“For us to move this [agenda] forward, we can’t focus on the global level alone, we need to move it at the regional arena, the country arena, at the subnational arena and also at the community arena…all of us have a role to play and action to take.

–Angela Nguku, White Ribbon Alliance

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Key Take Ways from The Opening Forum

We know the data. More than 800 women die every day from preventable causes related to pregnancy and childbirth. Every year, 2 million babies are stillborn. In 2019, 2.4 million children died in the first month of life. Forty percent of women experience stigma and discrimination during childbirth. And more than 60 countries are not on track to meet Sustainable Development Goal (SDG) targets. In fact, as Queen Dube, Malawi’s Director of Health Services, informed us in her keynote address, if current trends continue, it will take 110 years to reach the 2030 SDG targets. Dr. Dube urged us to come together at this pivotal moment, saying, “We have been comfortable with how things are for way too long. Let’s push boundaries. Let’s demand collective action.” It is time to scale up midwifery as one of the “medicines” the world needs to improve outcomes for women and newborns. Ties Boerma from the University of Manitoba challenged the group, “Can we use this unwanted opportunity of the pandemic to change the level of the playing field for data and evidence on MNH?”—because the life of every woman and every newborn, everywhere, matters.

We have been comfortable with how things are for way too long. Let’s push the boundaries. Let’s demand collective action.” –Dr Queen Dube, Chief of Health Services, Ministry of Health, Malawi

“Without leadership and accountability for results from government, achieving a strong health system, and achieving the SDGs, is very difficult.” The importance of local leadership and accountability. The need for local leadership and accountability, as well as aligning donor support, private sector, and innovative financing around government priorities, was a theme across a number of sessions. Participants discussed increasing effective coverage of high-impact interventions by putting local actors in the lead, ensuring collaboration between private and public sectors, and strengthening local institutions.

 

“Not all jackets fit well. We’ve got to contextualize our own mitigation plans.”Building resilience in the face of COVID-19. In 2020 and beyond, COVID-19 has challenged us to rapidly respond, adapt, and prioritize. We discussed COVID-19’s prolonged impact on maternal and newborn health (MNH), and the slower recovery in MNH than in some other service areas. For instance, although the use of immunization services decreased early in the pandemic, these services rebounded quickly and were able to catch up. For services with more immediate impact, such as cesarean birth and care of small and sick newborns (SSNBs), a similar catch up is not possible. Other trends, particular to individual country contexts, emerged. South Africa, for example, saw pregnant women leaving cities to return to rural homes where less resourced health care systems were already overstretched by COVID-19. Overall, COVID-19 highlighted clear needs: to invest in strong data systems for countries to monitor their own data, to define and prioritize essential MNH services, and to count and audit every death. We were reminded that we must identify robust, locally designed, and culturally appropriate approaches, focus on respect and equity, and care for our health care workers as well as our patients.

 

Using data to help identify key levers that have led to progress.” MNH exemplars and maternal health scoping review. We heard from panelists from Bangladesh, Nepal, Sierra Leone, and Guatemala about their progress in meeting the needs of women and newborns. They discussed preliminary findings on success factors and strategies for overcoming challenges to provide insights into the key levers and drivers of success.Each country showed impressive achievements, but took slightly different paths. The panelists stressed important contextual factors, but noted that political will and commitment, aligning donors and stakeholders, rallying professional associations, coordinating across levels and across sectors, investing in the health workforce, and focusing on equity and quality are keys to success.

Without leadership and accountability for results from government, achieving a strong health system, and achieving the SDGs is very difficult.” –Dr Lia Tadesse Gebremedhin, Minister of Health, Federal Republic of Ethiopia

“A safe, useful, and untapped intervention.” Antenatal corticosteroids (ACS) for preterm birth. We learned about the World Health Organization (WHO) ACTION-I trial, designed to clarify recommendations on ACS to improve preterm birth outcomes. In 2020, the ACTION-1 trialfound that a single course of ACS given to women at risk of delivering prematurely reduces the risk of serious respiratory illness and death in neonates in low-, middle-, and high-income countries. To realize the benefits of ACS, obstetricians, midwives, pediatricians, and neonatologists must work together.

 “Alive in her heart, but not in her arms.” The neglected tragedy of stillbirth. Attendees heard the latest global evidence on stillbirths, a largely preventable tragedy that disproportionately affects families in lower income settings. And we heard from women, who courageously told us about the babies they hold in their hearts, but not in their arms, offering important lessons about the need for clear and honest information, respectful bereavement care, psycho-emotional support, and the freedom to voice their needs, desires, and stories. With the Every Newborn Action Plan (ENAP) setting targets and tracking progress on decreasing stillbirth, we have an opportunity to advocate for policy change and action.

 

“Beyond what we think we know.” Strengthening maternal and perinatal death surveillance and response (MPDSR). We reviewed the latest evidence on MPDSR, following a recently published scoping review of key lessons from 58 studies in 24 low- and middle-income countries over 15 years, and looked at community-based MPDSR in Bangladesh. The evidence suggests that when implemented with quality and with engaged communities, MPDSR can be effective in improving maternal and perinatal outcomes and strengthening health systems (within a “no blame” environment).

“Why can’t we have small NICUs in district hospitals?” State of the evidence and the implementation of quality improvements for SSNBs. Participants heard how Ethiopia, India, Malawi, and Rwanda achieved dramatic reductions in their neonatal mortality rates from 1990 to 2019. Presenters shared that establishing systems for effective inpatient care of SSNBs is feasible and affordable, but requires a strong policy framework, leadership and champions at all levels, task-shifting, support for ongoing mentorship, and functional referral pathways. We also heard about the Nest360 Implementation Toolkit for Small and Sick Newborn Care, a collaborative global resource to help identify gaps in evidence and implementation.

Antenatal corticosteroids for preterm birth is a safe, useful and untapped intervention[1] –Dr. Femi Oladapo, WHO

“Quality is key.” Building the network for improving quality of care for maternal, newborn, and child health. With a focus on leadership, action, learning and accountability, and county-led implementation since 2017, Quality of Care Network countries have developed national guidelines on quality of care (QoC), adopted the WHO’s standards for improving quality of MNH in health facilities, and implemented QoC initiatives at the district and facility levels. With a focus on lessons learned in Nigeria and Ghana, we heard that strengthening QoC takes a whole health system approach, government leadership, long-term commitment, dedicated support, contextualized approaches, program design at the district level, early and intentional investments in data systems, and recognition that demonstrating impact takes time.

 “We need to think also about how to redesign and plan systems that can deliver on the respect and dignity for women and girls and their babies.” Improving the experience of care. We had a discussion—and lively Q&A—about how to offer ALL women and newborns dignified and respectful care, including a call for credible, usable data to guide improvements. We talked about the issue’s complexity, and the fact that providers, often midwives, also battle significant sociocultural, economic, and professional barriers. We heard about the 2018 “What Women Want” campaign. The top responses, from 1.2 million women across 114 countries? Respectful and dignified care. Water, sanitation, and hygiene. Medicines and supplies. More competent and better-supported midwives and nurses. And more functional, accessible facilities.

We need to think also about how to redesign and plan systems that can deliver on the respect and dignity for women and girls and their babies.” – Dr. Allisyn Moran, WHO

The Opening Forum ended by echoing the resonant themes of the event. We must put the health of women and newborns together, and at the center of our collective efforts, at all levels. For instance, the ENAP and Ending Preventable Maternal Mortality (EPMM) strategic objectives are complementary, with healthy women and newborns at the center of both. (ENAP is finalizing its Results Framework 2021–2025, and EPMM milestones and targets will be launched this summer.) As Jeff Smith from the Bill & Melinda Gates Foundation expressed in his closing remarks, “It’s not about what we want. It’s about what women want. We need to be designing our solutions and our approaches and our innovations to meet the needs of women and the systems that are caring for these women.”

AlignMNH will continue to build an integrated MNH community through regular convenings and biannual in-person meetings—the first to be held in Cape Town, South Africa, in May 2023. These events will be opportunities to come together to review the data, examine trends, share the state of the evidence and our latest programmatic learnings, and chart our progress. Participants are encouraged to become active members of this movement by joining an AlignMNH subcommittee and contributing content to the AlignMNH knowledge hub (alignmnh.org, details to follow). And, finally, in the words of Angela Nguku from White Ribbon Alliance Kenya, “For us to move this [agenda] forward, we can’t focus on the global level alone, we need to move it at the regional arena, the country arena, at the subnational arena and also at the community arena . . . all of us have a role to play and action to take.”

It’s not about what we want. It’s about what women want. We need to be designing our solutions and our approaches and our innovations to meet the needs of women and the systems that are caring for these women.” –Dr. Jeffrey Smith, The Bill & Melinda Gates Foundation