of systematic reduction in maternal and perinatal death mortality. The Centre for Strategic and International Studies (CSIS), in its publication on the first year of ABIYE3, succinctly encapsulated this by saying ―With leadership, progress is possible.‖ Specifically, under my leadership as Governor of Ondo State, we commenced a unique Abiye maternal health program that offered free maternal and child health services to pregnant mothers and children less than five years old (including sophisticated referral care) that brought maternal and child health care to the doorstep of every citizen in the state. The consequence was a significant reduction in maternal mortality in the state, enabling the state to achieve the target of Goal-5 of the Millennium Development Goals. But this was not achieved without some noteworthy challenges. The purpose of this presentation therefore is to describe the philosophy that led us to focus on the delivery of free maternal health care, to summarize the methods and challenges in its implementation and to make recommendations on ways to build political will for improved delivery of maternal health care and the reduction of maternal and perinatal mortality in Nigeria. I believe that the recommendations made will be useful for policymakers elsewhere to understand the social context of health care and to prioritize the delivery of maternal health care as a social justice and human rights requirement of citizens.