Making the right technical and strategic choices
There is no doubt that the technical knowledge exists to respond to many, if not most, of the critical health problems and hazards that affect the health and survival of mothers, newborns and children. The strategies through which households and health systems together can make sure these technical solutions are put into action for all, in the right place and at the right time, are also becoming increasingly clear.
Antenatal care is a major success story: demand has increased and continues to increase in most parts of the world. However, more can be made of the considerable potential of antenatal care by emphasizing effective interventions and by using it as a platform for other health programmes such as HIV/AIDS and the prevention and treatment of sexually transmitted infections, tuberculosis and malaria initiatives, and family planning. Health workers, too, can make more use of antenatal care to help mothers prepare for birthing and parenting, or to assist them in dealing with an environment that does not always favour a healthy and happy pregnancy. Pregnant women, adolescents in particular, may be exposed to violence, discrimination in the workplace or at school, or marginalization. Such problems need to be dealt with also, but not only, by improving the social, political and legal environments. A case in point is how societies face up to the problem of the many millions of unintended, mistimed and unwanted pregnancies. There remains a large unmet need for contraception, as well as for more and better information and education. There is also a real need to facilitate access to responsive post-abortion care of high quality and to safe abortion services to the fullest extent allowed by law.
Attending to all of the 136 million births every year is one of the major challenges that now faces the world’s health systems. This challenge will increase in the near future as large cohorts of young people move into their reproductive years, mainly in those parts of the world where giving birth is most dangerous. Women risk death to give life, but with skilled and responsive care, at and after birth, nearly all fatal outcomes and disabling sequelae can be averted – the tragedy of obstetric fistulas, for example – and much of the suffering can be eased. Childbirth is a central event in the lives of families and in the construction of communities; it should remain so, but it must be made safe as well. For optimum safety, every woman, without exception, needs professional skilled care when giving birth, in an appropriate environment that is close to where she lives and respects her birthing culture. Such care can best be provided by a registered midwife or a health worker with midwifery skills, in decentralized, first-level facilities. This can avert, contain or solve many of the life-threatening problems that may arise during childbirth, and reduce maternal mortality to surprisingly low levels. Skilled midwifery professionals do need the back-up only a hospital can provide, however, for women with problems that go beyond the competency or equipment available at the first level of care. All women need first-level maternal care and back-up care is only necessary for a minority, but to be effective both levels need to work in tandem and both must be put in place simultaneously.
The need for care does not stop as soon as the birth is over. The hours, days and weeks that follow birth can be dangerous for women as well as for their babies. The welcome emphasis, in recent years, on improving skilled attendance at birth should not divert attention from this critical period, during which half of maternal deaths occur as well as a considerable amount of illness. There is an urgent need to develop effective ways of organizing continuity of care during the first weeks after birth, when health service responsibilities are often ill-defined or ambiguous.
The postpartum gap in providing care for women is also a postnatal gap. Although the picture of the unmet need in caring for newborns is still very incomplete, it shows that the health problems of newborns have been unduly neglected and underestimated. Newborn babies seem to have fallen between the cracks of safe motherhood programmes on one side and child survival initiatives on the other. Newborn mortality is a sizeable proportion of the mortality of children under five years of age. It has become clear that the MDG for child mortality will not be reached without substantial advances for the newborn. Although modest declines in neonatal mortality have occurred worldwide (for example, vaccination is well on the way to eliminating tetanus as a cause of neonatal death), in sub-Saharan Africa some countries have seen reversals that are both unusual and disturbing.
Progress in newborn health does not require expensive technology. It does however require health systems that provide continuity of care starting from the beginning of pregnancy (and even before) and continuing through professional skilled care at birth into the postnatal period. Most crucially, there is a need to ensure that the delicate and often overlooked handover between maternal and child services actually takes place. Newborns who are breastfed, loved and kept warm will mostly be fine, but problems can and do occur. It is essential to empower households – mothers and fathers in particular – so that they can take good care of their babies, recognize dangers early, and get professional help immediately when difficulties arise.
The greatest risks to life are in its beginning, but they do not disappear as the newborn grows into an infant and a young child. Programmes to tackle vaccinepreventable diseases, malnutrition, diarrhoea, or respiratory infections still have a large unfinished agenda. Immunization, for example, has made satisfactory progress in some regions, but in others coverage is stagnating at levels between 50% and 70% and has to find a new momentum. These programmes have, however, made such inroads on the burden of ill-health that in many countries its profile has changed. There is now a need for more integrated approaches: first, to deal efficiently with the changing spectrum of problems that need attention; second, to broaden the focus of care from the child’s survival to its growth and development. This is what is needed from a public health point of view; it is also what families expect.
The Integrated Management of Childhood Illness (IMCI) combines a set of effective interventions for preventing death and for improving healthy growth and development. More than just adding more subsets to a single delivery channel, IMCI has transformed the way the health system looks at child care – going beyond the mere treatment of illness. IMCI has three components: improving the skills of health workers to treat diseases and to counsel families, strengthening the health system’s support, and helping households and communities to bring up their children healthily and deal with ill-health when it occurs. IMCI has thus moved beyond the traditional notion of health centre staff providing a set of technical interventions to their target population. It is bringing health care closer to the home, while at the same time improving referral links and hospital care; the challenge now is to make IMCI available to all families with children, and create the conditions for them to avail themselves of such care whenever needed.