Comment
Survival convergence: bringing maternal and newborn health together for 2015 and beyond the Every Newborn Action Plan7,9 calls for including or strengthening a specific newborn focus within maternal, child, and reproductive health plans. The third opportunity is increased clarity on the most effective technical interventions for saving the lives of newborn babies,5 and what is needed to deliver those interventions.6 Maternal and newborn health need strong, functional health systems with an educated, enabled workforce in sufficient numbers; functioning commodity systems; attention to quality of care; and effective mechanisms for recording, analysing, and using data. However, interventions and technologies specific to newborn babies must also be available to improve newborn health and survival. Experience shows that health-worker training programmes or commodity systems for maternal or child health will not automatically include those interventions and technologies—they must be explicitly and consciously included in planning and budgeting. To achieve optimum integration of maternal and newborn health requires that we must recognise and respond to the remaining challenges, especially in the political realm. The first is the centrality of reproductive health to maternal and newborn health and wellbeing. The newborn and child health communities have recently begun to acknowledge that access to quality, comprehensive contraceptive services is important for
www.thelancet.com Published online May 20, 2014 http://dx.doi.org/10.1016/S0140-6736(14)60838-2
Published Online May 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60838-2 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(14)60458-X, http://dx.doi.org/10.1016/ S0140-6736(14)60496-7, http://dx.doi.org/10.1016/ S0140-6736(14)60792-3, http://dx.doi.org/10.1016/ S0140-6736(14)60582-1, and http://dx.doi.org/10.1016/ S0140-6736(14)60750-9 For the Lancet 2005 Series on neonatal survival see http://www.thelancet.com/ series/neonatal-survival
Corbis
When WHO published the Mother-Baby Package in 1996,1 mothers and newborn babies were viewed as a dyad, and it was assumed that what was good for the mother was good for the baby. Basic interventions to deal with newborn complications were included, but neonatal mortality received little attention from the broader public health community, or even from the maternal health and child health communities. Although global attention to newborn health began in 2000 with the launch of the Saving Newborn Lives initiative,2 and accelerated with the publication of the Lancet Series on Neonatal Survival in 2005, reductions in neonatal mortality lagged behind maternal and under-5 mortality. Worldwide, 44% of deaths in children younger than 5 years now occur in the first month of life, a huge and highly inequitable burden.3,4 The Every Newborn Series3–7 in The Lancet highlights many of the future opportunities and challenges in forging true integration between the maternal and newborn health communities. The first opportunity is in defining new goals and targets. As we shift from the Millennium Development Goals (MDGs) to the post-2015 era, there will probably be a single overarching health goal, with measurable targets relating both to the unfinished agenda of the health MDGs and to major new challenges in responding to the burden of non-communicable diseases.8 As noted by Elizabeth Mason and colleagues7 in this Series, targets for ending preventable newborn deaths and stillbirths must be included in the post-2015 agenda, along with targets for ending preventable maternal and child deaths, as well as for sexual and reproductive health. Ideally a cohesive set of targets on reproductive, maternal, newborn, and child health will be clustered in the agenda so that their linkages across the continuum of care are clear. The second opportunity is the emerging expansion of country ownership in setting priorities, designing programmes, and defining goals. As countries adopt more integrated approaches to designing, implementing, and funding health services and health systems, there is less appetite for externally driven initiatives that promote dealing with health challenges in vertical silos. In keeping with country preferences,
1
Comment
the health and survival of infants and children. Such services allow women to avoid unintended pregnancy, space births, and achieve their desired family size, thereby reducing the risk of prematurity and low birthweight and improving the health of mothers and the economic wellbeing of families.10 Abortion, however, remains a sensitive issue. The inclusion of “every pregnancy wanted” in the Every Newborn Action Plan vision statement has generated concern in some countries that this is code for abortion; in fact, the Every Newborn Action Plan includes no references to this element of reproductive health.9 Both the newborn and maternal health communities need to acknowledge that access to safe abortion is an essential intervention, as defined by WHO, the Partnership for Maternal, Newborn and Child Health, and a range of partners.11 The technical evidence is clear, and provides the basis for addressing this critical element of the continuum of care. Finally, the maternal and newborn health communities must move beyond the lingering tensions that limit full cooperation and acceptance of each other’s priorities. On the maternal health side, this wariness reflects a concern that embracing the newborn baby would inhibit efforts to address reproductive health and to anchor programmes and policies in a rights framework. On the newborn health side, there are concerns that embracing the full maternal health agenda might slow the momentum of the Every Newborn Action Plan9 and compromise its achievements (such as inclusion on the agenda of the 2014 World Health Assembly12), concerns that were reflected in an initial reluctance to include the proposed global target for ending preventable maternal deaths in the Every Newborn Action Plan. The maternal and newborn health communities need to pledge to each other that any policy, programme, or initiative focusing on either maternal or newborn health will incorporate the other as well: for example, any effort to train midwives in care during childbirth must include essential interventions for the newborn baby; maternal
2
death audits must also investigate newborn deaths; and postnatal home visits by community health workers must assess the mother’s as well as the newborn baby’s health and needs. Following this principle of survival convergence will ensure that the mother–baby dyad will not be broken, and will maximise our opportunity to end preventable maternal and newborn deaths in the next generation. Ann M Starrs Family Care International, New York, NY 10006, USA [email protected] I am President of Family Care International and declare no competing interests. 1 2
3
4
5
6
7
8
9
10 11
12
WHO. Mother-baby package: implementing safe motherhood in countries. Geneva: World Health Organization, 1996. The Bill & Melinda Gates Foundation. Major funding announced to save newborn lives. 2005. http://www.gatesfoundation.org/Media-Center/ Press-Releases/2005/12/Major-Funding-Announced-to-Save-NewbornLives (accessed May 12, 2014). Darmstadt GL, Kinney MV, Chopra M, et al, for The Lancet Every Newborn Study Group. Who has been caring for the baby? Lancet 2014; published online May 20. http://dx.doi.org/10.1016/S0140-6736(14)60458-X. Lawn JE, Blencowe H, Oza S, et al, for The Lancet Every Newborn Study Group. Progress, priorities, and potential beyond survival. Lancet 2014; published online May 20. http://dx.doi.org/10.1016/S01406736(14)60496-7. Bhutta ZA, Das JK, Bahl R, et al, for The Lancet Newborn Interventions Review Group and The Lancet Every Newborn Study Group. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; published online May 20. http:// dx.doi.org/10.1016/S0140-6736(14)60792-3. Dickson KE, Simen-Kapeu A, Kinney MV, et al, for The Lancet Every Newborn Study Group. Health-systems bottlenecks and strategies to accelerate scale-up in countries. Lancet 2014; published online May 20. http://dx.doi. org/10.1016/S0140-6736(14)60582-1. Mason E, McDougall L, Lawn JE, et al, for The Lancet Every Newborn Study Group, on behalf of the Every Newborn Steering Committee. From evidence to action to deliver a healthy start for the next generation. Lancet 2014; published online May 20. http://dx.doi.org/10.1016/S01406736(14)60750-9. Secretary-General’s High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. A new global partnership: eradicate poverty and transform societies through sustainable development, annex I. New York: United Nations, 2013. WHO. Every newborn: an action plan to end preventable deaths. May 2, 2014. http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_21-en. pdf?ua=1 (accessed May 11, 2014). UNICEF. Committing to child survival: a promise renewed, progress report 2013. New York: UNICEF, 2013. PMNCH. A global review of the key interventions related to reproductive, maternal, newborn and child health. Geneva: Partnership for Maternal, Newborn and Child Health, 2011. WHO. Provisional agenda, Sixty-Seventh World Health Assembly. Geneva: World Health Organization, 2014.
www.thelancet.com Published online May 20, 2014 http://dx.doi.org/10.1016/S0140-6736(14)60838-2
Survival convergence: bringing maternal and newborn health together for 2015 and beyond the Every Newborn Action Plan7,9 calls for including or strengthening a specific newborn focus within maternal, child, and reproductive health plans. The third opportunity is increased clarity on the most effective technical interventions for saving the lives of newborn babies,5 and what is needed to deliver those interventions.6 Maternal and newborn health need strong, functional health systems with an educated, enabled workforce in sufficient numbers; functioning commodity systems; attention to quality of care; and effective mechanisms for recording, analysing, and using data. However, interventions and technologies specific to newborn babies must also be available to improve newborn health and survival. Experience shows that health-worker training programmes or commodity systems for maternal or child health will not automatically include those interventions and technologies—they must be explicitly and consciously included in planning and budgeting. To achieve optimum integration of maternal and newborn health requires that we must recognise and respond to the remaining challenges, especially in the political realm. The first is the centrality of reproductive health to maternal and newborn health and wellbeing. The newborn and child health communities have recently begun to acknowledge that access to quality, comprehensive contraceptive services is important for
www.thelancet.com Published online May 20, 2014 http://dx.doi.org/10.1016/S0140-6736(14)60838-2
Published Online May 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60838-2 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(14)60458-X, http://dx.doi.org/10.1016/ S0140-6736(14)60496-7, http://dx.doi.org/10.1016/ S0140-6736(14)60792-3, http://dx.doi.org/10.1016/ S0140-6736(14)60582-1, and http://dx.doi.org/10.1016/ S0140-6736(14)60750-9 For the Lancet 2005 Series on neonatal survival see http://www.thelancet.com/ series/neonatal-survival
Corbis
When WHO published the Mother-Baby Package in 1996,1 mothers and newborn babies were viewed as a dyad, and it was assumed that what was good for the mother was good for the baby. Basic interventions to deal with newborn complications were included, but neonatal mortality received little attention from the broader public health community, or even from the maternal health and child health communities. Although global attention to newborn health began in 2000 with the launch of the Saving Newborn Lives initiative,2 and accelerated with the publication of the Lancet Series on Neonatal Survival in 2005, reductions in neonatal mortality lagged behind maternal and under-5 mortality. Worldwide, 44% of deaths in children younger than 5 years now occur in the first month of life, a huge and highly inequitable burden.3,4 The Every Newborn Series3–7 in The Lancet highlights many of the future opportunities and challenges in forging true integration between the maternal and newborn health communities. The first opportunity is in defining new goals and targets. As we shift from the Millennium Development Goals (MDGs) to the post-2015 era, there will probably be a single overarching health goal, with measurable targets relating both to the unfinished agenda of the health MDGs and to major new challenges in responding to the burden of non-communicable diseases.8 As noted by Elizabeth Mason and colleagues7 in this Series, targets for ending preventable newborn deaths and stillbirths must be included in the post-2015 agenda, along with targets for ending preventable maternal and child deaths, as well as for sexual and reproductive health. Ideally a cohesive set of targets on reproductive, maternal, newborn, and child health will be clustered in the agenda so that their linkages across the continuum of care are clear. The second opportunity is the emerging expansion of country ownership in setting priorities, designing programmes, and defining goals. As countries adopt more integrated approaches to designing, implementing, and funding health services and health systems, there is less appetite for externally driven initiatives that promote dealing with health challenges in vertical silos. In keeping with country preferences,
1
Comment
the health and survival of infants and children. Such services allow women to avoid unintended pregnancy, space births, and achieve their desired family size, thereby reducing the risk of prematurity and low birthweight and improving the health of mothers and the economic wellbeing of families.10 Abortion, however, remains a sensitive issue. The inclusion of “every pregnancy wanted” in the Every Newborn Action Plan vision statement has generated concern in some countries that this is code for abortion; in fact, the Every Newborn Action Plan includes no references to this element of reproductive health.9 Both the newborn and maternal health communities need to acknowledge that access to safe abortion is an essential intervention, as defined by WHO, the Partnership for Maternal, Newborn and Child Health, and a range of partners.11 The technical evidence is clear, and provides the basis for addressing this critical element of the continuum of care. Finally, the maternal and newborn health communities must move beyond the lingering tensions that limit full cooperation and acceptance of each other’s priorities. On the maternal health side, this wariness reflects a concern that embracing the newborn baby would inhibit efforts to address reproductive health and to anchor programmes and policies in a rights framework. On the newborn health side, there are concerns that embracing the full maternal health agenda might slow the momentum of the Every Newborn Action Plan9 and compromise its achievements (such as inclusion on the agenda of the 2014 World Health Assembly12), concerns that were reflected in an initial reluctance to include the proposed global target for ending preventable maternal deaths in the Every Newborn Action Plan. The maternal and newborn health communities need to pledge to each other that any policy, programme, or initiative focusing on either maternal or newborn health will incorporate the other as well: for example, any effort to train midwives in care during childbirth must include essential interventions for the newborn baby; maternal
2
death audits must also investigate newborn deaths; and postnatal home visits by community health workers must assess the mother’s as well as the newborn baby’s health and needs. Following this principle of survival convergence will ensure that the mother–baby dyad will not be broken, and will maximise our opportunity to end preventable maternal and newborn deaths in the next generation. Ann M Starrs Family Care International, New York, NY 10006, USA [email protected] I am President of Family Care International and declare no competing interests. 1 2
3
4
5
6
7
8
9
10 11
12
WHO. Mother-baby package: implementing safe motherhood in countries. Geneva: World Health Organization, 1996. The Bill & Melinda Gates Foundation. Major funding announced to save newborn lives. 2005. http://www.gatesfoundation.org/Media-Center/ Press-Releases/2005/12/Major-Funding-Announced-to-Save-NewbornLives (accessed May 12, 2014). Darmstadt GL, Kinney MV, Chopra M, et al, for The Lancet Every Newborn Study Group. Who has been caring for the baby? Lancet 2014; published online May 20. http://dx.doi.org/10.1016/S0140-6736(14)60458-X. Lawn JE, Blencowe H, Oza S, et al, for The Lancet Every Newborn Study Group. Progress, priorities, and potential beyond survival. Lancet 2014; published online May 20. http://dx.doi.org/10.1016/S01406736(14)60496-7. Bhutta ZA, Das JK, Bahl R, et al, for The Lancet Newborn Interventions Review Group and The Lancet Every Newborn Study Group. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; published online May 20. http:// dx.doi.org/10.1016/S0140-6736(14)60792-3. Dickson KE, Simen-Kapeu A, Kinney MV, et al, for The Lancet Every Newborn Study Group. Health-systems bottlenecks and strategies to accelerate scale-up in countries. Lancet 2014; published online May 20. http://dx.doi. org/10.1016/S0140-6736(14)60582-1. Mason E, McDougall L, Lawn JE, et al, for The Lancet Every Newborn Study Group, on behalf of the Every Newborn Steering Committee. From evidence to action to deliver a healthy start for the next generation. Lancet 2014; published online May 20. http://dx.doi.org/10.1016/S01406736(14)60750-9. Secretary-General’s High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. A new global partnership: eradicate poverty and transform societies through sustainable development, annex I. New York: United Nations, 2013. WHO. Every newborn: an action plan to end preventable deaths. May 2, 2014. http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_21-en. pdf?ua=1 (accessed May 11, 2014). UNICEF. Committing to child survival: a promise renewed, progress report 2013. New York: UNICEF, 2013. PMNCH. A global review of the key interventions related to reproductive, maternal, newborn and child health. Geneva: Partnership for Maternal, Newborn and Child Health, 2011. WHO. Provisional agenda, Sixty-Seventh World Health Assembly. Geneva: World Health Organization, 2014.
www.thelancet.com Published online May 20, 2014 http://dx.doi.org/10.1016/S0140-6736(14)60838-2
