Healthcare Policies & Women's Health

Improving Maternal and Child Health: Towards Universal Access

WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC)

Working towards universal coverage of maternal, newborn and child health interventions is our mission. In shaping the global political economy with the view to protecting health in particular that in the most deprived populations is a challenge for rich and poor countries alike. The 58th World Health Assembly Resolution (WHA58. 31) call on World Health Organization to strengthen coordination, collaboration and synergies of World Health Organization programs including those for health systems development. The country cooperation initiative ensures that World Health Organization technical support to countries is coordinated and in line with national priorities. Application of the continuum-of-care concept as promoted in the World health report 2005 suggests the way in which programs should be planned.

The purpose of this document is promotion of the continuum of care concept and calls for vision, long-term planning, and investment in solutions that are sustainable within the framework of national health systems in which public-private partnership are taking root and developing. This approach requires focus, not only on the interventions and their delivery, but also (and perhaps most strongly) on the development of the systems in which the provision of quality services can be institutionalized. The Women's Health and Education Center seeks to improve partner coordination, advocate globally for more resources, and monitor progress towards achieving Millennium Development Goals (MDGs) for maternal and child mortality reduction.

Collaboration and coordination: implementation of healthy public policies

With the turn of century, the global community recognized that basic health is a prerequisite for sustainable development. The problems and disease without passports are expanding, threatening new regions, and are potentially undermining the welfare of the entire world. Human health -- and its influence on every aspect of life -- is central to the larger picture. Those of us who commit our lives to improving health can help to make sure that hope will predominate over uncertainty in the century to come. Opportunity entails responsibility. Working together we have the opportunity to transform lives now debilitated by disease and fear of economic ruin into lives filled with realistic hope. Health is at the core of the global agenda -- that is where it belongs. We tend to collect, analyze and spread the evidence that investing in health is a one major avenue towards poverty alleviation. The diverse interests of a big project / program guarantee the liberty of all. Investments in human resources, financial protection mechanisms, district health management and infrastructure, are urgently needed to increase access to health services and to achieve universal coverage of essential maternal, neonatal and child health services in countries. Without such investments, sustainable delivery will remain a challenge and short-term goals will erode when priorities shift or sources of funding dry up.

To help secure coordination, and to strengthen the long-term commitment of different actors, and NGOs the new global Partnership for Maternal, Newborn and Child Health seeks to track progress, highlight inequality, and promote greater accountability. Education that empowers women to make decisions about their lives and health is the key to reduce maternal mortality. The tragedy is that these women die not from disease, but during the normal, life-enhancing process of procreation; every woman who dies, many more suffer from serious conditions that can affect them for the rest of their lives. Maternal mortality is an indicator of disparity and inequality between men and women. Millions of women around the world risk their lives and health to end an unwanted pregnancy. Every day, 55,000 unsafe abortions take place -- 95% of them in developing countries. They cause the deaths of more than 200 women daily and untold numbers of disabilities. Globally, one unsafe abortion takes place for every seven births, and in some countries is the most common cause of maternal mortality and morbidity. Abortion is a contentious topic but purpose of this discussion is not to be contentious. Rather, it is to draw attention to a problem that kills almost 80,000 women a year in the hope that, by doing so, it will help to hasten the day when unsafe abortion is a thing of the past. Pregnancies among very young women and women with many children, and unwanted pregnancies are all associated with increased likelihood of mortality.

Healthcare system development:

Long-term sustained improvements in maternal, newborn and child health require long-term commitments that go well beyond the political lifespan of many decision-makers. The proper technical strategies to improve maternal and child health can be put in place effectively only if they are implemented, across programs and service providers, throughout pregnancy and childbirth through to childhood. It makes no sense to provide care for a child and ignore the mother, or to worry about a mother giving birth and fail to pay attention to the health of the baby. To provide families universal access to such a continuum of care requires programs to work together, but is ultimately dependent on extending and strengthening health systems. Moving towards universal access has the potential to transform the lives of millions for decades to come. Universal access provides a platform for building sustainable health systems where existing structures are weak or fragile. "Political will" and "ownership" are essential to build up health systems over many years. Most analysts would agree that a reasonable degree of macroeconomic and political stability and budget predictability is a precondition for mobilizing the institutional, human and financial resources that strengthening the health system requires. Without sustained political momentum, however, effective leadership is unlikely to be present, be it at the center where the broad sectoral decisions are made, or at the operational level, in the districts where the interaction with the population takes place.

Political-will first requires information on the magnitude, distribution and root causes of the problems that mothers and children face, and on the consequences, in terms of human capital and economic development, of failing to confront them effectively. Maternal, newborn and child health can boast a large framework of advocates at the international level that has done much to produce and disseminate such information. Along with the shortages, it appears that many countries have also witnessed deterioration in the effectiveness of their workforce. The public expects skills, knowledge and competencies in maternal, newborn and child health care that health workers often lack, putting lives at risk. Upgrading can improve the effectiveness of the present workforce, but the current levels of skills are so poor and the mix so inappropriate that the potential of upgrading is limited. In-service training and supervision are generally considered key elements in improving outcomes, but there is a dire lack of evidence on cost-effective approaches to improving competency, particularly in conditions where pre-service training is poor and working conditions inadequate.

What kind of healthcare systems for 21st century? Obstacles that limit women's access to health care -- such as distance from home to appropriate health facilities, lack of transport, and financial and social barriers -- must be removed. Legislation that supports women's access to care must be formulated and statutes that restrict women's access to family planning services should be repealed. Policies must ensure that all couples and individuals have access to services that offer a wide choice of effective contraceptive methods. Policies that increase women's decision-making power, particularly in regard to their own health, are also essential. The support of families and communities is the key to reducing maternal mortality. Input from a wide range of groups and individuals is therefore essential, including community and religious leaders, women's groups, youth groups, other local associations, and healthcare professionals.

There is no doubt that health workers are the cornerstone of functioning health systems. Chronic under-funding of health systems in developing countries has led to the current health worker crisis, which threatens the achievement of the Millennium Development Goals (MDGs). Donors also play an important role in the health workforce crisis. For decades, most donors accorded low priority to spending in the health sector in developing countries: their support was limited, short term and unpredictable, focusing on projects that ran parallel to the national health systems and did not fund recurrent costs such as salaries. Meanwhile, government budgets suffered from a lack of adequate domestic resources, coupled with debt services, aid conditions and unpredictable aid with delays or even incomplete disbursements. Resource-poor governments are reluctant to take on such commitments without clear support from the international community.

Today maternal, newborn and child health are no longer discussed in purely technical terms, but as a part of a broader agenda of universal access. This frames it within a straight-forward political project: responding to society's demand for the protection of the health of citizens and access to care, a demand that is increasingly seen as legitimate. The real and lasting gain in global health are going to be achieved through long-term commitment, investment and cooperation.

Organization of maternal and child health services:

The common project that can bring together the interests and preoccupations of the Maternal and Child Health Programs, as well as those of sector manager and health providers, is that of universal access to care for mothers and children, embedded within an overall strategy of universal access for the whole population. Providing universal access requires a viable and effective health workforce. Yet, as demand has increased and as more ways of delivering effective treatment and prevention have become available to respond to increasing needs and demand, the size, skills and infrastructure of the workforce have not kept pace. Indeed, in many countries economic and financial crises have destabilized and undermined the workforce during the past two decades.

The key to moving towards universal access and financial protection is the organization of financing. Current government expenditure and international flows cannot guarantee universal access and financial protection, because they are insufficient and because they are too unpredictable. At the same time, historical patterns of financial management -- incremental adjustments of the recurrent program budgets, supplemented by donor-funded projects -- have often been slow to adapt to initiatives aimed at scaling up universal access to healthcare. Funding flows have not only to increase, they have to be channeled in a different way. To frame maternal, newborn and child health services in terms of universal access and financial protection may command the wide constituency and promise the political visibility that mobilization of decision-makers requires. It is important that stakeholders from civil society are represented in steering financial protection mechanisms, and particularly in the priority-setting process.

Universal access for mothers and children requires health systems to be able to respond to the needs and demands of the population, and to offer protection against the financial hardship that results from ill-health. Women around the world face many inequalities during pregnancy. At this crucial time women rely on care and help from health services, as well as on support systems in the home and community. Exclusion, marginalization and discrimination can severely affect the health of mothers and that of their babies. Tackling the low status of women, violence against women and lack of employment rights for pregnant women is vital in helping to build societies that support pregnant women. In U. S. under the Pregnancy Discrimination Act, a patient might qualify for disability leave until delivery because of complications during pregnancy. Many employers in U. S. have a 4- to 6-week maximum for paid maternity leave. The Family and Medical Leave Act (FMLA) enacted in 1993 mandates that covered employers provide up to 12 weeks of unpaid, job-protected leave to "eligible" employees for certain family and medical reasons. Some states in the USA have expanded on the FMLA provisions to allow women additional, unpaid maternity leave.

Lessons from the field:

Over the years, the United Nations, governments, civil society and individuals have created countless worthy plans of actions and intended solutions to world issues, increasingly placing them within binding documents and quantifiable frameworks. However, experience shows that, no matter how well-intentioned, a technical or political approach to development cannot alone bring about the desired outcome. Development needs the power of individual commitment, collective or national political will, and most importantly political action. Care rendered to an individual patient does not take place in a vacuum but rather within a community. Decisions made in one sphere affect those in the other. A strong and vital health workforce is an investment in health for today and the future. The ultimate goal is a workforce that can guarantee universal access to healthcare to all citizens in every country. It has profound effect on all the Citizens of the World, and political, social, economic systems.

What does it take to encourage national leaders to act to ensure the health rights of mothers and children -- rights to which they are committed? There is extensive knowledge of the technical and contextual interventions required to improve maternal, newborn and child health. In contrast, little is known about what can be done to make national political leaders give it their sustained support. The international community knows how to put things on the global policy agenda -- the MDGs are proof of that -- but there is a lot more to learn about how to bridge the gap between global attention and national action, and on how to maintain attention spans long enough to make a difference.

Maternal deaths can be prevented through one of three mechanisms: prevention of pregnancy, prevention of complications during pregnancy, and appropriate management of any complications that do occur. Women's overall health influences their maternal health. A diet that has sufficient calories and micronutrients is essential for a pregnancy to be successfully carried to term. Various supplements can be given where there are micronutrients deficiencies but in the long term improvement in women's nutrition is essential. Women often eat less, less often, and less nutritiously than their children and other family members. Such a change can take place only at the community level and in the house-hold. The preconceptual and pregnancy periods offer opportunities to detect and manage nutritional deficiencies and to treat endemic diseases such as malaria, helminth infestations, and sexually transmitted diseases, as well as to offer prophylactic care such as tetanus toxoid immunization, iron / folate supplementation, and voluntary and confidential counseling for HIV. Every opportunity must be taken to educate women and their families about when and where to seek care.

Prevention of unwanted pregnancy and prevention and management of unsafe abortion are key interventions for safe motherhood. Whatever a country's legal position on abortion, all women suffering from abortion-related complications have a right to treatment and high quality post-abortion care, including family planning counseling and services, offered with compassion and full confidentiality.

Pregnancy & Nutrition

Editor's note:

This work is important and must continue. Framing discussions on maternal, newborn and child health in terms of a wide range of technical interventions, however, has given the impression of a complex and expensive undertaking. To attract the sustained attention of policy-makers, it needs to be articulated in a different language. The programs have to be perceived by national decision-makers as effective and affordable ways of tackling well-organized problems, but also as an agenda that commands a wide constituency and provides political mileage. Maternal, newborn and child health should constitute the core of the health entitlements protected and funded through universal coverage systems.

The Women's Health and Education Center's central objective for making pregnancy safer is to assist countries in strengthening their health systems, and in applying lessons learnt from the global action on Safe Motherhood according to their own country's needs and resources. To achieve this objective, Women's Health and Education Center (WHEC) is working with countries to develop partnerships within public sector and between the public sectors and non-governmental organizations. The work is focusing on partnerships for interventions and community-based actions. In this way, women and their newborns will have access to care they need, when they need it. The priority areas are: advocacy in support of activities and decision-making at all levels; partnerships to increase funding and coordination in order to make the provision of services more effective and efficient; monitoring and evaluating the implementation of interventions in order to measure changes in practice and impact in terms of health gains.

Many laws and regulations have a potential impact on people's health. For instance, laws on abortion, female genital mutilation, rape and domestic violence can directly affect a woman's health, while laws on education, employment and property -- which affect a woman's status in society -- can indirectly affect it. People want and societies need mothers and children to be healthy. That is why every mother and every child counts so much in our ambitions for a better tomorrow.