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From Vol. XLIV, No. 4, "The MDGs: Are We on Track?",? December 2007

The international community came together 20 years ago in Nairobi, Kenya, to launch the Safe Motherhood Initiative and highlight the most striking inequity in public health. This global initiative was developed to generate political will, identify effective interventions and mobilize resources that would rectify a horrifying injustice. Yet, each year 3.3 million babies are stillborn and more than 4 million newborns die within 28 days of coming into the world. Some 536,000, often sudden, unpredicted deaths occur among women during pregnancy, childbirth or after the baby is born, leaving behind devastated families who are often pushed into poverty because of the cost of health care that came too late or was ineffective.

Although an increasing number of developing countries has succeeded in improving the health and well-being of mothers and their newborns in recent years, the countries that started off with the highest burdens of maternal and neonatal mortality and ill-health made least progress during the 1990s. In some countries, the situation has actually worsened. Worrying reversals in maternal and newborn mortality have taken place. Progress has slowed down and is increasingly uneven, leaving large disparities between regions and countries. Moreover, within individual countries, there are often striking inequities and differences between population groups. National figures often mask substantial internal variations -- geographical, economic and social. Rural populations have less access to skilled care than urban dwellers; mortality is higher among slum populations within urban dwellers; rates can vary widely by ethnicity or wealth status; and remote areas often bear a heavy death burden. Unless efforts are stepped up significantly, there is little hope of eliminating avoidable maternal and newborn mortality.

There is no doubt that technical knowledge exists to respond to most of the critical problems that affect the health and survival of mothers and newborns. The strategies through which households and health systems together can make sure technical solutions are put into action for all, in the right place and at the right time, are also becoming increasingly clear. However, too often programmes have been allowed to fragment, thus hampering the continuity of care, or have failed to give due attention to professionalizing services. Technical experience and the successes and failures of the recent past have shown how best to move forward.

Antenatal care is a major success story. Demand has increased and continues to do so in most parts of the world. However, more can be made of the considerable potential of antenatal care by emphasizing effective interventions and using them as a platform for other health programmes, such as combatting HIV/AIDS, and the prevention and treatment of tuberculosis and malaria, as well as sexually transmitted infections. Another important challenge is providing support for family planning and meeting a largely unmet need for contraception that can prevent millions of unintended, untimely and unwanted pregnancies.

Attending to all of the 136 million births a year is one of the major challenges facing the world's health systems. This will increase in the near future as large groups of young people move into their reproductive years, mainly in parts of the world where giving birth is most dangerous. Women risk death to give life, but with skilled and responsive care during pregnancy, at birth and immediately afterwards, nearly all fatal outcomes and disabling consequences can be averted. Such care can be best provided by a professional health worker with midwifery skills in decentralized, first-level facilities, and linked with referral care for emergency obstetric and newborn care for the management of life-threatening complications. But to be effective, both levels need to work in tandem and must be put in place simultaneously. A number of countries, such as Botswana, Cape Verde, China, Costa Rica, Cuba, Honduras, Malaysia, Sri Lanka, South Africa and Thailand, among others, have managed to achieve significant reduction of maternal and newborn mortality by adopting the above strategy.

The health and survival of newborns is closely linked to that of their mothers. Firstly, healthier mothers have healthier babies. Secondly, where a mother gets inadequate or no care during pregnancy, childbirth and the post-partum period, this is usually the case also for her newborn. Thirdly, newborn babies whose mothers die in childbirth are three to ten times more likely to die within two years than those whose mothers survive. Both mothers and newborns have a better chance of survival if they have access to skilled care and emergency care services. Therefore, progress in newborn health does not require expensive technology, but it needs health systems that provide continuity of care, from the beginning of pregnancy (and even before) and continuing through professional skilled care at birth into the post-natal period. It is essential to empower households, in particular the parents, so that the mother and her newborn get adequate home care and recognize the dangers early and get professional help immediately when difficulties arise.

There is a strong consensus that even if all the right technical choices are made, maternal and newborn health programmes will only be effective if they establish, together with households and communities, a continuum of care from pregnancy through childbirth and into the newborn period. This continuity requires greatly strengthened health systems, with maternal and newborn health care at the core of their development strategies, with effective planning for scaling up to provide universal coverage of services.

Putting in place the health workforce needed for scaling up maternal and newborn services towards universal access is the first and most pressing task. Making up for the staggering shortages and imbalances in the distribution of health workers in many countries will remain a major challenge for years to come. This workforce needs to deliver services in an integrated, coordinated fashion. Sustainable ways have to be devised for offering competitive remuneration and incentive packages that can attract, motivate and retain competent and productive health workers. Universal access, however, is more than deploying an effective workforce. For services to be taken up, financial barriers to access have to be eliminated and users given predictable financial protection against the costs of seeking care, particularly against the catastrophic payments that can push households into poverty. While the financing requirements seem to be within reasonable reach in some countries, in many it will go beyond what can be borne by Governments alone. Therefore, both developing countries and the international community will need to show a sustained political commitment to mobilize and redirect the considerable resources required to build the institutional capacity to manage them, and to ensure that maternal and newborn health remains at the core of the health-sector development efforts. Even where the Millennium Development Goals (MDGs) will not be fully achieved by 2015, moving towards universal access has the potential to transform the lives of millions for decades to come.

In conclusion, the challenges of making pregnancy safer require neither new technologies nor new knowledge of effective interventions. We know what needs to done to save the lives of mothers and newborn: family planning; skilled care during pregnancy, childbirth and immediately afterwards (the post-partum and post-natal periods); and timely access to life-saving emergency obstetric and newborn care. The challenges are how to deliver these services and scale up the coverage of interventions, particularly to vulnerable, hard-to-reach marginalized and excluded populations.

Key constraints to progress are the serious shortages and mismatches between what is needed and what is existing in terms of skills and geographical availability of human resources at the local, national and international levels. Other challenges are how to address the issues of deteriorating infrastructure, out-of-stock drugs, dwindling supplies and equipments, lack of transport, ineffective referral to and 24-hour availability of quality services, particularly emergency obstetric care, and weak management systems. We need to challenge policymakers and programme managers to refocus programme content, shifting emphasis from development of new technologies towards development of viable organizational strategies that ensure a continuum of care and account for every birth.

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