Public HealthPractical lessons from global safe motherhood initiatives: time for a new focus on implementation
Introduction
The safe motherhood movement reaches its 20th anniversary as the global health field embarks on ambitious new efforts to transform its practice. With the Millennium Development Goals (MDGs), the Paris Declaration on Aid Effectiveness, and the launch of the Global Campaign for the Health MDGs,1 the principles of country ownership, aid coordination, and results-based financing will create a new approach to national policymaking and financing. The success of these initiatives depends on the ability of countries to steadily expand their capacity to implement integrated programmes for service delivery while progressively advancing coverage and equity.
Four major global safe motherhood implementation and evaluation initiatives of the past decade—Averting Maternal Death and Disability (AMDD), Immpact, the Skilled Care Initiative (SCI), and ACCESS (panel 1)—call for a renewed and intensified focus on implementation. In this paper we use our complementary experiences in the field to offer a set of central lessons on which to build a new, collaborative effort to initiate change on the ground, where women live and die.
Section snippets
The time is ripe for a shift in focus
For much of its history, the Safe Motherhood Initiative focused largely on global debates about strategies and priorities. Little attention was devoted to expanding the capacity of countries with high mortality rates to implement and sustain any such strategies or to learning from the few local-level initiatives that did exist. New attention to implementation is now needed.
Several factors are already in place. First, the safe motherhood community has coalesced around three key elements that are
Global initiatives and local actors: lessons for implementation
Although each of the four initiatives focuses primarily on a different aspect of maternal health efforts, on the basis of these varied experiences we believe that implementation efforts aimed at service delivery at scale, and thus achievement of MDG5, should be firmly embedded in a health systems approach. Ultimately, this tenet means that the following needs to be addressed: both the supply and demand side; both home and community dynamics and facility-based services in a home-to-hospital
Remaining challenges
The inputs needed for maternal mortality reduction are within the reach of all countries over the next decade if the necessary rises in aid and budget allocations are forthcoming. Recognition of the deficits in human resources and infrastructure that hamper maternal health programmes has been growing. But attention to the poor capacity of the overall organisational system to convert these inputs into functioning, equitable services is now urgently needed.65
Efforts to strengthen capacity should
Conclusions
The focus of the global maternal health community needs to shift. Instead of energy spent on the fine points of precisely which effective interventions theoretically fit best into generic packages, we now need to address the health system that must deliver them. Yet virtually nothing in the maternal health field has been prepared or set up to address the type of systems capacity-building for scale that is the over-riding lesson of the diverse experiences of our four initiatives. To change this
References (69)
- et al.
The Global Campaign for the Health MDGs: challenges, opportunities, and the imperative of shared learning
Lancet
(2007) - et al.
Maternal mortality: who, when, where, and why
Lancet
(2006) - et al.
Strategies for reducing maternal mortality: getting on with what works
Lancet
(2006) - et al.
Evidence-based, cost-effective interventions: how many newborn babies can we save?
Lancet
(2005) - et al.
Going to scale with professional skilled care
Lancet
(2006) - et al.
Global patterns in availability of emergency obstetric care
Int J Gynecol Obstet
(2006) - et al.
The United Nations Process Indicators for emergency obstetric care: reflections based on a decade of experience
Int J Gynecol Obstet
(2006) - et al.
Mobilising financial resources for maternal health
Lancet
(2006) - et al.
The familial technique for linking maternal death with poverty
Lancet
(2004) - et al.
Strengthening emergency obstetric care in Ayacucho, Peru
Int J Gynecol Obstet
(2006)