Enhancing, and protecting, maternal and neonatal health care
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2020)

Nearly 10 years ago, The Lancet published a landmark Series of papers on a widespread mortality burden that had, until then, received virtually no recognition on the global health agenda. The six-part collection drew attention to the 2 million fetal deaths after 28 weeks’ gestation—stillbirths—that take place globally every year, and to the fact that a third of them occur in healthy pregnancies during labour, meaning that they are almost certainly avoidable with skilled delivery care. Stillbirths were not included in the global monitoring processes of the time—the Millennium Development Goals, the Countdown to 2015 initiative, or the Global Burden of Disease project—and country-level surveillance exercises for stillbirths were variable or non-existent. The final paper in the Series set out a “Vision for 2020”. At the end of this strangest of years, how is that vision looking? The Series in fact had a marked influence at the international policy level. Intrapartum stillbirth prevention was integrated into WHO and UNICEF's 2014 Every Newborn Action Plan and the UN's 2015 Global Strategy for Women's, Children's and Adolescents’ Health. Routine data collection at national level improved, and several countries—notably India—launched action plans of their own. Yet the latest stillbirth data, released in October 2020 in a first-of-its-kind report from the UN Inter-Agency Group for Child Mortality, showed that the annual rate of reduction in stillbirths since 2000 was almost half the reduction in under-5 mortality (to 2·3% vs 4·3%, respectively). A possible mechanism by which to accelerate progress is explored in an Article in this month's issue. Andrea Nove and colleagues modelled a resource with tremendous potential to reduce some of the main causes and risk factors for stillbirth (childbirth complications, antepartum haemorrhage, and maternal infections and disorders such as hypertension) as well as related causes of maternal and neonatal mortality. Nove and colleagues used the Lives Saved Tool to model by how much different levels of scale-up of a suite of midwife-delivered interventions (eg, intermittent preventive treatment for malaria; screening and management of diabetes, hypertension, and pre-eclampsia) could prevent all three tragedies. The authors estimate that a 25% increase in coverage of these interventions every 5 years from 2020 to 2035 in 88 high-burden countries would result in 41% fewer maternal deaths, 26% fewer stillbirths, and 39% fewer neonatal deaths. After another of The Lancet's landmark Series, on Midwifery, was published in 2014, the impact that a midwife trained to international standards can have on maternal, neonatal, and child health has been increasingly apparent. Yet, as Mary Renfrew notes in her linked Comment, “Research funding preferentially supports either technological solutions to obstetric emergencies or the implementation of less skilled workers to care for mothers and their infants”. The need for high-quality education of whomever attends women and their newborn babies at often the most dangerous moments of their lives is without question. Another Article in this month's issue explores the quality of the care neonates received in the first 2 hours after birth in nine hospitals in Ghana, Guinea, and Nigeria. Women and their health-care workers were observed throughout labour, childbirth, and the immediate postpartum period, and recommended practices such as immediate skin-to-skin contact between baby and mother, non-separation of the neonate from the mother, and breastfeeding within 30 min after birth were recorded. Alarmingly, more than half of babies were separated from their mothers after birth, recommended breasfeeding practices were encouraged in less than a third of cases, and several instances of mistreatment of the neonate were noted. Poor-quality and disrespectful or abusive care discourages women and their families from attending health-care facilities. Unfortunately, as we have found this year, so does a global pandemic. Empirical data from India and Nepal show the devastating impact of travel restrictions, health-worker displacement, and fear of contagion on facility birth rates and the numbers of stillbirths and neonatal deaths. Yet perhaps the very fact that these studies reported on the numbers of stillbirths points to a shift in mindset that might not have been apparent 10 years ago. So that these numbers do not continue to rise, now is the time to ensure that COVID-19 response measures are integrated into health-care systems for maternal, neonatal, and child health, and do not hinder safe, effective, and respectful care. The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational studyA high proportion of neonates did not receive recommended care practices, and some received practices that might constitute mistreatment. Further research is needed on understanding and measuring mistreatment to improve care, including respectful care, for mothers and neonates. Full-Text PDF Open AccessEffect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational studyInstitutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care. Some behaviours improved, notably hand hygiene and keeping the baby skin-to-skin with their mother. An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period. Full-Text PDF Open AccessCOVID-19 outbreak and decreased hospitalisation of pregnant women in labourAt a tertiary health-care level in India, which is mainly provided by medical colleges and advanced medical research institutes, specialised consultative care is given to patients who are referred from primary and secondary medical care, along with general care for the local community.1 The maternal mortality ratio in India has reduced by 78%, from 556 per 100 000 livebirths in 1990 to 122 per 100 000 livebirths in 2015–17, mainly because of an increase in institutional deliveries (from 18% in 2005 to 79% in 2016) and an effective referral system for emergency obstetric care. Full-Text PDF Open AccessPotential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling studyMidwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions. Full-Text PDF Open AccessScaling up care by midwives must now be a global priorityMidwives have the potential to save lives of women and children at a scale unmatched by other health interventions. In The Lancet Global Health, Andrea Nove and colleagues1 estimated that 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths in the 88 low-income and middle-income countries accounting for the vast majority of these deaths could be averted. The solution? Universal provision of care by midwives who meet international standards and are integrated into health systems in the context of multidisciplinary teams. Full-Text PDF Open Access