Eastern Mediterranean Health Journal | Past issues | Volume 21, 2015 | Volume 21, issue 6 | Addressing the main causes of maternal, neonatal and child mortality

Addressing the main causes of maternal, neonatal and child mortality

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Background

In January, 2013 the UNFPA, UNICEF and WHO launched an initiative Saving the Lives of Mothers and Children: Rising to the Challenge with the aim of accelerating efforts to reduce maternal and child mortality in high-burden countries in the Region. A high-level meeting of health ministers of the Region, technical experts, academia and leading UN agencies was held in Dubai, which culminated in a consensus “Dubai Declaration” and a renewal of pledges for accelerated efforts on saving the lives of mothers and children in the Region. This initiative has been a catalyst for change and has had a positive impact on mobilizing national leadership and commitment to promote maternal, neonatal and child health. However, two year on, maternal and child mortality remains a major public health problem in the Region. Several overarching factors contribute to the continued high burden of maternal and child mortality that exists in some countries. These include lack of sustained commitment to child and maternal health; manmade and natural disasters and political upheaval; the need to strengthen management of maternal and child health programmes; and suboptimal use of already limited human and financial resources.

National maternal, neonatal and child health programme managers play a critical role in programme support and implementation to tackle maternal, neonatal and child mortality. Therefore, to review progress made in reducing maternal, neonatal and child mortality, address its main causes and identify continuing challenges, a meeting was held of programme managers from countries of the Eastern Mediterranean Region in Amman, Jordan, from 29 March to 2 April 2015.

The meeting was jointly organized by the WHO Regional Office for the Eastern Mediterranean, United Nations Children’s Fund (UNICEF) Regional Office for the Middle East and North Africa, and United Nations Population Fund (UNFPA) Regional Office for the Arab States. It was attended by 130 participants from 19 countries of the Region, plus Algeria, together with experts from national and international organizations, and WHO, UNICEF and UNFPA staff members from headquarters, regional and country offices.

The objectives of the meeting were to: i) update programme managers from countries on addressing the main causes of maternal, neonatal and child deaths using cost- effective interventions; ii) review progress achieved in the implementation of maternal and child health plans in countries, determine enabling and disabling factors affecting the implementation of these plans, and identify priority actions for 2015; iii) identify country policy and programme gaps in order to facilitate the implementation of evidence-based interventions to prevent the main causes of maternal, neonatal and child deaths; iv) identify strategic directions for the post-2015 agenda; and v) agree on how to integrate mental health within existing maternal and child health services.

Challenges identified

Neonatal, maternal and child health

Key common challenges to reducing neonatal, maternal and child mortality include:

low coverage of evidence-based, cost-effective interventions

inadequate polices, or absence of or lack of adherence to updated guidelines and protocols

inequalities between urban/rural, rich/poor and educated/non-educated populations

lack of financial resources

lack of a surveillance system for maternal and child mortality.

Other specific challenges were noted.

Neonatal: lack or misdistribution of skilled human resources at all levels, especially skilled birth attendance and essential newborn care; fragmentation and verticality of interventions.

Maternal: poor infrastructure and human resource capacity in referral hospitals, specifically for comprehensive emergency obstetric and newborn care (caesarean section, blood transfusion and intensive care); inadequate basic and comprehensive family planning and preconception care interventions; low use of modern contraception; under-utilization of available services.

Child: low coverage of infant and young child feeding and integrated community case management interventions; low quality of child health services; a lack of adherence to standards and protocols and a need to update IMCI guidelines; weak supply chain management; poor water and sanitation.

Implementation of interventions

Regional surveys undertaken to assess the implementation of cost-effective, evidence-based interventions for maternal, neonatal and child health and the status of human resources in countries have revealed a wide discrepancy in the implementation coverage rate. Some lifesaving interventions have not been comprehensively implemented in some settings, mainly due to issues at policy and systems levels. These include: a lack of supportive policies and regulations; a lack of, or inadequate, financial resources; poor logistic systems; low coverage of interventions; an inadequate or imbalanced distribution of a skilled workforce; poor supervision systems; and non-functional monitoring and evaluation systems.

Health systems

The main challenges to strengthening health systems related to maternal, neonatal and child health are: an unregulated private sector; the unstable security and political situation in many countries; poor data quality; incomplete human resources policies; high out-of- pocket expenditure; and a lack of national funds for essential medicines.

Progress review

Eight of the nine regional Millennium Development Goal (MDG) priority countries presented their progress in implementation of the maternal and child health acceleration plan. While achievements have been made, significant challenges remain. Commonly-identified challenges include political instability and insecurity, a lack of financial resources, and a shortage and rapid turnover of human resources

Maternal and child mental health

The integration of mental health into maternal and child services is highly relevant to the contexts of countries in the Region. However, there are major potential challenges including a lack of understanding by policy-makers, a focus in programmes on mortality rather than morbidities, and the lack of human resources qualified in mental health.

Strategic planning for post-2015

Major strategic directions in maternal, newborn and child health for post-2015 include: promoting universal health coverage through improving access to maternal and child health services targeting under-served populations; increasing the coverage of maternal, newborn and child health care interventions in an integrated manner at all levels with a particular focus on the community level; advocacy to increase national budgets allocated for maternal, newborn and child health and mobilizing additional resources from various health partners/donors to support plans; developing country plans of action for pneumonia and diarrhoea that address protection, prevention and treatment interventions; prioritizing the quality of services through accreditation, certification and licensing, and ensuring adherence to guidelines and protocols; strengthening maternal and newborn death surveillance and response systems; reinforcing mechanisms to address shortages and the mal-distribution of health care providers; and strengthening supply chain management systems.

Conclusions

Between 1990 and 2013, maternal mortality in the Region reduced by 50% and child mortality by 46%. Indeed, some countries have already achieved their MDGs 4 and 5, while many of the remaining countries have succeeded in significantly lowering mortality rates for both mothers and children. However, there remains a group of countries with high number of deaths of mothers, newborns and children. Some countries are drastically affected by emergencies that require increased efforts and resources.

The rate of decrease in newborn mortality in the Region has been lower than for under-five mortality. Newborn mortality contributes almost half (47%) of the under-five mortality rate and therefore needs urgent attention.

Maternal and child health disparities based on urban and rural residence, ability to pay, education and women’s status, persist across the Region and within countries. Inequitable access in maternal, neonatal and child health service coverage, uneven quality of care and gaps in the continuum of care can be addressed through evidence-based, cost-effective interventions.

The UNFPA/UNICEF/WHO initiative for saving the lives of mothers and children in high-burden countries in the Region has galvanized national leadership and commitment to supporting maternal, neonatal and child health. Further collaborative efforts and coordination mechanisms at the country level remain critical to ensuring optimal outcomes for maternal, neonatal and child health.

Addressing the main causes of maternal, newborn and child mortality is necessary in order to eliminate preventable maternal, neonatal and child deaths. This includes a need to revisit policies, strategies and regulations related to maternal, neonatal and child health care, based on successful experiences and best practices in implementing feasible, cost-effective and high impact interventions that ensure that marginalized and underserved populations are reached.

It is important to implement evidence-based, cost-effective and lifesaving interventions in maternal, neonatal and child health based on the guiding principles of equity, quality and universal health coverage. Relevant reproductive, maternal, newborn, child and adolescent health (RMNCAH) guidelines should be updated and countries need to adopt them in accordance with their specific needs.

Strengthening health systems, in particular at the subnational level (such as the district level), is a key element in reducing disparities and inequity, and improving quality of care (particularly for childbirth and the first week of life) for mothers, newborns and children. Moreover, infection control measures play a major role in preventing maternal and child mortality, particularly in high burden countries.

Response to the inequity and low coverage of community-based health interventions is essential and integrating community health workers into the mainstream health system is important, especially in countries with low service coverage. Building the capacity of community health workers in early detection and primary management of maternal and child health cases can greatly contribute to reducing morbidity and mortality. There is also a need to integrate mental health into maternal and child health care services using existing evidence-based tools/guidelines.

Post-2015 RMNCAH strategic plans need to end preventable maternal, newborn and child deaths through implementation of maternal, neonatal and child health interventions in accordance with the six health system building blocks, using the infection control assessment tool and quality control documents developed by WHO. The focus should be on gaps in human resources, lifesaving commodities and quality of care.

The meeting concluded with recommendations for the next steps needed to be undertaken by the countries and UNFPA/UNICEF/WHO (Box 1).

Box 1 Next steps