Friday, 28 October 2016

Quality, equity, and dignity for women and babies

This Lancet Series on maternal health1, 2, 3, 4, 5, 6 comes just 1 year after countries committed to the Sustainable Development Goals (SDGs). The SDGs call on all stakeholders to leave no one behind in addressing the unfinished agenda for maternal and child health. The Global Strategy for Women's, Children's and Adolescents' Health (Global Strategy)7 calls for integrated solutions to prevent maternal, newborn, and child deaths and stillbirths and to realise a world where women and children thrive and transform their communities and nations. To achieve this, we must address social determinants of maternal and newborn health, and improve access to respectful, high-quality, integrated care.
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GMB Akash/Panos
As representatives of civil society organisations working with women and children, we are deeply concerned about the divergence in the burden of poor maternal health “reflecting inequities in wealth, rights, and access to care”,1 and the concomitant effect on newborn and child health, and survival and adverse birth outcomes. The health and survival of women and their babies are inextricably linked; a coordinated, integrated “continuum of care” approach that optimises the health of the mother–baby dyad is required to fully maximise the potential benefits. Linking health care for a mother and her baby promotes greater efficiency, lower costs, reduces duplication of resources, and maximises the effect on their health and survival in the same way investments in family planning and reproductive health improve health and wellbeing of women and their children.8The investment case is strong, since the return on investment includes not only averted deaths (maternal, newborn, and stillbirth), but also improved child neurodevelopmental outcomes and reduced maternal morbidities.9
There have long been calls to integrate maternal and newborn baby health priorities. A comment by Ann Starrs in The Lancet Every Newborn Series10 challenged the maternal and newborn health communities “to pledge to each other that any policy, programme, or initiative focusing on either maternal or newborn health will incorporate the other as well”. 2 years later, the global health community seems to have heeded that call. The 2015 Global Maternal Newborn Health Conference gave voice to a shared vision of maternal and newborn health. Two strategies developed in the lead-up to the SDGs—the Every Newborn Action Plan and Strategies toward Ending Preventable Maternal Mortality—converged with common objectives,11 and were incorporated into the Global Strategy.7The Global Financing Facility supports countries in identifying national priorities across the spectrum of reproductive, maternal, newborn, child and adolescent health (RMNCAH) and was built upon a full potential investment case.12 The Lancet has also published multiple Series relating to maternal–newborn health in the past 2 years: Midwifery (2014),13 Every Newborn (2014),14 Ending preventable stillbirth (2016),9 and Maternal health (2016).1, 2, 3, 4, 5, 6 Even though these Series' titles appear siloed in approach, each Series calls for integration. Evidence also indicates that women are more satisfied with a more integrated approach.15
With the many global strategies in place and multiple Lancet Series published, one wonders whether countries are effectively supported to act upon these priorities as well as respond to what women want and deserve, in terms of quality, accessible, affordable, respectful maternal and newborn health care. How can governments, UN agencies, donors, private sector organisations, civil society, and other stakeholders work with women, communities, and countries to end preventable deaths in the face of the great divergence described in this Series?
One promising development is WHO's Quality of Care Framework for Maternal and Newborn Health16with accompanying technical standards and guidelines for quality of care.17 We are hopeful that the roll-out of the implementation framework—unlike the development of the framework itself—will provide opportunities to engage women and local stakeholders in the process of defining quality of care.
To this end, a new maternal–newborn health advocacy effort is underway to support implementation of the framework, influence supportive global and national policies and investments, and unify stakeholders in joint action with emphasis on the human rights-based goals of equity, universal coverage, access to quality care services, and dignity and respect for all women and babies. This effort takes up the call by Koblinsky and colleagues6 “to advocate for increased attention to maternal–perinatal health, and ensure women's rights and agency are acknowledged, which includes involving women in their own health care”. Defining of priorities at national and local levels will require the voices of women, families, and broader civil society to be a starting point and not an afterthought. Efforts to mobilise citizens' voices, such as the Citizen Hearings, will be fundamental to successful implementation.
This Series highlights two fundamental issues that need to be addressed to improve maternal health: quality of maternal health care for all women and access to care for those left behind. It is a call for quality, equity, and dignity. Although similar, the new WHO initiative and accompanying advocacy movement call for a unified approach—one where maternal and newborn health communities are no longer in siloes or perceived competition but rather working together on an integrated effort to improve quality, equity, and dignity for all women and babies.
MVK is a Senior Specialist, Global Evidence and Advocacy, Saving Newborn Lives project, Save the Children; AB-B is Senior Director, FCI Program of Management Sciences for Health; and BM is Chief Executive Officer, White Ribbon Alliance. We declare no competing interests.


  1. Graham, W, Woodd, S, Byass, P et al. Diversity and divergence: the dynamic burden of poor maternal health. Lancet2016(published online Sept 15.)
  2. Miller, S, Abalos, E, Chamillard, M et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet2016(published online Sept 15.)
  3. Campbell, OMR, Calvert, C, Testa, A et al. The scale, scope, coverage, and capability of childbirth care. Lancet2016(published online Sept 15.)
  4. Shaw, D, Guise, J-M, Shah, N et al. Drivers of maternity care in high-income countries: can health systems support woman-centred care?. Lancet2016(published online Sept 15.)
  5. Kruk, ME, Kujawski, S, Moyer, CA et al. Next generation maternal health: external shocks and health-system innovations. Lancet2016(published online Sept 15.)
  6. Koblinsky, M, Moyer, CA, Calvert, C et al. Quality maternity care for every woman, everywhere: a call to action. Lancet2016(published online Sept 15.)
  7. Every Woman Every Child. The global strategy for women's, children's and adolescents' healthEvery Woman Every ChildNew York, NY2015
  8. Lassi, ZS, Majeed, A, Rashid, S, Yakoob, MY, and Bhutta, ZA. The interconnections between maternal and newborn health–evidence and implications for policy. J Matern Fetal Neonatal Med2013263–53
  9. de Bernis, L, Kinney, MV, Stones, W et al. Stillbirths: ending preventable deaths by 2030. Lancet2016387703–716
  10. Starrs, AM. Survival convergence: bringing maternal and newborn health together for 2015 and beyond. Lancet2014384211–213
  11. Chou, D, Daelmans, B, Jolivet, RR et al. Ending preventable maternal and newborn mortality and stillbirths. BMJ2015351h4255
  12. Stenberg, K, Axelson, H, Sheehan, P..., and on behalf of the Study Group for the Global Investment Framework for Women's Children's Health. Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.Lancet20143831333–1354
  13. ten Hoope-Bender, P, de Bernis, L, Campbell, J et al. Improvement of maternal and newborn health through midwifery. Lancet20143841226–1235
  14. Mason, E, McDougall, L, Lawn, JE et al. From evidence to action to deliver a healthy start for the next generation. Lancet2014384455–467
  15. Sandall, J, Soltani, H, Gates, S, Shennan, A, and Devane, D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev20164 (CD004667)
  16. Tuncalp, Ö, Were, WM, MacLennan, C et al. Quality of care for pregnant women and newborns—the WHO vision. BJOG20151221045–1049
  17. WHO. Standards for improving quality of maternal and newborn care in health facilitiesWorld Health OrganizationGeneva2016