WHAT CAN BE DONE: A CONTINUUM OF MATERNAL, NEWBORN AND CHILD HEALTH CARE
More than half of all maternal and newborn deaths occur during childbirth and the first few days of a baby’s life; this is also the period when health coverage is lowest. An effective continuum of care connects essential maternal, newborn and child health packages through pregnancy, childbirth, postnatal and newborn periods, and into childhood and adolescence. The advantage of such a continuum is that each stage builds on the success of the previous stage. For example, providing integrated services to adolescent girls means fewer unintended or poorly timed pregnancies. Visits to a health-care practitioner can prevent problems during pregnancy and make it more likely that mothers will get the appropriate care at birth. Skilled care before, during and immediately after birth reduces the risk of death or disability for both the mother and the baby. Continued care for children supports their right to health.
The continuum of maternal, newborn and child health care focuses on two dimensions in its provision:
- Time, or recognizing the need to ensure essential services for mothers and children during pregnancy, childbirth, the postpartum period, infancy and early childhood. The focus on this element derives from the fact that the birth period – before, during and after – is the time when mortality and morbidity risks are highest for both mother and child. For instance, babies with birth asphyxia, sepsis or complications from a preterm birth can die within hours or even minutes if appropriate care is not provided.
- Place, or linking the delivery of essential services in a primary-health-care system that integrates home, community, outreach and facility-based care. The impetus for this focus is the recognition that gaps in care are often most prevalent at the locations – the household and community – where care is most required. More than 60 million women in the developing world deliver at home. It is, therefore, critical that a skilled attendant be present at birth and have the backup of a local health clinic or another first-level facility and the hospital, should complications arise. Quality of care at all of these levels is crucial.
Interlinkages between causes of maternal and child deaths
The continuum of care also addresses the fact that maternal, newborn and child deaths and ill health share a number of similar and interrelated structural causes. These causes include such factors as undernutrition and food insecurity, female illiteracy, early pregnancy and poor birth outcomes, including low birthweights; inadequate feeding practices, lack of hygiene and access to safe water or adequate sanitation; exclusion from access to health and nutrition services as a result of poverty or geographic or political marginalization; and poorly resourced, unresponsive and culturally inappropriate health and nutrition services.
Packaging interventions helps strengthen the continuum of care
In the past, safe motherhood and child survival programmes often operated separately, leaving disconnections in care that affected both mothers and newborns. Now it is being recognized that delivering specific interventions at pivotal points in the continuum has multiple benefits. If, for instance, insecticide-treated mosquito nets are distributed in a community on one day, folic acid supplementation for pregnant women is provided on another day and immunizations take place on yet a different day, children and mothers are less likely to benefit from all three interventions than they would if these were made available on a single day. The packaged approach, by combining low-cost interventions such as vaccines, antibiotics, insecticide-treated mosquito nets and micronutrient supplementation for mothers and children, and adding the promotion of improved feeding and hygiene practices, can markedly increase their efficiency and cost-effectiveness. Similarly, integrating services can encourage their uptake and provide opportunities to enhance coverage.
Scaling up the continuum of care
Scaling up the continuum of care with packaged interventions could markedly expand universal coverage of essential care for mothers and children across their life cycles in an integrated primary-health-care system. The impact of achieving high rates of coverage could be profound. In sub-Saharan Africa, achieving a continuum of care that covered 90 per cent of mothers and newborns could avert two thirds of newborn deaths, saving 800,000 lives each year. The paradigm is increasingly being adopted in international public health policies and programmes and forms the foundation of the work of the Partnership for Maternal, Newborn & Child Health (PMNCH). The PMNCH was launched in September 2005 and brings together 180 member maternal, newborn and child communities in an alliance to reduce mortality and morbidity. The PMNCH is the product of an alliance between the three leading partnerships on maternal, newborn and child health: the Partnership for Safe Motherhood and Newborn Health, hosted by WHO in Geneva; the Healthy Newborn Partnership, based at Save the Children USA and the Child Survival Partnership, hosted by UNICEF in New York.