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The importance of advocating for the development of a national network of referral maternity facilities

Advocate for the development of a national network of referral maternity facilities

1. The importance of advocating for the development of a national network of referral maternity facilities

1.1. The political dimension of maternal and newborn mortality

During the last three decades, advocacy for MNH within civil society and the international community has gradually succeeded in making maternal and newborn mortality an increasingly important political matter. The mobilization prompted by MDG5 on improving maternal health and its target 5.A to reduce the MMR has helped encourage countries to define and implement strategies for achieving the ambitious goal of reducing the global MMR by three quarters between 1990 and 2015.

The SDGs do not have a specific goal on maternal health, but have an ambitious target of reducing the MMR (target 3.1 in SDG 3). On the upside, this target on maternal health is part of a wider group of health targets. However, the downside is that it has been diluted within a broader health goal, risking a possible decrease in political attention and financing for maternal health.

1.2. The difficult journey from policy to implementation of the maternal and newborn health programme

While most countries with the highest MMR defined strategies for reducing the number of deaths by 75 per cent between 1990 and 2015 (MDG target 5.a), unfortunately a majority have not managed to meet this target. The reasons for this relative failure vary but also reflect the difficulties in translating a policy into effective implementation.

Within the parameters of the maternal health programme, we note that the countries not achieving MDG target 5.a were lacking sufficient funding6 and an effective development of EmONC facilities. They also lacked the ambition to confer a professional status to midwives in recognition of their ability to manage 87 per cent of the requirements in essential services for sexual, reproductive, maternal and newborn health, once they are trained and their profession regulated according to international standards.7

Beyond the aforementioned shortcomings, the implementation of the ‘programmatic cycle’ (Figure 4) in maternal health also posed problems in a number of countries, particularly in regard to the following:

Addressing the ‘implementation issue’

MONITORING and QUALITY IMPROVEMENT PLANNING of the national

network of EmONC facilities Addressing the ‘planning issues’

Situation Analysis (Baseline)

Development and Implementation of the National EmONC Plan (as part of the National MNH Plan)

• National Health

(SPA), etc Regular review of the performance of the monitoring and quality improvement (CH 7) PHASE 2

FIGURE 3: PHASE 1 - POLICY DIALOGUE

FIGURE 4: THE PROGRAMMATIC CYCLE

EVALUATION

IMPLEMENTATION AND MONITORING

SITUATION ANALYSIS

PLANNING

a) Situation Analysis

Solely focusing on EmONC facilities, there have been gaps noted in many countries in the analysis of their strengths and weaknesses and the way in which a national network of referral facilities should be organized. Similarly, it was only late on in the MDG era that countries took into consideration the importance of the link between quality of care and pre-service education curricula meeting the competency-based standards recommended by the International Confederation of Midwives (ICM), the International Federation of Gynaecology and Obstetrics (FIGO) and WHO. Furthermore, robust and detailed maternal health situation analyses were often lacking. Since 2009, only 35 countries have carried out an EmONC Needs Assessment developed by AMDDv that enables countries to conduct a proper analysis of the situation, to establish a database on the activities of maternity facilities as a whole and to produce the process indicators detailed in the Monitoring emergency obstetric care handbook (2009). It is essential to note that SARA and SPA surveys only provide data on the availability of health services and not on their utilization.

Only (rapid) EmONC Needs Assessments can be used to prepare the phase 3 of the identification of the national EmONC network.

v  Available  on:  https://www.mailman.columbia.edu/research/averting-maternal-death-and  disability-amdd/

toolkit 

b) Planning

There has often been a disparity between the aims of the national MNH programme and the human and financial resources actually allocated to it. This is explored in more detail in Chapters 2 and 3, with the example of the planning issue encountered in many countries for identifying the required number of EmONC health facilities.

c) Implementation and monitoring

Due to a cumbersome, slow and unreliable Health Management Information System (HMIS) in most of the countries with a high burden of maternal mortality, the implementation of the maternal health programme in these countries has generally not been supported by regular monitoring of the maternal health indicators.

As an example, the Countdown to 2015-Maternal, Newborn & Child Survival responsible for the global monitoring of MDGs 4 and 5 has not been able to monitor the progress of EmONC indicators in the 75 countries with a high burden of maternal mortality, particularly in relation to availability of EmONC services. Furthermore, in its 2013 annual report on MNH services, UNFPA’s MHTF noted that most of the countries with the highest MMR are not able to annually document the number of maternity facilities offering EmONC services, nor what proportion of the staff working in these facilities are qualified in obstetric care.vi This inability to regularly measure key indicators on EmONC is still an issue in many countries with a high burden of maternal and newborn mortality and morbidity and has hampered the efficient and reactive implementation of the MNH programmes.

d) Evaluation

AMDD recommends carrying out an EmONC Needs Assessment at the end of each programmatic cycle (every three to five years, depending on the country). However, since these assessments were introduced in the early 2000s, only two countries have managed to carry out these assessments at five and 10 year intervals respectively. A few others have collected information with another type of assessment – generally the Service Availability and Readiness Assessment (SARA)vi. However, unlike the EmONC Needs Assessment, SARA is usually based on a sample of health facilities. The absence of regular EmONC Needs Assessments has made evidence-based evaluations of the MNH programme difficult at the end of each programmatic cycle.

vi  Available on: https://www.who.int/healthinfo/systems/sara_introduction/en/ 

In summary, despite its importance in reducing maternal and newborn mortality, the process of setting up a national network of referral maternity facilities that can offer quality obstetric and newborn care, as well as manage emergency situations, has not been given due attention over the last decade.

2. Advocacy principles for developing a national network of referral