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Skip to 0 minutes and 12 seconds LORI MCDOUGALL: Although the global maternal mortality ratio nearly halved between 1990 and 2015, progress was uneven between countries with some doing very well, and some making no progress, and some experiencing increased maternal mortality ratios. Marge Koblinsky and colleagues’ paper in The Lancet Maternal Health Series presents a call to action with five key priorities to focus on in the next five years to instigate action towards achieving the Sustainable Development Goal of less than 70 maternal deaths per 100,000 live births by 2030 with no country exceeding 140.

Skip to 0 minutes and 47 seconds These priorities are around promoting equity and maternal health services, increasing resilience on a health systems level, guaranteeing sustainable financing for maternal and perinatal health, and improving the availability of use of evidence, each of which we will discuss more in this session. We have covered maternal health issues relating to this in weeks one and two, and those we haven’t covered yet are coming up this week. Quality maternal care for every woman, everywhere requires health services that respond to local specificities of need and meet emerging challenges.

Skip to 1 minute and 20 seconds First, countries must ensure context appropriate implementation strategies at all stages in maternal health, from ensuring access to contraception and safe abortion for women who want to avoid childbearing, to providing quality care for pregnant women continuing to term. The focus of strategies to improve maternal health should be context specific and respond to local specific needs. The focus will vary according to the stage of obstetric transition. We will discuss this in more detail later this week. Secondly, countries must build linkages within and between maternal, perinatal, and other health care services to address the increasing burden of indirect causes of maternal morbidity and mortality and to prevent breakdown of care. The burden of indirect causes of maternal morbidity and mortality varies across settings.

Skip to 2 minutes and 10 seconds In sub-Saharan Africa infectious diseases such as malaria and HIV are more common, whereas in other settings, non-communicable diseases and mental health become more prominent, often in relation to older maternal age and obesity. The kinds of linkages to be built will therefore differ across settings. Finally, linkages between maternal health services is important, an example being effective linkages between antenatal care and hospital-based services for the reduction of maternal and perinatal deaths from eclampsia and pre-eclampsia. We talked about this in week one. The second priority focuses on equity. Women everywhere don’t seek care or are unable to access it for many reasons. These include sociocultural factors, such as gender inequality; location, for example remoteness or conflict; and financial constraints.

Skip to 2 minutes and 59 seconds We discussed some of these issues in week one. Making equity a priority means addressing these barriers to accessing quality maternal care. Gender inequality is a complex sociocultural issue, but there are ways in which it is possible to reduce its impact on maternal health. These might include improving access to basic information about maternal health, addressing the influence of men and influential family members, and the use of messages shared through mass media. Ways to improve access to care for women living in rural areas include linking women to delivery services during antenatal care, providing maternity waiting homes, and improving and subsidising transport. During humanitarian crises even basic maternal health services, such as family planning and emergency obstetric care, are often non-existent.

Skip to 3 minutes and 47 seconds Ensuring access and availability of services is necessary everywhere. Schemes comprising large prepayment and risk pooling mechanisms, which reduce reliance on out-of-pocket spending could reduce catastrophic health expenses and reduce financial barriers to care. The resilience of health systems is a challenge in countries where staff are overstretched and where governance is weak. A key element, therefore, of increasing the strength and resilience of health systems is increasing and optimising the workforce and improving facility capability. In terms of workforce, this means both the actual numbers of skilled professionals and their composition, deployment, retention, and productivity. Estimates suggest that more than 18 million additional health workers will be needed by 2030 if global targets are to be met.

Skip to 4 minutes and 35 seconds This map shows the wide variation and the ratio of human resources for health per 1,000 pregnancies in Africa in 2012. Countries with the largest number of births have some of the lowest densities of midwives and obstetricians. The geographical distribution of providers also needs to be taken into account, making sure that provider density is sufficient for both rural and urban areas. Task shifting could play a part in expanding services, and access to some services. Improving the strength and resilience of health systems also means improving facility capability, which we talked about in week one. The case for investing in health is clear. Increasing investments in high maternal and child mortality countries would yield high rates of return. However, a resource gap remains.

Skip to 5 minutes and 20 seconds Where need cannot be met by government resources, continued donor support remains important. New initiatives, such as the Global Financing Facility aim to increase, coordinate, and better target donor and domestic financing for women’s, children’s, and adolescents’ health. Also important is the optimal use of these resources. Strategic purchasing means identifying which models of care and interventions to invest in, determining how they should be purchased and for whom, and choosing the right health care providers to purchase services from. These should ideally be those that could provide the highest quality of care most efficiently. Finally as we have discussed in previous steps, universal health coverage has enormous potential for achieving greater equity.

Skip to 6 minutes and 3 seconds Universal health coverage initiatives should include a strong maternal health focus and ensure that it reaches every woman, every child, everywhere. The final priority set out in the call to action in this series is to improve the availability and use of local evidence to inform quality improvements. In order to guide intervention research, set implementation priorities, and improve quality of care, we need better measurement and coding of maternal mortality and improvements in vital registration systems to document births, still births, and deaths. This will provide a more accurate and comprehensive picture at both global and local levels. Better measurement also requires standardising definitions and methods of measurement. We will talk of the future of data in maternal health later this week.

Skip to 6 minutes and 49 seconds We also need more research to understand the changing patterns of sociodemographic, obstetric and medical risk factors, and maternal mortality and morbidity to increase our understanding of what, why, and how interventions work and to develop national and global tracking indicators. This is crucial in informing ways to effectively and equitably improve maternal health and quality of care, and monitoring change. Finally, this evidence must be translated into action through effective advocacy and accountability for maternal health, which we will discuss in detail later this week. These priorities are relevant on both a local and a global level. National and local stakeholders can identify and address the key elements needed to improve maternal care for all women.

Skip to 7 minutes and 35 seconds Regional and global stakeholders can advocate for increased attention to maternal health and ensure that women’s rights and agency are acknowledged. Together local and global stakeholders can move forward to ensure that every woman, and every newborn, everywhere, reaches good quality health care.

Action plan (quality, equity, systems, financing, evidence)

What are the key priority actions needed to improve global maternal health?

In this step Lori McDougall (PMNCH) outlines the 5 priorities and priority actions for accelerated progress toward improved maternal health, proposed by The Lancet Maternal Health Series. The Call to Action highlights focusing on: 1) Quality; 2) Equity; 3) Systems; 4) Financing; and 5) Evidence, to ensure every woman, every newborn, everywhere has good quality care.

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This video is from the free online course:

The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine