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)

To document factors that hinder or enable strategies to reduce the first and second delays of the Three Delays in rural and pastoralist areas in Ethiopia. A key informant study was conducted with 44 Health Extension Workers in Afar Region, Kafa Zone (Southern Nation, Nationalities and Peoples' Region), and Adwa Woreda (Tigray Region). Health Extension Workers were trained to interview women and ask for stories about their recent experiences of birth. We interviewed the Health Extension Workers about their experiences referring women for Skilled Birth Attendance and Emergency Obstetric and Newborn Care. Data were analysed using thematic analysis. Themes related to reducing the first delay, such as the tradition of home birth, decision-making, distance and unavailability of transport, did not differ between the three locations. Themes related to reducing the second delay differed substantially. Health Extension Workers in Adwa Woreda were more likely to call ambulances due to support from the Health Development Army and a functioning referral system. In Kafa Zone, some Health Extension Workers were discouraged from calling ambulances as they were used for other purposes. In Afar Region, few Health Extension Workers were called to assist women as most women give birth at home with Traditional Birth Attendants unless they need to travel to health facilities for Emergency Obstetric and Newborn Care. Initiatives to reduce delays can improve access to maternal health services, especially when Health Extension Workers are supported by the Health Development Army and a functioning referral system, but district (woreda) health offices should ensure that ambulances are used as intended.

IntroductionIn Ethiopia, rural residence and limited access to skilled providers and health services pose challenges for maternal and newborn survival. The Maternal Health in Ethiopia Partnership (MaNHEP) developed a community‐based model of maternal and newborn health focusing on birth and the early postnatal period and positioned it for scale‐up. MaNHEP's 3‐pronged intervention included community‐ and facility‐based community maternal and newborn health training, continuous quality improvement, and behavior change communications.MethodsEvaluation included baseline and endline surveys conducted with random samples of health extension workers, community health development agents, traditional birth attendants (TBAs), and women who gave birth the year prior to the survey; pretraining, posttraining, and postintervention clinical skills assessments conducted with health extension workers, community health development agents, and traditional birth attendants; endline surveys conducted with quality improvement teams; and a perinatal verbal autopsy study.ResultsThere were significant improvements in the completeness of maternal and newborn health care provided by the team of health extension workers, community health development agents, and TBAs in their demonstrated capacity and confidence to provide care and a sense of being part of a maternal and newborn health care team. There were also significant improvements in women's awareness of and trust in the ability of these team members to provide maternal and newborn health care, in the completeness of care that women received, and in the use of skilled providers and health extension workers for antenatal and postnatal care. In addition, a shift occurred toward the use of providers with a higher level of skills for birth care. Successful local solutions for pregnancy identification, antenatal care registration, labor‐birth notification, and postnatal follow‐up were adopted across 51 project communities. The number of days between perinatal deaths increased over the duration of the project.DiscussionMaNHEP was associated with more, and more complete, coverage of maternal and newborn health care and improved perinatal outcomes. The model is adaptable and potentially scalable, as indicated by the pilot test of its integration into the Ethiopian Ministry of Health's newly revised Primary Health Care Unit and Health Extension Program structures.

Petra ten Hoope-Bender: a “midwife's midwife”

Supplement1 December 2020Looking Outward to Look Within: The Health Resources and Services Administration Maternal Mortality Summit, and What It Means for Women EverywhereFREEDoris Chou, MDDoris Chou, MDUNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland (D.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3259 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In 2015, when world leaders approved and became signatories to the Sustainable Development Goals 2015–2030 (SDG) Framework, a critical nuance was noted (1). Unlike the Millennium Development Goals, which focused on improving the status of lower-resourced countries between 1990 and 2015, this global pact intends for all countries, regardless of resource level, to collectively contribute to the global agenda. High-, middle-, and low-income countries alike are expected to report on and improve their populations' and countries' status across 17 goals as measured by targets with more than 200 indicators (2).In that framework, SDG 3.1/3.2 assesses the state of maternal and child health services and outcomes (2). As a vital barometer of any health system, SDG 3.1/3.2 asks whether a country can sustain itself by ensuring its future: the lives of women and their newborns. Unfortunately, the promise of the future often goes unfulfilled. In the United States, it is estimated that 2 women die every 3 days because of pregnancy (3–5). The absolute numbers may appear to be small, but any maternal death is unacceptable.To address this issue, the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services convened the HRSA Maternal Mortality Summit in June 2018. The purpose of the summit was to "discuss evidence-based approaches and identify innovative solutions to decreasing maternal mortality and morbidity rates in the U.S. and globally" (6). Participants included U.S. domestic experts as well as those from Brazil, Canada, Finland, India, Rwanda, and the United Kingdom.Although at first glance the experiences of Canada, Finland, and the United Kingdom are natural comparisons, U.S.-based practitioners readily found commonalities among all the shared experiences in the root causes of ill maternal health. Before the summit, it is unlikely that the general U.S. public would spontaneously identify with maternal health experiences from Brazil, India, and Rwanda. However, many of the participants found resonance in the discourse around the effects of nutrition, education, and social and cultural forces that shape care-seeking and implementation of medical advice (issues of access, accessibility, and acceptance). Above all, constructs of ethnicity, race, social status, and "women's agency and autonomy" amplified throughout the country-led discussions. The same themes could be found both between countries and across U.S. states.During the summit, countries shared openly on the challenges of measuring and documenting maternal deaths. All countries discussed the limitations of any one measurement system to accurately capture all the maternal deaths as it directly affects the ability of programs and efforts made by countries to address the causes of maternal death (and morbidity). The discussants shared how shifting demographics, social determinants, and risk factors could result in inequities, which often contributed to maternal morbidity and deaths.Nevertheless, maternal ill health is preventable. A positive pregnancy brings benefits not only to the individual, but also to her community, society, and country. Sweeping and long-standing changes do not come easily; there is no single "magic bullet." Concerted and transparent efforts are needed to change the rhetoric from "It's not my/our problem" to asking the difficult questions of "Why does maternal ill health occur?" and "How can we move forward?" by focusing on what can be done rather than focusing on what cannot.The World Health Organization (WHO) works worldwide to promote health, keep the world safe, and serve vulnerable persons. With partners, the WHO developed the Ending Preventable Maternal Mortality (EPMM) initiative to support countries as they determine the processes to assure appropriate resource allocation to strengthen health systems and enable them to move toward universal health coverage for all who are in need, with the aim of improving maternal and newborn health (7). Integrating EPMM principles and strategies enables countries to realize improved maternal health by prioritizing country leadership and supportive legal, regulatory, and financial mechanisms and integrating maternal and newborn health care to preserve the mother–baby dyad (7). The EPMM initiative calls for a human rights framework to ensure that high-quality sexual, reproductive, maternal, and newborn health care is accessible and available to all who need it and for the empowerment of women, girls, families, and communities (7).Focusing the EPMM lens on the United States, the HRSA summit highlighted essential areas to address. These include general health among women and the effects of inequities and disparities. Additional concerns are the availability of a robust health workforce and the relevant policies and financial implications that drive the overall U.S. health agenda. Readers of this supplement will find thoughtful consideration of these themes and articulation of some of the efforts undertaken to address American maternal mortality and morbidity.The first article provides a narrative landscape review of U.S. maternal health epidemiology (8). The robust series of papers that follow distill the U.S context of racial/ethnic, socioeconomic, and geographic disparities in the care and health outcomes of reproductive-aged women (9–11) and consider the availability of timely access to skilled health personnel and high-quality care, which provide opportunities for prevention and intervention (10–12). Finally, changes in care for mothers of the sickest newborns (13) and maternal comorbid conditions (14, 15) provide concrete strategies to improve health outcomes.Within HRSA sits the Maternal and Child Health Bureau, whose mission is to "improve the health of America's mothers, children, and families" (16). With the summit and this supplement, the HRSA and the United States have taken a step toward ensuring that maternal health is a priority both domestically and internationally. The global community welcomes the continuation and development of this initiative from the landmark meeting.Maternal mortality remains a scourge for every country. Although it can strike any woman, anywhere, fundamentally some predictable patterns can be addressed, with the result that fewer women will die during pregnancy and childbirth. Multilateral sharing and learning from mutual experiences provide potential paths forward in order to reach the collective SDG maternal mortality goal of a global maternal mortality ratio of less than 70 deaths per 100 000 live births (2, 7).

Significant progress has been made in maternal, newborn, and child health (MNCH) in recent decades. Between 1990 and 2015, the global mortality rate for children under age five years dropped by 53 percent, from 90.6 deaths per 1,000 live births in 1990 to 42.5 in 2015 (Liu and others 2016). Maternal mortality is also on the decline globally.Despite progress, maternal, neonatal, and under-five mortality remain high in many low- and middle-income countries (LMICs). In 2015, approximately 303,000 women died as a result of complications from pregnancy and childbirth (WHO 2015). Globally, an estimated 5.9 million children under age five years die each year, including 2.7 million within the first month of life (Liu and others 2016).Health indicators differ across countries, regions, and socioeconomic levels (Lozano and others 2011). Approximately 99 percent of all newborn deaths occur in LMICs (Bayer 2001). Maternal mortality is concentrated in Sub-Saharan Africa (Hogan and others 2010), where mortality rates for the poor are double those for the nonpoor, and they are higher among rural populations and women with low levels of education (PLoS Medicine Editors 2010). Children living in low-income countries are three times more likely to die before age five years than children living in high-income countries (HICs) (Black and others 2013).Pneumonia, diarrhea, malaria, and inadequate nutrition drive early childhood deaths around the world. In 2015, an estimated 526,000 episodes of diarrhea and 922,000 cases of pneumonia in children under age five years led to death (Liu and others 2016). Undernutrition is a primary underlying cause of 3.5 million maternal and child deaths each year (Black and others 2013); stunting, wasting, and micronutrient deficiencies are responsible for approximately 35 percent of the disease burden in children under age five years and 11 percent of the total global disease burden (Lozano and others 2011). Although maternal mortality is caused chiefly by postpartum hemorrhage, preeclampsia and eclampsia, and sepsis, a large proportion of maternal deaths can be attributed to limited access to skilled care during childbirth and the postnatal period (Lozano and others 2011) as well as to limited access to family planning services and safe abortions (UNFPA and Guttmacher Institute 2010).An appropriate mix of interventions can significantly reduce the burden of maternal and child mortality and morbidity. However, these interventions often do not reach those who need them most (Bayer 2001; Sines, Tinker, and Ruben 2006). An integrated approach that includes community-based care as an essential component has the potential to substantially improve maternal, newborn, and child health outcomes.This chapter provides a summary of community-based programs for improving MNCH. The chapter discusses strategies to improve the supply of services, including through community-based interventions and home visitations implemented by community health workers (CHWs), and strategies to increase demand for services, including through community mobilization efforts. The chapter summarizes the evidence about the impact of such interventions, describes contextual factors that affect implementation, and considers issues of cost-effectiveness. It concludes by highlighting research gaps, the challenges of scaling up, and the way forward.

BackgroundDespite the progress towards the MDG 4 and 5, compared to the developed world maternal and newborn deaths are still high in Bangladesh and poor quality of maternal and newborn...

Objectivethere is little evidence about disabled women׳s access to maternal and newborn health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and care seeking. Our study explores disabled women׳s experiences of maternal and newborn care in rural Nepal. Designwe used a qualitative methodology, using semi-structured interviews. Settingrural Makwanpur District of central Nepal. Participantswe purposively sampled married women with different impairments who had delivered a baby in the past 10 years from different topographical areas of the district. We also interviewed maternal health workers. We compared our findings with a recent qualitative study of non-disabled women in the same district to explore the differences between disabled and non-disabled women. Findingsmarried disabled women considered pregnancy and childbirth to be normal and preferred to deliver at home. Issues of quality, cost and lack of family support were as pertinent for disabled women as they were for their non-disabled peers. Health workers felt unprepared to meet the maternal health needs of disabled women. Key conclusions and implications for practiceintegration of disability into existing Skilled Birth Attendant training curricula may improve maternal health care for disabled women. There is a need to monitor progress of interventions that encourage institutional delivery through the use of disaggregated data, to check that disabled women are benefiting equally in efforts to improve access to maternal health care.

BackgroundDespite reports of universal access to and modest utilization of maternal and newborn health services in Ethiopia, mothers and newborns continue to die from preventable causes. Studies indicate this could be due to poor quality of care provided in health systems. Evidences show that high quality health care prevents more than half of all maternal deaths. In Ethiopia, there is limited knowledge surrounding the status of the quality of maternal and newborn health care in health facilities. This study aims to assess the quality of maternal and neonatal health care provision at the health facility level in four regions in Ethiopia.MethodologyThis study employed a facility-based cross-sectional study design. It included 32 health facilities which were part of the facilities for prototyping maternal and neonatal health quality improvement interventions. Data was collected using a structured questionnaire, key informant interviews and record reviews. Data was entered in Microsoft Excel and exported to STATA for analysis. Descriptive analysis results are presented in texts, tables and graphs. Quality of maternal and neonatal health care was measured by input, process and outputs components. The components were developed by computing scores using standards used to measure the three components of the quality of maternal and neonatal health care.ResultThe study was done in a total of 32 health facilities: 5 hospitals and 27 health centers in four regions. The study revealed that the average value of the quality of the maternal and neonatal health care input component among health facilities was 62%, while the quality of the process component was 43%. The quality of the maternal and neonatal health output component was 48%. According to the standard cut-off point for MNH quality of care, only 5 (15.6%), 3 (9.3%) and 3 (10.7%) of health facilities met the expected input, process and output maternal and neonatal health care quality standards, respectively.ConclusionThis study revealed that the majority of health facilities did not meet the national MNH quality of care standards. Focus should be directed towards improving the input, process and output standards of the maternal and neonatal health care quality, with the strongest focus on process improvement.

Editors' choice.

Maternal health: time for a radical reappraisal

Ethiopia has high maternal and neonatal mortality and low use of skilled maternity care. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), a 3.5-year learning project, used a community collaborative quality improvement approach to improve maternal and newborn health care during the birth-to-48-hour period. This study examines how the promotion of community maternal and newborn health (CMNH) family meetings and labor and birth notification contributed to increased postnatal care within 48 hours by skilled providers or health extension workers. Baseline and endline surveys, monthly quality improvement data, and MaNHEP's CMNH change package, a compendium of the most effective changes developed and tested by communities, were reviewed. Logistic regression assessed factors associated with postnatal care receipt. Monthly postnatal care receipt was plotted with control charts. The baseline (n = 1027) and endline (n = 1019) surveys showed significant increases in postnatal care, from 5% to 51% and from 15% to 47% in the Amhara and Oromiya regions, respectively (both P < .001). Notification of health extension workers for labor and birth within 48 hours was closely linked with receipt of postnatal care. Women with any antenatal care were 1.7 times more likely to have had a postnatal care visit (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.10-2.54; P < .001). Women who had additionally attended 2 or more CMNH meetings with family members and had access to a health extension worker's mobile phone number were 4.9 times more likely to have received postnatal care (OR, 4.86; 95% CI, 2.67-8.86; P < .001). The increase in postnatal care far exceeds the 7% postnatal care coverage rate reported in the 2011 Ethiopian Demographic and Health Survey (EDHS). This result was linked to ideas generated by community quality improvement teams for labor and birth notification and cooperation with community-level health workers to promote antenatal care and CMNH family meetings.

Overall this important area of quality of care will clearly require more research to be fully understood. Better quality monitoring tools also need to be developed with a focus on labour and labour outcome prediction. Meanwhile to complement Kruk and colleagues’ research efforts smaller facilities need to be better equipped with both the requisite and trained human resources for health care as well as with other inputs that are essential to quality provision of EmONC services. (Excerpt) Copyright © The Author(s). Published by Elsevier Ltd. Open Access.

A renaissance in primary health care

World Prematurity Day: improving survival and quality of life for millions of babies born preterm around the world

IntroductionHealth facility preparedness is essential for delivering quality maternal and newborn care, minimizing morbidity and mortality by addressing delays in seeking skilled care, reaching appropriate facilities, and receiving emergency care. A rapid assessment of 23 government health facilities in Kilifi and Kisii counties identified poor maternal and newborn indicators in 16 facilities. The Access to Quality Care through Extending and Strengthening Health Systems (AQCESS) project supported these facilities with training, equipment, and referral linkages. This study focuses on facility preparedness of the 16 facilities to deliver maternal and newborn health services, specifically delays two and three at the end of the project implementation.MethodsA descriptive cross-sectional study was carried-out on behalf of AQCESS project team by respective county ministry of health in-charge of reproductive maternal newborn and child health programs and trained nurses and medical doctors from Aga Khan health services in December 2019. The study evaluated the accessibility and reliability of drugs, commodities, equipment, personnel, basic necessities (such as water and electricity), and guidelines using validated World Health Organization service availability and readiness assessment tool. The findings of the assessment are presented through frequency and percentage analysis, along with a comparative analysis between the two counties.ResultsAll the 16 facilities assessed offered routine antenatal care (ANC) and normal delivery, but only two provided comprehensive emergency obstetric and newborn care (CEmONC). Most essential medicines, commodities, and required equipment were available. BEmONC and CEmONC guidelines were present in Kilifi, not in Kisii. One staff member was available 24/7 for cesarean section (CS) in each county, with one anesthetist in Kilifi. Electricity was accessible in all facilities, but only half had secondary power supply. Facilities offering CS had backup generators.ConclusionThe Facilities assessed had necessary drugs, commodities, equipment, and requirements, but staffing and guidelines were limited. Kilifi outperformed Kisii in most indicators. Additional support is needed for infrastructure and human resources to deliver quality maternal and newborn health services. Continuous monitoring will facilitate resource allocation based on facility needs.