SeriesInterventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make?
Introduction
Recent years have seen a major emphasis on the persisting burden of maternal, newborn, and child mortality globally with a particular focus on the Millennium Development Goals (MDGs) for maternal and child health. Issues pertaining to the burden of this mortality and interventions to reduce it have been the subject of several recent Lancet series and other publications. These include reviews on child,1, 2 newborn,3 and maternal survival,4, 5 child development,6 and maternal and childhood undernutrition.7 All of these analyses have provided estimates of disease burden and described a wide array of effective interventions that could make a difference (webtable 1).8
Despite calls for action to improve maternal, newborn, and child health (MNCH) and survival in health systems,9 how many interventions can be operationally scaled up in country-level programmes is unclear. With so many options, consensus on a reasonable number of interventions that work in primary health care is needed, as are strategies to distribute them. In a recent exercise to support provision of maternal, newborn, and child interventions across the continuum of care, a case has been made for providing some 190 interventions through eight packages that could be delivered at various levels of the health system.8 Of these, five packages of interventions were identified (webfigure) that could be delivered through family and community care and through outpatient or outreach services at first-level facilities. Our definition of primary health-care settings retains the same framework inclusive of interventions delivered at first-level health facilities.10
A recent investigation of intervention coverage from 68 countries with 97% of the global burden of maternal and child deaths revealed that the implementation, uptake, and extent to which distribution of interventions is equitable varies greatly.11 Interventions that can be routinely scheduled and delivered, such as immunisation and antenatal care, had much higher coverage than those that rely on 24 h availability of clinical services, such as skilled or emergency care at birth and care of sick newborn babies and children. For some interventions, such as postnatal care after birth (which lies somewhere between the two extremes above), either the coverage was poor or data were unavailable. A recent Cochrane review revealed that few studies have assessed integrated MNCH interventions at the primary health-care level, none including efforts at community level for demand generation.12 Although many countries implement MNCH interventions with some degree of integration, the range of proven interventions implemented is limited, and there have been no systematic assessments relevant to MNCH and survival.
These findings are a major cause for concern and reflection. Three decades after the Alma-Ata Declaration, the state of primary care for mothers, newborns, and children remains poor, and as a result only 16 countries are on track to reach the fourth MDG of reducing child mortality, and data from which to estimate maternal mortality trends reliably simply do not exist.11 Some of the factors associated with this include lack of coordination between various programmes (both vertical and horizontal) and existing health workers and crucial shortages of trained health staff in primary care settings in populations at risk. These problems are exacerbated by a lack of common measures, messages, and targets across the continuum of care for MNCH and by sometimes strongly conflicting views with respect to the best balance between community, outreach, and facility-based delivery strategies.8
The emphasis on facility-based care and emergency obstetric care from those concerned with maternal survival is understandable, whereas advocates for newborn and child survival have placed more emphasis on community-based strategies. Despite the proliferation of recent reviews, no clear, consistent, and agreed strategy for integrated MNCH care at primary care level has emerged. The evidence base for the types of interventions that a range of primary health-care workers, such as medical and paramedical staff, community health workers and other providers can deliver, along with complementary community and health system support strategies, is limited and often focused on selected interventions. In general, previous studies13 and reviews14 of community-based interventions have largely addressed care at the household level without clear linkages to health facilities. Although attempts have been made to package interventions for newborn and child survival,15 comparable efforts to understand the evidence base for suitable and scalable maternal health interventions in primary health-care settings have lagged behind.
We did a systematic review of various MNCH interventions with the aim of identifying a mix of evidence-based interventions and best delivery strategies for primary health care in developing countries. Our specific aim was to complement previous reviews with newer evidence on potentially useful interventions and delivery strategies and to quantify their effects. We then did two specific case studies from representative countries in Africa (Uganda) and south Asia (Pakistan) to assess how these might be delivered cost effectively within existing health systems, and what difference these integrated primary care strategies might make to MNCH, especially mortality in these circumstances.
Section snippets
Search strategy and selection criteria
We searched Medline, the Cochrane Database of Systematic Reviews, the WHO/RHR Reproductive Health Library, Medcaribe, Wholis, PAHO, Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde), and Scielo (Scientific Electronic Library Online). Additional studies were obtained through hand search of references from identified studies. We assessed relevant publications from UN agencies, bilateral agencies, non-governmental organisations, research bodies, and academic institutions.
Results
The details of the review and findings from the subset of studies done in relevant primary health-care settings with integrated MNCH outcomes will be reported elsewhere, and are available from the authors upon request. Webtables 3–5 summarise the pathways by which interventions that are feasible in primary health-care settings might effect maternal, newborn, and child mortality and provide cause-specific estimates of their effects. The paucity of studies reporting outcomes across the continuum
Discussion
Our review reaffirms that primary health-care interventions can make a significant difference to MNCH and mortality outcomes. The two country case studies and modelling exercise were done with existing health-system capacity and care providers in mind, setting realistic short-term coverage targets. These studies indicate that even without delivering care through secondary-care hospitals, substantial advances can be made if interventions are made available through primary health care (service
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