Bridging Equity Gaps and Improving the Quality of Maternal and Newborn Health Care Post-2015: How Will We Hold Ourselves Accountable?
The global public health community has made significant gains to date improving maternal and newborn health, but as we approach the post-2015 landscape, we are confronted with the important and ambitious objectives of the Sustainable Development Goals. Goal 3 states that we must, “Ensure healthy lives and promote well-being for all at all ages,” and the first two targets of this goal are to reduce maternal mortality and end preventable deaths of newborns and children under age 5.[i] If we are to narrow equity gaps and improve quality, we must investigate what is happening among populations who have historically been socially excluded. As such, the 2015 Global Maternal Newborn Health Conference (GMNHC) in Mexico City has chosen three timely and important themes: quality, equity and integration. These cross-cutting themes invite us out of our topical or service-specific silos to confront critical dimensions of care that, if addressed, will improve health outcomes and increase the likelihood of achieving the SDGs.
Let’s consider the example of Latin America, which is known for significant improvements in terms of development, but marked by extreme disparities. The maternal mortality ratio in Latin America (excluding the Caribbean) has reduced over time from 130 in 1990 to 77 per 100,000 in 2013.[ii] Additionally, 94% of pregnant women in Latin America and the Caribbean have a skilled birth attendant present at their deliveries.[iii] Despite these overall gains, maternal mortality ratios range widely from 22 per 100,000 in Uruguay to 200 per 100,000 in Bolivia.[iv] Those at highest risk of not receiving adequate care are the geographically isolated, rural poor residing in certain low- and middle-income countries.[v]
Guatemala, which has the second highest maternal mortality ratio in Latin America, is a great example of how one half of the population drives up national gains in health and development and thus masks underlying disparities. The other half of the population that identifies as indigenous has disproportionately lower health and development outcomes, including a maternal mortality ratio that may be three times that of the non-indigenous population.[vi] Not only are indigenous populations located on the fringes of the formal health system and less likely to seek care, but they are also more likely to be disrespected and abused during facility-based childbirth compared to non-indigenous populations when they do seek care, as our forthcoming research shows. How will we achieve progress if we further marginalize the most vulnerable?
Failure to address the needs of “left behind” populations will hinder the achievement of national and global maternal health goals and targets such as universal health coverage and the SDGs.[vii] As we forge ahead to improve maternal and newborn care, we should ask ourselves: Do we know what works? Why it works? And how it works in particular contexts? Equally as important, do our approaches improve equity and enhance the provision of high quality care?
At the GMNHC conference, I look forward to discussing how the global community will be accountable in our efforts to facilitate equitable and high-quality services across the continuum of care. A critical and honest assessment of our program implementation will hold us accountable to our investments, safeguard target populations from shouldering unintended consequences and inform policy makers and implementers about how to better serve their communities.
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[i] United Nations Sustainable Development Summit 2015 – Health. (n.d.). Retrieved from http://www.un.org/sustainabledevelopment/health/.
[ii] World Health Organization et al. (2014). Trends in Maternal Mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. ISBN 978 92 4 150722 6. World Health Organization. http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf?ua=1.
[iii] Boerma, J. T. (2015). World Health Organization, Department of Health Statistics and Information Systems, and World Bank. Tracking Universal Health Coverage: First Global Monitoring Report.
[iv] World Health Organization et. al. (2014).
[v] Byrne, A., Hodge, A., Jimenez-Soto, E. and Morgan, A. (2014). What Works? Strategies to Increase Reproductive, Maternal and Child Health in Difficult to Access Mountainous Locations: A Systematic Literature Review. Edited by Zulfiqar A. Bhutta. PLoS ONE 9(2): e87683. doi:10.1371/journal.pone.0087683.
[vi] Shiffman, J. and Garces del Valle, A.L. (2006). Political History and Disparities in Safe Motherhood between Guatemala and Honduras. Population and Development Review 32(1): 53–80. doi:10.1111/j.1728-4457.2006.00105.x.
[vii] Boerma, J. T. (2015). World Health Organization, Department of Health Statistics and Information Systems, and World Bank. Tracking Universal Health Coverage: First Global Monitoring Report. http://apps.who.int/iris/bitstream/10665/174536/1/9789241564977_eng.pdf?ua=1.