Ending preventable maternal and newborn mortality and stillbirths

Limited progress

As the era of the millennium development goals comes to a close, more needs to be done for women’s and children’s health. Although maternal deaths declined to 289 000 in 2013,1 the 45% reduction in maternal mortality since 1990 falls far short of the target of 75% in millennium development goal 5. The majority of maternal deaths are still due to direct obstetric causes—that is, haemorrhage (27%), hypertensive disorders (14%), sepsis (11%), and complications of abortion (8%).11 However, a rising number of deaths are related to chronic health conditions in pregnancy, such as diabetes, HIV, malaria, cardiovascular conditions, and obesity (fig 1⇓).

Figure 1 Causes of maternal and neonatal mortality11 12

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Newborn deaths have declined by 40% since 1990; about 2.8 million newborns died in 2013. The fall in newborn mortality has been slower than that in child mortality, and newborn deaths now account for 44% of all deaths in children under 5 globally.2 The three main causes of newborn deaths are preterm birth complications (35%), intrapartum conditions (24%), and infections (20%).12 Almost 80% of newborn deaths occur among babies who weigh less than 2500 g at birth, especially those born preterm (fig 1).13

Stillbirths have declined by only 15% since 1995. An estimated 2.6 million stillbirths occurred globally in 2009, of which 40% were intrapartum and probably due to inadequate care.3 14 In addition to prolonged and obstructed labour, untreated infections such as syphilis are an important cause of stillbirths in low resource settings.14

Optimal quality of care around childbirth and in the neonatal period could avert 113 000 maternal deaths, 531 000 stillbirths, and 1.3 million newborn deaths by 2020.15 Furthermore, satisfying the unmet need for family planning could prevent 29% of maternal deaths a year.16 Effective care that prevents mortality will also prevent maternal and neonatal morbidities and improve child neurodevelopmental outcomes and long term adult wellbeing.13 17 18 The health and survival of babies and their mothers are inextricably linked, calling for coordinated care before and during pregnancy, in childbirth, and in the postnatal period.

Strategic priorities

Evidence based strategy must inform planning for maternal and newborn health and survival, with due consideration of health system dynamics and social and environmental risk factors in different countries.19 Financial security and health equity are essential. The sustainable development goals provide a framework for universal health coverage described by three, interlinked objectives—enhancing the quality and availability of essential health services; achieving equitable and optimal uptake of services in relation to need; and improving cost efficiencies and financial protection.20 The Global Financing Facility can help to drive financial innovations to achieve the sustainable development goals across the continuum of reproductive, maternal, newborn, child, and adolescent health by 2030.21

We present five priorities, synthesised from the strategic objectives described by ENAP and EPMM (box 2).

Objective 1—Strengthen care around time of birth

Mothers and their babies are at highest risk of death during labour, childbirth, and the first week after birth. Investing in improved access to and quality of care around this time, and achieving high levels of coverage of effective interventions, has the potential to avert three million deaths of women, newborns, and stillborn babies a year, almost two million of which can be prevented around the time of birth (fig 2⇓).15

Figure 2 Potential impact of intervention packages by time period15

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Despite a global increase in coverage of skilled birth attendance, associated declines in maternal mortality have been modest, and for stillbirths virtually non-existent.3 4 22 23 This lack of improvement highlights the need to focus on quality of care, including provider competencies and environments that enable provision of essential clinical interventions with dignity. High quality healthcare is safe, effective, timely, efficient, equitable, people centred, and respectful.24 25 26 Given the inextricable link between mother and baby, care should also be administered without separation of mother and baby.23 24 25

Effective healthcare for all major causes of death will contribute to ending preventable maternal and newborn mortality and reaching the highest attainable level of health.11 15 27 For example, family planning will prevent closely spaced or ill timed pregnancies, which are directly correlated with increased mortality, and implementation of WHO’s technical and policy guidelines for access to safe abortion will also avert deaths.28 For newborn health, improved care around the time of childbirth and special care for small and sick newborns is essential to reduce mortality.8

Objective 2—Strengthen health systems

Health system strengthening must tackle both the hardware (essential health infrastructure, amenities, and commodities) and software (leadership and governance, transparent health information, innovation and private-public partnerships, mechanisms for participation and community engagement, and respectful care norms and values) of health systems.29 In addition, effective referral systems are needed to ensure seamless coordination across time, disciplines, and facilities.

Lack of an adequate health workforce and access to lifesaving commodities are major constraints in many countries. Thirty eight high burden countries face critical imbalances and shortages in the availability of healthcare providers.30 Nearly 90% of essential care services for maternal and neonatal health can be provided by health workers with midwifery skills, provided they are educated to achieve international standards of competency and regulated to ensure their skills are maintained.30 Yet midwives make up only 36% of the global maternity care workforce. The lack of complete registration of births and deaths and accurate information on causes of death to inform healthcare decision making and programme evaluation limit the equitable delivery of essential, quality interventions to populations in need. Research and development is needed to tackle intransigent problems in the delivery of healthcare services and to develop technologies that make birth safer, such as simplified resuscitation or better drug delivery. The global community must also explicitly describe what constitutes quality of care and skilled attendance at birth to enable appropriate monitoring and evaluation, and WHO is developing standards that respond to the quality framework published in its vision statement.31

Objective 3—Reach every woman and newborn

Equity is a fundamental human right and a prerequisite to achieving the sustainable development goals. Programme planners need to better understand barriers to access and the personal factors that make care acceptable to all. Equity includes not just access to services but provision of high quality care without discrimination and meeting sustained demand at scale.

Gender equality and the empowerment of women and girls are central to a rights based approach. Gender based violence is widespread and its adverse effects include unwanted pregnancies, pregnancy complications including low birth weight and miscarriage, maternal injury and death, and sexually transmitted infections such as HIV/AIDS.32 Strategies for empowering women in their reproductive and maternal healthcare must ensure not only the power of decision making—including whether, when, and how often to get pregnant—but the availability of options they need to exercise their choices.

The cost of health services can be a major barrier to care. Up to 11% of the population in some countries incur high out-of-pocket costs for healthcare, with as many as 5% forced into poverty by health related expenditures, including costs associated with essential maternal and newborn care.33 Universal health coverage means reaching all people in the population with essential services and protecting them from financial hardship owing to the cost of these services. Performance based financial incentives and conditional cash transfers have been effective in increasing care seeking and improving quality of care.34 Political and financial decision makers in countries and global donors must prioritise adequate and sustainable resources for maternal and newborn health.

Objective 4—Harness the power of parents, families, and communities

Ideally, families protect and care for women and newborns. Men have an important role in safeguarding family health, and they should receive support to do so.35 Evidence shows that women’s groups led by a skilled facilitator can improve maternal and neonatal health through participatory learning, particularly in rural settings with low access to health services.36 Trained community health workers can assist families to strengthen preventive and caregiving practices and facilitate appropriate care seeking. Participatory mechanisms at every level of the health system can help foster community engagement and ensure that services are transparent, inclusive, and responsive to those they serve. Civil society organisations, including parent groups, can contribute substantially to social mobilisation and can hold governments and health services to account for maternal and neonatal health commitments.

Objective 5—Improve data for decision making and accountability

Changing population demographics and disease burden affect the epidemiology of risk in countries and influence the choice of strategies to prevent maternal and newborn deaths and stillbirths.23 37 Better data are needed for such planning. Establishing national registration and vital statistics systems in every country is essential for counting births and deaths and tracking progress.38 In 2012 only a third of countries had high quality civil registration systems for maternal or neonatal deaths or stillbirths; about 137 million births globally, and nearly all neonatal deaths and stillbirths, were unregistered.13 The countries where little or no empirical data are available tend to be those where the estimated burden is highest. Accurate documentation of cause of death using standard definitions is also critical to designing effective health programmes to tackle preventable causes of mortality. Countries must invest in strengthening maternal and perinatal death review and response mechanisms.39 40

Additional global indicators are needed. Innovations in information technology (including m-health) can strengthen health systems through effective, real time data collection.41 Closing the loop of monitoring and evaluation through actual use of data to understand the effects of interventions is critical in ensuring accountability.42

Priority interventions

To achieve the targets of ENAP and EPMM an essential package of effective interventions must be implemented to reach every woman, pregnancy, and newborn. But the choice of interventions and measures of success must be tailored to each country based on local context. The interventions related to maternal and newborn care that are included in the UN Global Strategy for Women’s, Children’s and Adolescents’ Health (see data supplement on bmj.com)43 are not exhaustive but are prioritised based on their substantial effects on the main causes of maternal and newborn mortality and morbidity and stillbirth.15 19

Conclusion

As the agenda of the sustainable development goals emerges, healthy societies where women, adolescent girls, newborns, and children thrive, and pregnancy and childbirth are safe everywhere, should be at the heart of its ambition. Ending preventable maternal and newborn deaths and stillbirths is possible within a generation and requires focused attention on high impact interventions and strategies to improve access and quality of care. Effective care around the time of childbirth is most critical for survival and health, but comprehensive strategies and high impact interventions should span the continuum of care including before pregnancy. The detailed strategic guidance, specific targets, interventions, and milestones from the ENAP and EPMM global action plans provide guidance for countries to use in their formulation of national health plans and funding priorities.