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Skip to 0 minutes and 13 seconds DR CHERYL MOYER: Perhaps the most important concept underpinning this section is that maternal health outcomes do not occur in a vacuum. Maternal health is influenced by social factors, the political environment, environmental factors, and changing demographics, all of which are constantly evolving.

Skip to 0 minutes and 32 seconds In order to truly understand maternal health, we need to look at the potential impact of some of the factors occurring outside the health system. In this lecture, we review what we believe are some of the most important coming shocks and rapid societal and health system changes that will influence maternal health in the coming years. We focus on the following four areas - economic growth, governance, urbanisation, and health crises.

Skip to 1 minute and 3 seconds The first potential shock has to do with economic growth in many low-income and lower-middle-income countries. Projections suggest that low-income and lower-middle-income countries are on track to experience strong economic growth in the next 20 years. For example, annual growth in Gross Domestic Product, or GDP, between 2011 and 2035 in low-income countries is projected to be double that of high-income countries. At the same time, there are growing possibilities for domestic revenues, including taxation on tobacco and alcohol, tourist taxes, and redirection of fossil fuel subsidies. Such changes occur in a context where foreign development assistance for health has stagnated and will continue to decline. Countries are going to need to increase domestic financing for health.

Skip to 1 minute and 59 seconds Currently, the percent of domestic spending on health in many low resource countries is extremely low. If we look at this slide of data from India, we can see that India’s growth rate in terms of GDP is much higher than the world average, whereas the percent of GDP spent on health is nearly one sixth of the world average. Note that this is not in terms of raw numbers but in terms of percentages. This means India spends less than 1.5% of its total GDP on health compared to 6% spent globally. As GDPs rise and as less future health financing comes from donors, it will become increasingly important for countries to prioritise health spending.

Skip to 2 minutes and 42 seconds Our data suggests there will be ample capacity to do so, but what remains to be seen is if there will be the political will to do so. The next potential shock that is likely to impact maternal health in the next 20 years relates to shifts in governance for health. Perhaps the most profound shift in this regard relates to the transition from the United Nations sponsored Millennium Development Goals, or MDGs, to the Sustainable Development Goals, or SDGs. This slide shows the eight MDGs that expired in 2015 on the left, illustrating that maternal health had its own specific MDG, which resulted in a lot of focused energy around improving maternal health during the MDG era.

Skip to 3 minutes and 25 seconds The centre of the slide illustrates the 17 Sustainable Development Goals that replace the MDGs, only one of which is directly related to health. The right side of the slide shows the specific targets included in the SDG health goal, including reducing maternal mortality, ensuring universal access to reproductive health services, and achieving universal health coverage. While it’s great to see recognition of the many facets of health that are necessary to address, it also runs the risk of diluting efforts that were once more squarely focused on maternal health. A second important element of shifts in governance relates to the fragmentation of governance around women’s health.

Skip to 4 minutes and 9 seconds In the past decade, there were at least 18 high profile global efforts in maternal health launched to address maternal health issues, including such efforts as the Partnership for Maternal Newborn and Child Health - PMNCH - Every Woman Every Child, and Women Deliver. In addition, there are countless new initiatives that look beyond traditional maternal health issues, including a focus on newborns, children, adolescents, family planning, and nutrition. While all of these initiatives are extremely important and could be synergistic, the effect is often fragmentation and competition for limited resources. In addition, many such initiatives do not evaluate their impact, thus precluding educated decisions about resource allocation in the future.

Skip to 4 minutes and 57 seconds This is going to be increasingly problematic as donors continue to reduce their support, and countries will need to rely more heavily on their own funds to drive maternal health programming. Finally, decentralisation refers to the increasing shift from national level policy and decision making to state level decision making. Decentralisation carries a potential trade off. It may increase the efficiency of services because local planning may be more responsive to local needs. However, it may reduce consistency and accountability across locations within a country.

Skip to 5 minutes and 34 seconds The third shock external to the health system that is likely to have a profound effect on maternal health is urbanisation. We know that the percent of the global population living in urban areas is increasing over time. As this graph illustrates, by 2050, more than half of the population in India and Asia is likely to be living in urban areas. Not surprisingly, the proportion of births occurring in urban areas is also increasing. By the year 2030, data suggests that more than half of all births will occur in urban areas, rising to nearly two-thirds by 2050. Urbanisation brings with it both potential benefits and potential challenges. The benefits are that there can be greater access to health care in urban settings.

Skip to 6 minutes and 22 seconds Women may be in closer proximity to a variety of different service providers, allowing them to choose among them. They may have reduced travel time compared to when they lived in more rural areas. And they may benefit from facilities staffed by better trained providers. It is also possible that new arrivals to urban areas may adopt urban norms that may attenuate some of the traditional practises that may not be ideal for maternal health. On the downside, the rich-poor gap in urban areas tends to be much more pronounced than in rural areas. In addition, migrants to urban areas can cluster in slum settlements, which can create different problems for care seeking than simply living in an urban area.

Skip to 7 minutes and 7 seconds The last challenge we’re going to talk about today is that of health crises, including disease outbreaks, armed conflict, and natural disasters. Note that each of these can lead to widespread migration, which can create its own set of shocks to the health system.

Skip to 7 minutes and 25 seconds Disease outbreaks, armed conflict, and natural disasters disproportionately affect pregnant women. Obviously, some diseases, such as Zika, are known to directly and differentially affect pregnant women. Yet the Ebola outbreak in West Africa was projected to double the maternal mortality ratio in Liberia, Sierra Leone, and Guinea. At the same time, armed conflict limits women’s access to preventive and reproductive health services. The results are devastating. Maternal mortality in post-conflict countries was found to be 45% higher than in non-post countries. Finally, natural disasters can strip health systems of the ability to deal with basic maternal health care needs.

Skip to 8 minutes and 12 seconds Health crises, armed conflict, and natural disasters can initiate another type of shock - mass migration. For example, the war in Syria displaced an estimated 60 million people in 2014, many of whom were pregnant women or women of reproductive age. In addition, rural to urban migration can stress the health systems within countries as well. In summary, there are powerful shocks that are extremal to the health system that will influence maternal health and maternal survival in the coming years. Health systems must plan for such shocks and develop strategies to boost their resilience in the face of crises.

Skip to 8 minutes and 53 seconds Health systems will need to both respond to crises but also to be able to maintain core functioning, including the provision of routine health care, during and after crises.


Which factors outside the health system will impact on maternal health outcomes?

In this step Dr Cheryl Moyer (Michigan) links maternal health outcomes to social factors, the political environment, environmental factors, and changing demographics. Among the key potential shocks and rapid societal and health system changes that will influence maternal health are economic growth; governance; urbanisation; and health crises.

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The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine