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Skip to 0 minutes and 13 seconds DR CHERYL MOYER: As described in the previous section on external shocks, global maternal health will be transformed over the next 20 years by social, political, environmental, and demographic changes. Alongside these changes come new opportunities for progress. In this section, we will discuss some of the ways in which health system innovations can be leveraged to improve maternal health. We will cover Universal Health Coverage, behavioural economics, mHealth and the data revolution, and new ways of linking women to the care that they need.

Skip to 0 minutes and 50 seconds A key development with potential to improve maternal health is Universal Health Coverage. We covered this in detail previously, so we won’t spend too long on it now. Briefly, Universal Health Coverage is defined by the World Health Organisation as a means to ensure that all people can get the health services they need without experiencing financial hardship when paying for them. This definition adds the aspect of financial protection to previous declarations that focused on expanding access to care. Universal Health Coverage includes health promotion and prevention, rehabilitation and palliative care, as well as treatment. As we have seen in previous sections, by removing point-of-care fees for essential services, Universal Health Coverage can increase service use by reducing these financial barriers to care.

Skip to 1 minute and 37 seconds For example, in sub-Saharan Africa, countries that removed user fees for delivery saw increases in facility births and a decrease in neonatal mortality. Universal Health Coverage also provides financial protection by reducing the risk of catastrophic health expenditures, or people being pushed into poverty as a result of the financial consequences of paying for health care. Finally, Universal Health Coverage has been shown to improve health outcomes across a range of indicators.

Skip to 2 minutes and 7 seconds Now we’re going to talk about an innovation called behavioural economics. We know that health outcomes rely not only on high quality and accessibility of health care services, but also on decisions and actions taken by individuals. For example, maternal and neonatal health outcomes depend on decisions and actions taken by the mother and her partner. These include the frequency of antenatal care visits, where they choose to deliver, when they choose to leave to go to the delivery facility, and whether and when they choose to use postpartum contraception. We know that people don’t always behave rationally. Sometimes people do not make the decisions that best fit with their own stated goals and well-being.

Skip to 2 minutes and 50 seconds A growing body of evidence from the field of behavioural economics suggests that behavioural and psychological factors affect individuals’ decision-making. These factors include such things as social norms, misinformation, and procrastination. Behavioural economists have also found that people, particularly those living in poverty and dealing with the stresses that that brings, might minimise their cognitive burden in decision-making by choosing default options, for example. Or using decision heuristics or mental shortcuts, where people simplify complex choices to make a decision easier. This partly explains why removing barriers to access doesn’t necessarily improve uptake of lifesaving interventions.

Skip to 3 minutes and 36 seconds We can use insights from behavioural economics and the idea that changes in the framing of choices can change behaviour and outcomes to develop tools to improve health. Such tools have the greatest potential where access barriers are low, yet coverage and outcomes remain sub-optimal. Reminders have shown promise in improving health outcomes. For example, in improving medication adherence or attendance at antenatal care. Changing how choices are ordered by making the desired choice the default option can improve outcomes by reducing the cognitive burden required to make the desired choice. Shifting how information is framed, for example by presenting gains rather than losses, can also influence decision-making behaviour.

Skip to 4 minutes and 22 seconds Finally, economic incentives such as paying cash for facility delivery can help women and couples resist social and cultural pressures and shape their decisions.

Skip to 4 minutes and 35 seconds mHealth and the data revolution are another important category of innovations that has the potential to significantly affect women’s health in the coming years. First, expansion of mobile technology can improve the speed of communication and enable data sharing that was not possible before. Access to mobile phones is now near ubiquitous, and mobile phone networks cover vast rural areas that were previously not accessible. Furthermore, the cost of both mobile phones and network usage have declined substantially over the last decade, making it feasible to use mobile phones for communication, data collection, and data sharing for public health.

Skip to 5 minutes and 15 seconds And mHealth has many potential uses. It is commonly used in data collection, surveillance, and follow-up, and in civil registration and vital statistics systems. For example, some lower-middle income countries are using text message based notification of life events in combination with digitisation of civil registration and vital statistics systems to improve tracking systems. mHealth also has potential for individual-level users. With improving technology comes more self-care and diagnostic tools that patients can use at home. These save patients both time and money. Mobile phones can be used to send patient reminders and health education messages. Technology can even help patients to demand better quality services through a proliferation of social accountability mechanisms.

Skip to 6 minutes and 8 seconds For example, Uganda and India have systems for citizen reporting of health services, from corruption to facility dysfunction to experiences of disrespectful care, by mobile phone. Such innovations offer new approaches for improving the effectiveness and responsiveness of health care, but note that mobile technology may not be readily available to the poorest and those living in the most remote areas. Women may have less ready access to mobile phones and their access may be controlled, making it difficult for information to reach them. And very important to consider privacy One example of a project that used both mHealth and behavioural economics comes from Zanzibar, where providers used text message reminders to increase antenatal care attendance.

Skip to 6 minutes and 58 seconds In a randomised control trial, one group of pregnant women received text messages with health information and antenatal care appointment reminders, while a comparable group did not. Those pregnant women who got the text messages were significantly more likely to attend antenatal care than those who did not receive the text messages.

Skip to 7 minutes and 21 seconds Finally, we’d like to talk a little about innovative ways to link women to health care. As we saw previously, access to services remains a key barrier to receiving routine and emergency care. Innovations in ways of linking women to services are designed to improve access to care. Such innovations include alongside midwifery-led units, maternity waiting homes, and innovations in routine and emergency transport. Alongside midwifery-led units are located on hospital sites, and they allow women to deliver in lower capability facilities while eliminating travel time to comprehensive emergency obstetric care facilities if needed. They are used in South Africa and the UK.

Skip to 8 minutes and 4 seconds The advantages of alongside midwifery-led units are that they reduce the high costs associated with hospital delivery, as well as overcrowding and over-intervention. They also preclude the need for transportation between facilities in the event of complications. However, unlike maternity waiting homes, they do not address issues around routine transport of women in labour. Maternity waiting homes enable pregnant women who are approaching their expected delivery date who live far from a facility to stay next to the health facility to reduce travel time and labour. A maternity waiting home might be provided by the health sector, or it might be a patient hotel, a private hotel, hostel, or the home of friends and relatives. Sometimes called informal maternity waiting homes.

Skip to 8 minutes and 50 seconds Maternity waiting homes are a way of addressing the need for routine transport to delivery services for women in remote areas. In Canada, about 6% of women travelled more than a day before birth to another city, town, or community to deliver. We discussed transport for routine and emergency obstetric care previously. Some countries, such as India, Nepal and South Sudan, have established subsidised transport systems for women seeking routine obstetric care. This enables women in remote areas and with limited resources to travel to health facilities to deliver. For emergencies, referral systems and coordinated emergency transport are needed to transfer patients and communicate critical health records to receiving hospitals.

Skip to 9 minutes and 35 seconds Community-based emergency vehicles show some promise, as we saw in Cambodia, but their sustainability, cost, and scale up have been poorly studied.

Skip to 9 minutes and 46 seconds In this lecture, we’ve covered some of the most promising innovations that have the potential to improve global maternal health. These include Universal Health Coverage, behavioural economics, mHealth, and innovative ways to link women to health care. In this course, we focused less on individual technological innovations. However, there are many innovations that may prove promising. One to note is the recent trial on tranexamic acid for haemorrhage, which was shown to reduce death due to bleeding in women with postpartum haemorrhage.


What are the most promising innovations with the potential to improve global maternal health?

In this step Dr Cheryl Moyer (Michigan) describes the potential for new opportunities for progress in global maternal health, given the anticipated impacts of social, political, environmental, and demographic changes. Health system innovations to improve maternal health are discussed including Universal Health Coverage, behavioural economics, mHealth and the data revolution, and new ways of linking women to the care that they need.

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The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine