September, 2016 www.thelancet.com

Maternal Health

“This Series... suggests two fundamental issues that need to be addressed to improve maternal health: to ensure the quality of maternal health care for all women, and to guarantee access to care for those left behind or those who are most vulnerable.”

A Series by The Lancet The Lancet—London 125 London Wall, London EC2Y 5AS, UK T +44 (0)20 7424 4910 Maternal Health 2016 · September 2016 F +44 (0)20 7424 4911 The Lancet—New York 360 Park Avenue South, New York, NY 10010–1710, USA T +1 212 633 3810 F +1 212 633 3853 The Lancet—Beijing Unit 1–6, 7F, Tower W1, Oriental Plaza, Beijing 100738, China T + 86 10 85208872 F + 86 10 85189297 [email protected] Comment 1 Maternal health: time for a radical reappraisal A Ceschia, R Horton Editor 2 Quality, equity, and dignity for women and babies Richard Horton M V Kinney and others Deputy Editor Astrid James 4 Implementation and aspiration gaps: whose view counts? Senior Executive Editors L P Freedman Pam Das Sabine Kleinert Series Stuart Spencer William Summerskill 7 Maternal Health 1 Executive Editors Diversity and divergence: the dynamic burden of poor maternal health Jocalyn Clark W Graham and others Stephanie Clark Helen Frankish 19 Maternal Health 2 Tamara Lucas Joanna Palmer Beyond too little, too late and too much, too soon: a pathway towards North America Executive Editor evidence-based, respectful maternity care worldwide Rebecca Cooney (New York) S Miller and others Asia Executive Editor 36 Maternal Health 3 Helena Hui Wang (Beijing) The scale, scope, coverage, and capability of care Managing Editors O M R Campbell and others Lucy Banham Hannah Jones 52 Maternal Health 4 Web Editors Drivers of maternity care in high-income countries: can health systems support Gavin Cleaver Richard Lane woman-centred care? Naomi Lee D Shaw and others Erika Niesner 66 Maternal Health 5 Senior Editors Philippa Berman Next generation maternal health: external shocks and health-system innovations Selina Lo M E Kruk and others Udani Samarasekera Jennifer Sargent 77 Maternal Health 6 Liz Zuccala Quality maternity care for every woman, everywhere: a call to action Conference Editor M Koblinsky and others Laura Hart Senior Deputy Managing Editors Olaya Astudillo Tim Dehnel Laura Pryce Deputy Managing Editor Helen Penny Senior Assistant Editors Stephanie Clague Nicholas Dolan Emilia Harding Natalie Harrison Richard Henderson Samuel Hinsley Esther Lau Patricia Lobo Marta Lozano-Wilhelmi Zena Nyakoojo Louise Rishton Francesca Towey Priya Venkatesan Luke Worley Assistant Editors Helen Brooks Previously published online Rachel Hellier Kayleigh Hook See www.thelancet.com for supplementary material Rhiannon Howe Cover image copyright Cheryl Lai Version verified by CrossMark GMB Akash/Panos Sheila Pinion Paul Kiet Tang Giulia Vivaldi International Advisory Board Christina Wayman Karen Antman (Boston) Karen Gelmon (Vancouver) Alwyn Mwinga (Lusaka) Caroline Savage (Birmingham) Valerie Beral (Oxford) David Grimes (Durham) Marie-Louise Newell (Somkhele) Ken Schulz (Chapel Hill) Media Relations Manager Seil Collins Robert Beaglehole (Auckland) Ana Langer (Cambridge, MA) Magne Nylenna (Oslo) Frank Shann (Melbourne) Anthony Costello (London) Judith Lumley (Melbourne) Peter Piot (London) Jan Vandenbroucke (Leiden) Editorial Assistants Robert Fletcher (Boston) Elizabeth Molyneux (Blantyre) Stuart Pocock (London) Cesar Victora (Pelotas) Jonathan Blott Suzanne Fletcher (Boston) Christopher Murray (Seattle) Giuseppe Remuzzi (Bergamo) Nick White (Bangkok) Angela Bonsu Anna Kennedy Abigail Murdy Jessica Short The Lancet is a trade mark of RELX Ombudsman Alexandra York Intellectual Properties SA, used under license. Malcolm Molyneux (c/o The Lancet or [email protected]) Comment

Maternal health: time for a radical reappraisal

It is tempting to see progress towards better maternal additional 120 million women by 2020. That goal Published Online health in linear terms. If only, the argument goes, one required 15 million women each year to gain such September 15, 2016 http://dx.doi.org/10.1016/ could scale up evidence-based interventions and policies access. According to data from FP2020, a global S0140-6736(16)31534-3 in all countries for all women, maternal mortality would initiative to deliver the promises of the London Summit, See Online/Comment http://dx.doi.org/10.1016/ fall and maternal health would advance. The past year only 8 million additional women each year are accessing S0140-6736(16)31525-2, and has shown the desperate fallacy in this argument. The modern contraceptive methods. This failure must http://dx.doi.org/10.1016/ S0140-6736(16)31530-6 mortal dangers and uncertainties faced by millions be owned by the international health community. See Online/Series of women and young mothers who find themselves The same story of failure is also true for maternal and http://dx.doi.org/10.1016/ in the midst of conflict-induced displacement across child nutrition. Undernutrition during is a S0140-6736(16)31533-1, http://dx.doi.org/10.1016/ large parts of the Middle East, Africa, and Europe prove major determinant of both stunting of linear growth S0140-6736(16)31472-6, that such idealised notions of progress are little more and subsequent obesity and non-communicable http://dx.doi.org/10.1016/ S0140-6736(16)31528-8, than a comforting myth. Added to this unprecedented disease in adulthood. Despite the committed efforts http://dx.doi.org/10.1016/ predicament is the epidemic of Zika virus infection of initiatives such as Scaling Up Nutrition, adequate S0140-6736(16)31527-6, http://dx.doi.org/10.1016/ across Latin America, and now the southern parts of maternal nutrition remains a marginal concern for most S0140-6736(16)31395-2, and the USA, which has spread understandable fear among countries. As one maternal and child nutrition scientist http://dx.doi.org/10.1016/ S0140-6736(16)31333-2 millions of women of childbearing age. The result—the wrote to us recently, “health and nutrition programs appearance of a new teratogenic condition, congenital are no closer now than 20 years ago”. The unfinished For FP2020 see http://www. Zika syndrome—has introduced a tragic and severe agenda for maternal health is a huge obstacle to further familyplanning2020.org/ For Scaling Up Nutrition see burden on the lives of countless new mothers and progress. http://scalingupnutrition.org/ families. The lesson from these crises is that progress in Meanwhile, a new agenda beckons. The SDGs offer a maternal health is fragile and non-linear. The gains that once-in-a-generation political moment to add energy have been made—and genuine gains have been made to maternal health advocacy and action. At the centre during the era of the Millennium Development Goals— must never be taken for granted. Constant vigilance is essential. Now is therefore the moment for a radical reappraisal of practices, programmes, and policies to achieve sustainable maternal health and wellbeing worldwide. In an attempt to understand and take stock of efforts to improve maternal health, and add momentum for maternal health in the era of the Sustainable Development Goals (SDGs), The Lancet now publishes a Series of six papers1–6 that dissect the epidemiology of maternal health, the landscape of maternal health care and services, and the future challenges and strategies to improve maternal wellbeing. We also publish Comments from Mary Kinney and colleagues7 and Lynn Freedman,8 who examine how maternal health fits into the broader picture for the future of women and children. This Series must be seen in the context of a much larger health agenda for women and prospective mothers. Access to modern contraception is a critical foundation for maternal and child health. The London Summit on , held in 2012, committed

countries to provide access to contraception for an Trayler-Smith/H4+/Panos Abbie

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of the SDGs for the health of women and children 12 months, these leadership transitions represent the is the goal of universal health coverage. But while right time to strengthen science-based advocacy for strengthening health systems is central for progress in women, children, and adolescents. And it is also time to maternal health, sustainable results will only be delivered reframe a call to action to countries and international by paying attention to the linkages between the SDGs— partners, not only to embrace the scaling up of safe, for example, the connection between maternal health effective, and respectful quality of care, but also to and education, maternal health and gender equity, and broaden the meaning of health to include the wider maternal health and reduction. social, economic, and political determinants that are Key elements that are essential to advance maternal shaping their still too vulnerable lives. health are missing from the SDGs. Unless adolescent girls and young women are given a higher priority in society, Audrey Ceschia, Richard Horton many of the theoretical gains that can be achieved in The Lancet, London EC2Y 5AS, UK maternal health will be missed. The adolescent health We thank the coordinators of this Series, Oona Campbell and Wendy Graham, for leading this project; and the Bill & Melinda Gates Foundation and the John D and perspective adds entirely new dimensions to the Catherine T MacArthur Foundation for their generous financial support. meaning of maternal health. For example, in women 1 Graham W, Woodd S, Byass P, et al. Diversity and divergence: the dynamic burden of poor maternal health. Lancet 2016; published online Sept 15. aged 15–24 years the most important cause of death is http://dx.doi.org/10.1016/S0140-6736(16)31533-1. self-harm.9 Among this age group, the largest contributor 2 Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late and too 9 much, too soon: a pathway towards evidence-based, respectful maternity to disability is . The and care worldwide. Lancet 2016; published online Sept 15. http://dx.doi. wellbeing of women must be a new and urgent concern org/10.1016/S0140-6736(16)31472-6. 3 Campbell OMR, Calvert C, Testa A, et al. The scale, scope, coverage, and for maternal health advocates and decision makers capability of childbirth care. Lancet 2016; published online Sept 15. (which currently it is not). And while saving the lives of http://dx.doi.org/10.1016/S0140-6736(16)31528-8. 4 Shaw D, Guise J-M, Shah N, et al. Drivers of maternity care in high-income mothers is important, much greater attention needs to countries: can health systems support woman-centred care? Lancet 2016; published online Sept 15. http://dx.doi.org/10.1016/S0140- be paid to what women need after the safe delivery of a 6736(16)31527-6. healthy newborn baby. Maternal and newborn health 5 Kruk ME, Kujawski S, Moyer CA, et al. Next generation maternal health: external shocks and health-system innovations. Lancet 2016; published programmes need to be considered as an integrated online Sept 15. http://dx.doi.org/10.1016/S0140-6736(16)31395-2. whole, and these programmes also need to be linked to 6 Koblinsky M, Moyer CA, Calvert C, et al. Quality maternity care for every woman, everywhere: a call to action. Lancet 2016; published online practices that ensure good early child development—eg, Sept 15. http://dx.doi.org/10.1016/S0140-6736(16)31333-2. effective programmes. 7 Kinney MV, Boldosser-Boesch A, McCallon B. Quality, equity, and dignity for women and babies. Lancet 2016; published online Sept 15. With the appointment of a new Secretary-General of http://dx.doi.org/10.1016/S0140-6736(16)31525-2. 8 Freedman LP. Implementation and aspiration gaps: whose view counts? the UN (Ban Ki-moon has been an unrelenting force Lancet 2016; published online Sept 15. http://dx.doi.org/10.1016/ for good, with his signature Every Woman, Every Child S0140-6736(16)31530-6. 9 Mokdad AH, Forouzanfar MH, Daoud F, et al. Global burden of diseases, initiative) and the election of a new Director-General of injuries, and risk factors for young people’s health during 1990–2013: WHO (Margaret Chan has done more for women and a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2016; 387: 2383–401. children than any recent leader of WHO) during the next

Quality, equity, and dignity for women and babies

Published Online This Lancet Series on maternal health1–6 comes just children thrive and transform their communities September 15, 2016 http://dx.doi.org/10.1016/ 1 year after countries committed to the Sustainable and nations. To achieve this, we must address social S0140-6736(16)31525-2 Development Goals (SDGs). The SDGs call on all determinants of maternal and newborn health, and See Online/Comment stakeholders to leave no one behind in addressing the improve access to respectful, high-quality, integrated http://dx.doi.org/10.1016/ S0140-6736(16)31534-3, and unfinished agenda for maternal and child health. The care. http://dx.doi.org/10.1016/ Global Strategy for Women’s, Children’s and Adolescents’ As representatives of civil society organisations S0140-6736(16)31530-6 Health (Global Strategy)7 calls for integrated solutions working with women and children, we are deeply to prevent maternal, newborn, and child deaths and concerned about the divergence in the burden of poor and to realise a world where women and maternal health “reflecting inequities in wealth, rights,

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and access to care”,1 and the concomitant effect on newborn and child health, and survival and adverse birth outcomes. The health and survival of women and their babies are inextricably linked; a coordinated, integrated “continuum of care” approach that optimises the health of the mother–baby dyad is required to fully maximise the potential benefits. Linking health care for a mother and her baby promotes greater efficiency, lower costs, reduces duplication of resources, and maximises the effect on their health and survival in the same way investments in family planning and reproductive health improve health and wellbeing of women and their children.8 The investment case is strong, since the return on investment includes not only averted deaths (maternal, newborn, and ), but also improved child neurodevelopmental outcomes and reduced maternal morbidities.9 Akash/Panos GMB There have long been calls to integrate maternal and respectful maternal and newborn health care. How See Online/Series newborn baby health priorities. A comment by Ann Starrs can governments, UN agencies, donors, private sector http://dx.doi.org/10.1016/ S0140-6736(16)31533-1, in The Lancet Every Newborn Series10 challenged the organisations, civil society, and other stakeholders http://dx.doi.org/10.1016/ maternal and newborn health communities “to pledge work with women, communities, and countries to end S0140-6736(16)31472-6, http://dx.doi.org/10.1016/ to each other that any policy, programme, or initiative preventable deaths in the face of the great divergence S0140-6736(16)31528-8, http://dx.doi.org/10.1016/ focusing on either maternal or newborn health will described in this Series? S0140-6736(16)31527-6, incorporate the other as well”. 2 years later, the global One promising development is WHO’s Quality of Care http://dx.doi.org/10.1016/ 16 S0140-6736(16)31395-2, and health community seems to have heeded that call. The Framework for Maternal and Newborn Health with http://dx.doi.org/10.1016/ 2015 Global Maternal Newborn Health Conference gave accompanying technical standards and guidelines for S0140-6736(16)31333-2 voice to a shared vision of maternal and newborn health. quality of care.17 We are hopeful that the roll-out of the Two strategies developed in the lead-up to the SDGs— implementation framework—unlike the development the Every Newborn Action Plan and Strategies toward of the framework itself—will provide opportunities to Ending Preventable Maternal Mortality—converged with engage women and local stakeholders in the process of common objectives,11 and were incorporated into the defining quality of care. Global Strategy.7 The Global Financing Facility supports To this end, a new maternal–newborn health advocacy countries in identifying national priorities across the effort is underway to support implementation of the spectrum of reproductive, maternal, newborn, child framework, influence supportive global and national and adolescent health (RMNCAH) and was built upon policies and investments, and unify stakeholders in a full potential investment case.12 The Lancet has also joint action with emphasis on the -based published multiple Series relating to maternal–newborn goals of equity, universal coverage, access to quality health in the past 2 years: (2014),13 Every care services, and dignity and respect for all women Newborn (2014),14 Ending preventable stillbirth (2016),9 and babies. This effort takes up the call by Koblinsky and Maternal health (2016).1–6 Even though these Series’ and colleagues6 “to advocate for increased attention titles appear siloed in approach, each Series calls for to maternal–perinatal health, and ensure women’s integration. Evidence also indicates that women are more rights and agency are acknowledged, which includes satisfied with a more integrated approach.15 involving women in their own health care”. Defining With the many global strategies in place and of priorities at national and local levels will require the multiple Lancet Series published, one wonders whether voices of women, families, and broader civil society to countries are effectively supported to act upon these be a starting point and not an afterthought. Efforts to priorities as well as respond to what women want and mobilise citizens’ voices, such as the Citizen Hearings, For more on Citizen Hearings deserve, in terms of quality, accessible, affordable, will be fundamental to successful implementation. see http://www.citizens-post.org

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This Series highlights two fundamental issues that 3 Campbell OMR, Calvert C, Testa A, et al. The scale, scope, coverage, and capability of childbirth care. Lancet 2016; published online Sept 15. need to be addressed to improve maternal health: http://dx.doi.org/10.1016/S0140-6736(16)31528-8. quality of maternal health care for all women and access 4 Shaw D, Guise J-M, Shah N, et al. Drivers of maternity care in high-income countries: can health systems support woman-centred care? Lancet 2016; to care for those left behind. It is a call for quality, equity, published online Sept 15. http://dx.doi.org/10.1016/S0140-6736(16)31527-6. and dignity. Although similar, the new WHO initiative 5 Kruk ME, Kujawski S, Moyer CA, et al. Next generation maternal health: external shocks and health-system innovations. Lancet 2016; published and accompanying advocacy movement call for a online Sept 15. http://dx.doi.org/10.1016/S0140-6736(16)31395-2. unified approach—one where maternal and newborn 6 Koblinsky M, Moyer CA, Calvert C, et al. Quality maternity care for every woman, everywhere: a call to action. Lancet 2016; published online Sept 15. health communities are no longer in siloes or perceived http://dx.doi.org/10.1016/S0140-6736(16)31333-2. 7 Every Woman Every Child. The global strategy for women’s, children’s and competition but rather working together on an integrated adolescents’ health. New York, NY: Every Woman Every Child, 2015. effort to improve quality, equity, and dignity for all 8 Lassi ZS, Majeed A, Rashid S, Yakoob MY, Bhutta ZA. The interconnections between maternal and newborn health–evidence and implications for policy. women and babies. J Matern Fetal Neonatal Med 2013; 26 (suppl 1): 3–53. 9 de Bernis L, Kinney MV, Stones W, et al. Stillbirths: ending preventable deaths by 2030. Lancet 2016; 387: 703–16. *Mary V Kinney, Amy Boldosser-Boesch, Betsy McCallon 10 Starrs AM. Survival convergence: bringing maternal and newborn health Save the Children, Saving Newborn Lives, Edgemead 7441, South together for 2015 and beyond. Lancet 2014; 384: 211–13. Africa (MVK); FCI Program of Management Sciences for Health, 11 Chou D, Daelmans B, Jolivet RR, et al. Ending preventable maternal and newborn mortality and stillbirths. BMJ 2015; 351: h4255. New York, NY, USA (AB-B); and White Ribbon Alliance, 12 Stenberg K, Axelson H, Sheehan P, et al, on behalf of the Study Group for the Washington, DC, USA (BM) Global Investment Framework for Women’s Children’s Health. Advancing [email protected] social and economic development by investing in women’s and children’s health: a new Global Investment Framework. Lancet 2014; 383: 1333–54. MVK is a Senior Specialist, Global Evidence and Advocacy, Saving Newborn Lives 13 ten Hoope-Bender P, de Bernis L, Campbell J, et al. Improvement of maternal project, Save the Children; AB-B is Senior Director, FCI Program of Management and newborn health through midwifery. Lancet 2014; 384: 1226–35. Sciences for Health; and BM is Chief Executive Officer, White Ribbon Alliance. 14 Mason E, McDougall L, Lawn JE, et al. From evidence to action to deliver a We declare no competing interests. healthy start for the next generation. Lancet 2014; 384: 455–67. 1 Graham W, Woodd S, Byass P, et al. Diversity and divergence: the dynamic 15 Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led burden of poor maternal health. Lancet 2016; published online Sept 15. continuity models versus other models of care for childbearing women. http://dx.doi.org/10.1016/S0140-6736(16)31533-1. Cochrane Database Syst Rev 2016; 4: CD004667. 2 Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late and too 16 Tuncalp Ö, Were WM, MacLennan C, et al. Quality of care for pregnant much, too soon: a pathway towards evidence-based, respectful maternity women and newborns—the WHO vision. BJOG 2015; 122: 1045–49. care worldwide. Lancet 2016; published online Sept 15. http://dx.doi. 17 WHO. Standards for improving quality of maternal and newborn care in org/10.1016/S0140-6736(16)31472-6. health facilities. Geneva: World Health Organization, 2016.

Implementation and aspiration gaps: whose view counts?

1–6 Published Online The Lancet’s Maternal Health Series paints a sobering has been to ensure that routine births are managed September 15, 2016 picture of the state of maternal health today. The in accordance with evidence-based practices and that http://dx.doi.org/10.1016/ S0140-6736(16)31530-6 Series focuses on the “mismatch between burden and obstetric complications are treated in facilities where See Online/Comment coverage”, which “exposes a crucial gap in quality of emergency obstetric care (EmOC) is delivered. Whether http://dx.doi.org/10.1016/ 6 S0140-6736(16)31534-3, and care” and spotlights the millions of pregnant women women are driven to deliver in facilities by their own http://dx.doi.org/10.1016/ and adolescents who never get access to services at desires, by financial incentives, or even by government S0140-6736(16)31525-2, all. But 30 years after the start of the safe motherhood compulsion is often unclear—and rarely considered to See Online/Series http://dx.doi.org/10.1016/ initiative, this mismatch exposes something else as well: a matter. Seemingly, what counts is that facility-based S0140-6736(16)31533-1, dangerous disconnect between the way the global health delivery has increased, sometimes dramatically. What do http://dx.doi.org/10.1016/ S0140-6736(16)31472-6, community has framed problems, proposed strategies, women experience when they arrive at facilities ready to http://dx.doi.org/10.1016/ and pushed solutions, and the lived experience of people give birth? S0140-6736(16)31528-8, 2 http://dx.doi.org/10.1016/ and providers. Thus the quality and access gaps defined Suellen Miller and colleagues identify 51 high-quality S0140-6736(16)31527-6, in the Lancet Series through epidemiological analysis and global and national clinical practice guidelines issued since http://dx.doi.org/10.1016/ S0140-6736(16)31395-2, quantitative data could also be framed as implementation 2010 for routine maternity care in facilities. Focusing and http://dx.doi.org/10.1016/ and aspiration gaps, drawing on a wider range of empirical on middle-income countries to determine what actually S0140-6736(16)31333-2 data to speak a different truth to power. transpires, they document pervasive, health-threatening Take the example of facility-based delivery care. The deviations from those guidelines, characterised by too central aim of global skilled-birth-attendance strategies little, too late (insufficient appropriate care) and too

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much, too soon (excessive medicalisation).2 Other recent reviews7 round out the picture by exposing a startling range and level of disrespectful and abusive treatment, in countries both rich and poor. Implementation gaps are not limited to the four walls of the health facility. Oona Campbell and colleagues3 show that the indicators we in the global health community have so confidently promoted for coverage measurement at the population level often serve only to hide catastrophic failures. They say that “governments and policy makers can no longer pretend to provide life-saving care, using phrases such as skilled birth attendant and EmOC to mask poor quality”.3 Pretend is perhaps a good choice of verb. Campbell and colleagues3 show that standardised, globally formulated strategies pressed upon countries in an attempt to make services AP widely available and accessible ultimately ignore the Even as progress against indicators is made, the reality varied topographies, health-system configurations, and experienced on the ground—a reality that finds only demographic characteristics of different countries— muted expression in global health literature—diverges which makes achievement of globally determined norms ever more starkly from the dominant global discourse. at a globally determined pace manifestly unrealistic. The point is not that global strategies, evidence-based A view from the ground would show globally guidelines, or high-level monitoring and accountability formulated strategies ignore many other things as initiatives are inherently wrong or unnecessary. But when well: different histories, governance styles, and social they consume most of the oxygen in the room, drowning dynamics; minimal state capability to influence out voices and signals coming from the ground, they the dynamics at the periphery of the system; 8 and distort both understanding and action. corrosive distrust of health systems by both the people Three emerging areas of work are beginning to who work for them and the people meant to benefit rectify this imbalance. First, in the programme domain, from them.9 A view from the ground would show that implementation support practices are increasingly people’s interactions with maternal health services are designed not just to assure compliance but to create never only about attaining health outcomes. These systems attuned and responsive to learning from the interactions are also about aspirations to have some ground, where challenging social and organisational control over their birth experience, to be treated with contexts can blunt even the purest commitment to dignity and respect, and to use their choices around behaviour change. Use of the active implementation childbirth to signal who they are and who they want frameworks12 and problem-driven iterative adap- to be.10,11 tation13 are two examples of how evidence-based But in the fervour to see results, the global health implementation strategies can be adapted, applied, community has inadvertently turned the policy face and sustained within programmes to strengthen health of countries (especially aid-dependent countries) services. Second, in the research domain, field-building toward the global, instead of toward their own citizens. efforts such as those around health policy and systems Data elicited in this Series display the telltale signs research and South–South research coalitions are alert to of isomorphic mimicry, the phenomenon in which ground-level dynamics and give heightened attention countries adopt the outward-facing forms (eg, policies, to these issues.14 Third, in the advocacy domain, the indicators, curricula) that international donors demand, expanding field of social accountability bolsters efforts For more on social but do not change the fundamental content or to create a robust civil society. We in the global health accountability see http://www. copasah.net/ dynamics of health services.8 When the mimicry works, community can call for people’s voices all we want, funds continue to flow, and the cycle begins again. but unless investments are made in the organisational

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structures to make these voices heard over the clatter of 3 Campbell OMR, Calvert C, Testa A, et al. The scale, scope, coverage, and capability of childbirth care. Lancet 2016; published online Sept 15. globally driven advocacy initiatives, that call will be little http://dx.doi.org/10.1016/S0140-6736(16)31528-8. more than rhetorical flourish. 4 Shaw D, Guise J-M, Shah N, et al. Drivers of maternity care in high-income countries: can health systems support woman-centred care? Lancet 2016; For those of us who work primarily in the global published online Sept 15. http://dx.doi.org/10.1016/S0140-6736(16)31527-6. arena—no matter which countries we are from— 5 Kruk ME, Kujawski S, Moyer CA, et al. Next generation maternal health: external shocks and health-system innovations. Lancet 2016; published some humility is in order. The true engine of change online Sept 15. http://dx.doi.org/10.1016/S0140-6736(16)31395-2. in maternal health will not be the formal clinical 6 Koblinsky M, Moyer CA, Calvert C, et al. Quality maternity care for every woman, everywhere: a call to action. Lancet 2016; published online Sept 15. guidelines, polished training curricula, model laws, or http://dx.doi.org/10.1016/S0140-6736(16)31333-2. 7 Bohren MA, Vogel JP, Hunter EC, et al. The mistreatment of women during patient rights charters we produce. The engine will be childbirth in health facilities globally: a mixed-methods systematic review. the determination of people at the front-lines of health PLoS Med 2015; 12: e1001847. 8 Pritchett L, Woolcock M, Andrews M. Looking like a state: techniques of systems—patients, providers, and managers—to find or persistent failure in state capability for implementation. J Dev Stud 2013; take the power to transform their own lived reality. Our 49: 1–18. 9 Topp SM, Chipukuma JM. A qualitative study of the role of workplace and job in global health is first to listen to them, and then to interpersonal trust in shaping service quality and responsiveness in co-create the conditions at every level of the system that Zambian primary health centres. Health Policy Plan 2016; 31: 192–204. 10 Downe S, Finlayson K, Tunçalp Ö, Metin Gülmezoglu A. What matters to can make that locally driven transformation possible. women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women. BJOG 2016; 123: 529–39. Lynn P Freedman 11 Mumtaz Z, Levay A, Bhatti A, Salway S. Signalling, status and inequities in Averting and Disability Program (AMDD), maternal healthcare use in Punjab, Pakistan. Soc Sci Med 2013; 94: 98–105. 12 Fixsen D, Blase K, Metz A, Van Dyke M. Implementation science. In: Columbia University Mailman School of Public Health, New York, Wright JD, ed. International encyclopedia of the social & behavioral NY 10032, USA sciences, 2nd edn. Oxford: Elsevier, 2015: 695–702. [email protected] 13 Andrews M, Pritchett L, Samji S, Woolcock M. Building capability by delivering results: putting problem-driven iterative adaptation (PDIA) I received funding from the London School of Hygiene & Tropical Medicine to principles into practice. In: Whaites A, Gonzalez E, Fyson S, Teskey G, eds. support my participation in this Series. A governance practitioner’s notebook: alternative ideas and approaches. Paris: OECD, 2015: 123–33. 1 Graham W, Woodd S, Byass P, et al. Diversity and divergence: the dynamic burden of poor maternal health. Lancet 2016; published online Sept 15. 14 Sheikh K, Schneider H, Agyepong IA, Lehmann U, Gilson L. http://dx.doi.org/10.1016/S0140-6736(16)31533-1. Boundary-spanning: reflections on the practices and principles of global health. BMJ Glob Health 2016; 1: e000058. 2 Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016; published online Sept 15. http://dx.doi. org/10.1016/S0140-6736(16)31472-6.

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Maternal Health 1 Diversity and divergence: the dynamic burden of poor maternal health

Wendy Graham, Susannah Woodd, Peter Byass, Veronique Filippi, Giorgia Gon, Sandra Virgo, Doris Chou, Sennen Hounton, Rafael Lozano, Robert Pattinson, Susheela Singh

Maternal health is a big issue and is central to sustainable development. Each year, about 210 million women become Published Online pregnant and about 140 million newborn babies are delivered—the sheer scale of maternal health alone makes September 15, 2016 maternal well being and survival vital concerns. In this Series paper, we adopt primarily a numerical lens to illuminate http://dx.doi.org/10.1016/ S0140-6736(16)31533-1 patterns and trends in outcomes, but recognise that understanding of poor maternal health also warrants other This is the first in a Series of perspectives, such as human rights. Our use of the best available evidence highlights the dynamic burden of maternal six papers about maternal health health problems. Increased diversity in the magnitude and causes of maternal mortality and morbidity between and See Online/Comment within populations presents a major challenge to policies and programmes aiming to match varying needs with http://dx.doi.org/10.1016/ diverse types of care across different settings. This diversity, in turn, contributes to a widening gap or differences in S0140-6736(16)31534-3, levels of maternal mortality, seen most acutely in vulnerable populations, predominantly in sub-Saharan Africa. http://dx.doi.org/10.1016/ S0140-6736(16)31525-2, Strong political and technical commitment to improve equity-sensitive information systems is required to monitor http://dx.doi.org/10.1016/ the gap in maternal mortality, and robust research is needed to elucidate major interactions between the broad range S0140-6736(16)31530-6 of health problems. Diversity and divergence are defining characteristics of poor maternal health in the 21st century. See Online/Series Progress on this issue will be an ultimate judge of sustainable development. http://dx.doi.org/10.1016/ S0140-6736(16)31472-6, http://dx.doi.org/10.1016/ Introduction further illuminate the changing burden and so provide S0140-6736(16)31528-8, Around 210 million women become pregnant annually, insights for the new strategic frameworks for action in meaning that maternal health is not a marginal issue.1,2 the SDG era.5,6 Maternal health is key to sustainable development and to future generations. Poor maternal health as measured by mortality and morbidity, however, remains an issue Key messages for marginalised women—those women who are • Pregnancy and childbirth affects the lives of millions of women and families worldwide vulnerable by virtue of where they live or who they are. each year. At this scale, sustainable development goal (SDG) 3 will not be achieved As the world moves from Millennium Development without reducing the burden of poor maternal health in all populations. Goals (MDGs) to Sustainable Development Goals • Progress has been made in reducing maternal mortality globally, but this is patchy at (SDGs), patchy progress across regions and countries regional and national levels—the hard-won gains over the last 25 years in some has been achieved in the reduction of maternal mortality. countries are susceptible to slow down. High mortality con tinues in some populations, • The causes of maternal mortality and morbidity are increasingly diverse, including a presenting a major challenge to one of the strategic shift in the contribution of non-communicable diseases, reflecting large-scale cornerstones of the SDG agenda—reducing inequities— demographic, epidemiological, socioeconomic, and environmental transitions. 3 “leaving no one behind”. In 1876, William Farr • This diversity of burden has major implications for the crucial policy and programmatic commented on maternal death as “A deep, dark goal of matching needs with care. Diverse maternal health needs require diverse continuous stream of mortality” and asked “how long is maternity services, within the framework of universal health coverage. 4 this sacrifice to continue?”. Drastic reductions in • At the dawn of the SDG era, the distribution of poor maternal health is highly maternal mortality—ending the sacrifice to which inequitable between and within populations; the gap between the group of countries William Farr refers—are realistic, and have already been with the lowest and highest maternal mortality increased from around 100 times to achieved in some countries and for some women. The 200 times difference between 1990 and 2013. challenge to replicate this success for all populations by • The highest burden of maternal mortality and severe morbidity clusters where 2030 is complex but not insurmountable. In this Series health systems are weakest and where the broader context is challenging, such as paper, we examine two important contributors to the in fragile states. challenge: first, the increasing diversity in the magnitude • In all countries, the burden falls disproportionately on the most vulnerable groups of and causes of maternal mortality and morbidity and, women. This reality presents a challenge both to the rapid catch-up required to achieve second, the widening inequities or divergence in these grand convergence and to the underlying aim of the SDGs—“to leave no one behind”. key indicators, between countries and within popu- • Reliable population-based data on poor maternal health, disaggregated by key lations. This diversity and divergence emphasises the indicators of vulnerability, are essential to monitor widening inequities, and to inform dynamic nature of the burden of maternal mortality and innovative policies and programmes to halt this divergence and to manage the morbidity and hence the key need for dynamic health increasing diversity of burden.. systems. We aim to use the best available evidence to www.thelancet.com 7 Series

http://dx.doi.org/10.1016/ This paper is the first in the 2016 Lancet Series on SDGs include just one explicitly framed health goal out S0140-6736(16)31527-6, maternal health. It focuses on creating the overall picture of 17: “Ensure healthy lives and promote well-being for http://dx.doi.org/10.1016/ and thus relies heavily on aggregate evidence, which all at all ages”.17 This goal acknowledges a social S0140-6736(16)31395-2, and http://dx.doi.org/10.1016/ enables large-scale regional and international com- determinants framework built on the two-way relation- S0140-6736(16)31333-2 parisons. Both the ’ Maternal Mortality ship between health and development.18 The way SDG3 Department of Infectious Estimation Inter-agency Group (MMEIG)7 and the Global is framed has significance for all health conditions, Disease Epidemiology, London Burden of Disease (GBD)8 study estimated maternal with promotion of a broader perspective and School of Hygiene & Tropical health parameters at global, regional, and national levels, acknowledgment of diversity. SDG3 goes beyond Medicine, London, UK (Prof W Graham DPhil, and used different but overlapping data inputs, data mortality to consider morbidity, disability, and func- S Woodd MSc, V Filippi PhD, adjustments, and modelling methods. In this Series tionality; it goes beyond physical health to include G Gon MSc, S Virgo PhD); paper, we did not aim to compare and cross-validate social and mental well being and also goes beyond Institute of Education for different estimates, something that other papers have individual episodes to a life-course perspective and Medical and Dental Sciences, 9–11 University of Aberdeen, undertaken. Instead, we pluralistically use both UN intergenerational or intra-household effects. Crucially, Aberdeen, UK (Prof W Graham); and GBD sources, drawing on each depending on the SDG3 emphasises the universal human right of every Umeå Centre for Global Health degree of temporal or regional specificity the sources individual to health. This emphasis provides renewed Research, Epidemiology and Global Health, Department of provide, along with other data to produce the most impetus and urgency to address the inequitable burden Public Health and Clinical appropriately disaggregated statement of the burden of of poor maternal health. In this paper we follow the Medicine, Umeå University, poor maternal health. We acknowledge that useful conceptualisation used in the GBD study8 and refer to Sweden (Prof P Byass PhD); insights can also be obtained from large-scale studies and burden as the effect of pregnancy-related health Medical Research Council/Wits University Rural Public Health datasets from individual countries. Our focus, however, is problems as measured by mortality and morbidity. Key and Health Transitions Research on lessons across major world regions, and specifically questions need to be revisited on where and whom this Unit (Agincourt), School of for low-income and middle-income countries (LMICs) burden falls and on the evidence for divergence and Public Health, Faculty of Health where levels of fertility (the primary exposure) and increasing inequities. Sciences, University of the Witwatersrand, Johannesburg, maternal death (the most adverse outcome of pregnancy- Reconceptualisation of burden has already occurred for South Africa (Prof P Byass); related health problems) are highest. This macro-level the broader domains of women’s sexual and reproductive Department of Reproductive focus is inevitably limited by the availability of relevant health and rights.19 Life-course approaches have emerged Health and Research, World data. We used three main approaches to creatively fill the as unifying frameworks,20 bringing together important Health Organization, Geneva, 12,13 Switzerland (D Chou MD); gaps: our own review of systematic reviews on a broad temporal dimensions for women and for their offspring. 14,15 Reproductive Health range of the morbidities identified by WHO; a Thus the fetal origins of adult disease link with maternal Commodity Security Branch, structured review of papers with international com- conditions in pregnancy, such as diabetes; life long United Nations Population parative analyses and grey literature published since advantages emerge from appropriate maternal nutrition,21 Fund, New York, NY, USA (S Hounton PhD); Centre for 2005; and secondary analyses of large-scale international and the long-term sequelae of childbirth, such as Health Systems Research, data series available in the public domain. prolapse, become visible. Examples of programmatic National Institute of Public responses include attention to the first 1000 days,22 Health, Cuernavaca, Acknowledgment of diversity in the burden of emphasising preconception and adolescent health.19,23 (Prof R Lozano MD); Institute for Health Metrics and Evaluation, poor maternal health University of Washington, As the MDG era ended, almost half of the world’s Maternal mortality and beyond Seattle, WA, USA estimated population of 7·3 billion were female, about The current strategic frameworks5,6 for the post-MDG (Prof R Lozano); South African 52% of whom were aged 15–49 years, and a further 5% period appropriately emphasise the unfinished agenda of Medical Research Council 1 Maternal and Infant Health were girls aged 12–14 years. With an estimated the estimated 98% of maternal deaths that are Care Strategies Unit, University 210 million and 140 million livebirths preventable.24,25 This emphasis should not, however, of Pretoria, Pretoria, South annually, the sheer scale of these numbers cannot be preclude acknowledgment of a broader range of Africa (Prof R Pattinson FRCOG); ignored.1,2 Ensuring the good health of women and pregnancy outcomes for women and newborn babies, and Guttmacher Institute, New 19,26,27 York, NY, USA (S Singh PhD) newborns during and after pregnancy, as well as and their implications for interventions. The shift Correspondence to: prevention of unintended pregnancies, has enormous from normality to pathology and back within one Prof Wendy Graham, implications for health systems. Thus while elimination pregnancy and between pregnancies is often un- Department of Infectious Disease of preventable maternal mortality16 should remain a predictable, mediated by a range of risk factors and Epidemiology, London School of priority, it is also timely to recognise death as the tip of broader determinants that influence uptake of care as Hygiene & Tropical Medicine, London WC1E 7HT, UK the iceberg beneath which the true diversity of the well as the availability of secondary or tertiary prevention. [email protected] burden or consequences of pregnancy-related health This complexity requires special attention because of the problems— ie, poor maternal health. Now is the moment implications for interventions, programmes, and to revisit this burden and so refine priorities and bases policies, in terms of how to match needs with care, at for judging progress. both individual and population levels. Similarly for measurement and research, routine information systems The new agenda for action need to be woman and family based, and to link health The SDG agenda reflects a new chapter in which the states across time and between a woman and her future needs of human beings are conceptualised. The children.

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What have been major drivers of change in the burden indicate this obstetric transition is underway in middle- of poor maternal health? income populations, and is apparent in historical In this section, we highlight four transitions that define patterns from high-income countries.31 and influence diversity and divergence in the burden as Demographic and epidemiological transitions need to measured by maternal mortality and morbidity: the be interpreted in the light of the socioeconomic transition demographic, epidemiological, socioeconomic, and and political drivers of change.32 As noted in The Lancet’s environmental transitions. Women and Health Commission,19 these transformations The demographic transition towards reduced fertility disproportionately affect women’s health, rights, and and mortality provides a framework for understanding roles, because of biological and gender-specific drivers. and prediction of population growth, change, and Similarly, the environmental transition of climate redistribution.28 Global fertility patterns are closely linked change, environmental degradation, and natural to maternal health because pregnancy is the prerequisite. disasters, brings changes that are not gender neutral.19 Although fertility has declined in almost all world These environmental changes broadly affect human regions,1 the young age structure of the population and health and well being, but particularly women in relation the continuing high unmet need for contraception— to, for example, opportunity costs of increased time spent estimated at 225 million women in 20142—continue to collecting fuel and water.33 drive high rates of population growth. Population growth has obvious repercussions for sustainable development, How do we know about the burden of poor maternal particularly in LMICs with fragile health systems.22 health? Projected numbers of pregnancies and deliveries have The range of data sources at national and international major consequences for achievement of equitable levels has changed little over the past half century, coverage and adequate quality of maternity services. including routine health information systems, vital Increased life expectancy associated with the demo- registration, and population-based censuses and graphic transition and changing roles of women are two surveys.34 Many limitations in these data sources persist, important factors linked to older age at first birth, and so such as incompleteness and poor reliability35—as does to increased prevalence and impact of obstetric the stark reality that the poorest information exists in the complications and non-communicable diseases, such as poorest contexts alongside the poorest maternal health.36 diabetes. This increase in complications shows the inter- Almost two-thirds of births and a greater proportion of action between demographic change and the epi- maternal deaths are unregistered or misclassified,34 and demiological transition, in which patterns of disease population-based data on maternal morbidity, stillbirths, shift from acute communicable episodes towards chronic and newborn outcomes are particularly sparse. Improved and non-communicable conditions.29 A variant specific to methods in data capture, processing capacity, and maternal health is called the obstetric transition, com- analytical techniques, are encouraging but lack prising a phased shift from high to low fertility and widespread implementation. Initiatives in LMICs to maternal mortality, and from a high to a low proportion strengthen the availability of actionable data on maternal of deaths due to direct obstetric causes.30 Several analyses deaths—referred to as Maternal Death Surveillance and

Maternal mortality ratio Number of maternal deaths Lifetime risk of maternal death* 1990 ratio 2015 ratio % change Average annual 1990 2015 1990 2015 Absolute Relative (80% UI) (80% UI) 1990–2015 % change change change World 385 (359–427) 216 (207–249) 44% 2·3 (1·7–2·7) 532 000 303 000 73 180 107 2·47 HICs 23 (22–25) 12 (11–14) 48% 2·6 (2·1–3·0) 3500 1700 2400 4900 2500 2·04 LMICs† 430 239 44% 2·4 .. 302 000 .. 150 .. .. Sub-Saharan Africa 987 (898–1120) 546 (511–652) 45% 2·4 (1·6–2·8) 223 000 201 000 16 36 20 2·25 Northern Africa 171 (145–204) 70 (56–92) 59% 3·6 (2·4–4·5) 6400 3100 130 450 320 3·46 East Asia 95 (79–114) 27 (23–33) 72% 5·0 (4·0–6·0) 26 000 4800 370 2300 1930 6·22 East Asia excluding China† 51 43 16% 0·7 ...... Southern Asia 538 (457–641) 176 (153–216) 67% 4·5 (3·5–5·2) 210 000 66 000 40 210 170 5·25 Southeastern Asia 320 (277–376) 110 (95–142) 66% 4·3 (3·1–5·0) 39 000 13 000 87 380 93 2·07 Western Asia 160 (132–199) 91 (73–125) 43% 2·2 (0·8–3·4) 6700 4700 130 360 230 2·77 Caucasus and central Asia 69 (65–73) 33 (27–45) 52% 3 (1·7–3·8) 1300 610 360 1100 740 3·06 Latin America and the Caribbean† 135 60 50% 2·8 14 000 6000 220 760 540 3·45 Oceania 391 (242–673) 187 (95–381) 52% 3·0 (1·1–4·9) 780 500 54 150 96 2·78

United Nations data from Alkema and colleagues.7 HICs=high-income countries. LMICs=low-income and middle-income countries. UI=uncertainty interval. *Expressed as 1 in N. †Uncertainty intervals not available.

Table : Global and regional estimates of maternal mortality by Millenium Development Goal region.

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A Response—is an important development but requires 37 51 1990 long-term investment and commitment. The Lancet 49 2013 Series on counting births and deaths emphasised the importance of strengthening vital registration,38 and such routine cause-of-death assignment is essential for 40 monitoring of maternal deaths.39 Although challenges 36 remain, the volume of data for global comparisons has 31 32 increased over the past decade, strengthened by links to 29 accountability mechanisms such as the Commission on 26 25 Information and Accountability and Independent Expert 22 40 21 21 Review Group. 17 Classifications of causes of maternal mortality and 13 morbidity have varied over time. Changes such as the introduction of late maternal deaths into International Statistical Classification of Diseases and Related Health Problems 10th Revision, and revisions in categorisation 1 1 of pregnancy-related deaths in women with HIV/AIDS, present challenges to the tracking of causes over time.36,41 HIV Sepsis Some conditions, such as the complications of unsafe abortion, continue to be under-reported in routine and HaemorrhageHypertension Indirect causes 42 Other direct causes ad-hoc sources, while others remain poorly captured by health services, such as post-partum genital tract B 39 Sepsis and other Complications infection. However, some advances in maternal maternal infections of abortion classification have occurred. The GBD study43 brought (10%) (15%) new insights on risk factors, co-morbidities, and sequelae, and their association with national socio- demographic scores. Similarly, work by WHO defined maternal morbidity as “any health condition attributed to Other maternal disorders and/or aggravated by pregnancy and childbirth that has a (21%) negative impact on the woman’s wellbeing”, and has Haemorrhage (22%) identified 121 diagnostic categories, so illustrating the diversity of the morbidity burden.14,15 This definition of maternal morbidity builds on earlier WHO work to Obstructed labour 44 (9%) develop standardised definitions of near miss cases. Indirect causes Acknowledgment of the potential for biases in Hypertensive disorders (12%) 45 (11%) HIV/AIDS morbidity data is crucial. Information about maternal (0%) morbidity is frequently collected in hospital studies and thus only representative of women who seek care. C Maternal morbidity gathered through community-based Sepsis and other Complications maternal infections of abortion studies is rare in LMICs, and estimates of prevalence (9%) (18%) from self-reporting generally mismatch with those derived from medical assessment.46 Studies reveal very high proportions of women who report pregnancy-related complications,47 suggesting self-perceived ill health is not Other maternal simply a result of biological change but also of social disorders 48,49 (22%) support and influences. The few community-based Haemorrhage (18%) studies that exist have focused on direct obstetric complications, and little is known about the nature and incidence of many indirect complications aggravated by Obstructed labour pregnancy, such as asthma. (8%) Indirect causes Hypertensive disorders (12%) Diversity in the burden of poor maternal health (12%) HIV/AIDS (1%) Maternal mortality The number of maternal deaths globally has fallen con- 50 Figure : Causes of maternal death in 1990 and 2013 tinuously since 1990. The UN7 estimates 303 000 maternal (A) Cause-specific maternal mortality ratios, 1990 and 2013 (maternal deaths from cause per 100 000 livebirths). (B) Percentage distribution of causes of maternal deaths occurred worldwide in 2015. This estimate mortality, 1990. (C) Percentage distribution of causes of maternal mortality, 2013. corresponds to a fall in the maternal mortality ratio of

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44% over 25 years (table 1). Such a decline is substantial declines from 1990 to 2015 varying from 5·0% in east in view of the number of women entering the Asia (China included) to 2·2% in western Asia. Declines reproductive period and the number of pregnancies and in maternal mortality accelerated for most world regions livebirths over the same time frame has steadily in 2005–15 compared with 1990–2004.7 National diversity increased. The decrease in the death numerator and the was extensive, with the highest annual decline in MMR increase in the livebirths denominator means the among all LMICs occurring in the Maldives at 9·2%, and maternal mortality ratio (MMR) has fallen from the joint seond highest declines occurring in Cambodia 385 (uncertainty interval 359–427) per 100 000 in 1990, to and Bhutan at 7·4%. In terms of achievement of the 216 (207–249) per 100 000 in 2015.7 Based on these MDG5a target, of 95 countries with an MMR over 100 in midpoint estimates and uncertainty intervals, there can 1990, nine achieved a 75% decline by the end of 2015. be reasonable confidence that a reduction in the global Conversely, 26 countries appeared to have had no scale of maternal deaths has occurred. These reductions reduction, and three countries showed increases in should be qualified by two messages: first, progress has MMR over the period (Guyana, South Africa, and been extremely patchy geographically, and second, the Suriname). The wide uncertainty boundaries for most MDG5a target of a 75% decline in the global maternal national estimates emphasise the need for caution in mortality ratio from 1990 to 2015 was not achieved. interpretation of national trends. Nevertheless, the Maternal mortality varies widely across countries and overall diversity in rates of change is striking. world regions.7 The overall maternal mortality ratio for Figure 1 shows the global picture of cause-specific high-income countries (12 per 100 000 livebirths) is mortality, using the GBD data, comparing 1990 with 2013.50 46 times lower than the highest figure in sub-Saharan All cause-specific MMRs appear to have declined over Africa (546 per 100 000). Various indicators show wide time, with the exception of HIV; the largest absolute diff erentials—lifetime risk reflects the widest gap decline occurred for haemorrhage, which had the highest because it is influenced by both levels of fertility and risk MMR in 1990. The cause showing the smallest decline was of maternal death per livebirth. The highest estimated abortion, as confirmed by other analyses,2 closely followed lifetime risk in 2015 was one in 36 for sub-Saharan Africa by modest declines for hypertensive disorders and indirect versus one in 4900 for high-income countries—more causes. The diverse category of other direct maternal than a 100 times difference. The sub-Saharan African disorders, including life-threatening conditions such as region alone accounted for an estimated 66% (201 000) of embolism and complications of anaesthesia, had the global maternal deaths, followed by southern Asia at 22% second highest cause-specific MMR in 1990, but became (66 000 deaths). At national level, two countries account the highest by 2013. However, the influence of improved for one-third of the global total: Nigeria at 19% differential diagnosis on these trends is hard to assess and (58 000 deaths) and at 15% (45 000 deaths); together an increasing number of conditions are now included in with eight other countries, the proportion of global the other disorders category. Distribution of causes is maternal deaths reaches 59%. Thus, 5% of the world’s shown in the pie charts in figure 1; the increased proportion countries account for over half of maternal deaths. owing to abortion and decrease in haemorrhage are the Present levels of maternal mortality reflect diverse most notable shifts. This finding differs, however, from the rates of change since 1990. Table 1 summarises these results of an earlier systematic analysis and a systematic diverse changes for world regions, with annual average review by WHO.36,51 Say and colleagues36 estimated that

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Percentage of all maternal deaths of all maternal Percentage 5

0 SSA NA SA SEA LA CE HIC SSA NA SA SEA LA CE HIC SSA NA SA SEA LA CE HIC SSA NA SA SEA LA CE HIC Abortion Haemorrhage Hypertensive disorders Indirect

Figure : Trends in the percentage distribution of four main causes of maternal death for world regions, 1990 and 2013 Data are from GBD 2013 Mortality and Causes of Death Collaborators.50 SSA=sub-Saharan Africa. NA=north Africa and Middle East. SA=southern Asia. SEA=south eastern Asia, east Asia, and Oceania. LA=Latin America and Caribbean. CE=central Europe, eastern Europe, and central Asia. HIC=high-income countries. www.thelancet.com 11 Series

fraction: 20% of deaths are linked to pre-existing medical SSA NA SA SEA LA CE HIC conditions in high-income countries, compared with Abortion 12% in sub-Saharan Africa.36 An important differentiating 1990 128·0 21·9 46·9 15·1 9·7 4·4 1·3 cause here is HIV: 6·4% of maternal deaths in 2013 92·0 11·4 16·9 4·5 3·7 1·0 0·6 sub-Saharan Africa and 2·7% in high-income countries Haemorrhage are HIV related. Estimates of the probable contribution 1990 117·1 36·1 89·7 22·8 13·0 2·8 0·8 of HIV/AIDS to maternal mortality vary considerably, 2013 75·1 16·6 23·3 4·9 4·5 0·9 0·3 with most estimates higher for sub-Saharan Africa than Hypertensive disorders the 6·4% as reported by WHO.36 Zaba and colleagues,41 1990 61·1 22·4 40·0 11·0 13·7 1·7 0·6 for example, estimated HIV-related maternal mortality to 2013 44·0 11·6 14·2 4·2 6·2 0·7 0·4 be 24%. Indirect 1990 56·0 13·1 51·5 13·9 6·5 2·5 0·5 Maternal morbidity and other outcomes 2013 46·6 7·9 17·9 3·6 4·5 1·0 0·8 In this section, we draw on multiple sources to construct a picture of morbidity related to pregnancy. The WHO SSA=sub-Saharan Africa. NA=north Africa and Middle East. SA=southern Asia. 30 SEA=southeastern Asia, east Asia, and Oceania. LA=Latin America and Caribbean. Multi-Country survey provides insights across CE=central Europe, eastern Europe, and central Asia. HIC=high-income countries. 28 LMICs, covering almost a third of a million women *Rates are calculated using maternal deaths from specific cause per who attended 357 district or tertiary hospitals. The 50 100 000 women of reproductive age, using GBD data. proportion of all deliveries and complications captured Table : Maternal mortality rates* for four main causes of maternal by these participating facilities is unknown, but selection death for world regions in 1990 and 2013 biases can be expected, as confirmed by a study in South Africa53 Table 3 summarises the key findings from the 7·9% of all maternal deaths were due to abortive outcomes WHO survey. Overall, for every maternal death there (95% CI 4·7–13·2%), including spontaneous or induced were just over five near misses. Of all women admitted and ectopic pregnancies; lower than the 13% to facilities, 0·8% experienced a near-miss episode reported in the earlier review51 of unsafe abortion. The (defined on the basis of organ dysfunction).54 The pattern proportion of maternal deaths attributed to indirect causes varied between direct obstetric causes, with rates for in the GBD study (12%)50 is low compared with other severe morbidity, near-miss and maternal deaths being sources. The figure was 27% in the WHO systematic highest for haemorrhage, although had the analysis,36 and a similar proportion was reported from worst near-miss to death ratio. Souza and colleagues30 INDEPTH demographic sites.52 also noted the high ratio for all infections, and significant Figure 2 and table 2 show patterns for four main death rates from this group of causes have also been causes of maternal death across seven world regions noted in the surveillance sites in the INDEPTH based on the proportional distribution and mortality network.52 rates in 1990 and 2013.50 Similar proportions of deaths We reviewed published systematic reviews to provide See Online for appendix from haemorrhage are seen across all LMIC regions further evidence on morbidity; the appendix contains and these decrease over time. Sub-Saharan Africa shows further details on the methods used and on the findings. the highest death rates with the smallest declines. For The burden of direct maternal morbidity was appreciable, two other direct causes—abortion and hypertensive with an estimated 27 million morbid episodes in 2015 disorders—more regional variation exists in from the five main direct obstetric causes. This proportions, rates, and trends. Sub-Saharan Africa has a estimation includes data from systematic reviews on higher proportion and death rates owing to abortion post-partum haemorrhage (prevalence 6·2–10·8%), than to hypertension, but the reverse is true in Latin eclampsia (0·5%), pre-eclampsia (2·3%), and severe America. The pattern of indirect deaths warrants further abortion complications (0·6%), together with the only comment. For six of seven regions, the proportional global estimate for puerperal sepsis (4·4%). Substantial contribution of indirect causes increased between 1990 direct maternal morbidity occurs in the antepartum and and 2013, almost doubling in the case of high-income post-partum period, with four systematic reviews on countries, but with more modest changes elsewhere. showing prevalence estimates of Thus the cause-specific patterns based on percentages 5·1% in Africa59 and 17·4% across LMICs.60 Extremely look different in 2013 compared with 1990, supporting common mild morbidities—such as nausea and our proposition of increasing diversity. However, vomiting—affected an estimated 69·4% of pregnant mortality rates due to indirect causes have declined women.61 The burden of indirect maternal morbidity was almost everywhere, but to a lesser extent than other also notable from our review, including from infectious causes, explaining the increasing proportion of indirect diseases and mental health conditions. Mental health is causes of all maternal deaths. commonly neglected by maternity services and is The WHO systematic analysis provides useful substantially associated with other forms of morbidity.62 additional information to breakdown the indirect causes Norhayati and colleagues,63 for example, found that

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All Post-partum Pre-eclampsia Eclampsia Puerperal Indirect* Abortion haemorrhage endometritis Women 314 623 4716 (1·5%) 7001 (2·2%) 1008 (0·3%) 321 (0·1%) 11 163 (3·5%) .. Livebirths 306 771 ...... Severe maternal outcome 3024 (96) 808 (25·7) 493 (15·7) 158 (5·0) 49 (12·4) 589 (19·0) 322 (10·2) (per 10 000 women) Maternal near miss (per 10 000 women) 2538 (81) 484 (17·6)† 262 (8·4)‡ 126 (4·0)‡ .. 467 (14·8) 295 (9·4) Maternal deaths (per 10 000 women) 486 (15) 105 (3·8)† 29 (0·9)‡ 32 (1·0)‡ .. 122 (3·9) 27 (0·8) Maternal near-miss mortality ratio§ 5·2 4·6 9·0 3·9 .. 3·8 10·9 Prevalence from systematic review in this .. 6·0–10·8% 2·3% 0·5% .. .. 0·6% Series paper Association with early neonatal .. .. 1·7 (1·4–2·2) 4·8 (3·2–6·2) .. 1·6 (1·1–2·2)¶ .. mortality; adjusted odds ratio (95% CI)

*Denominator 314 574; conditions include infections (pyelonephritis, influenza-like illness, sepsis, and other systemic infections), chronic hypertension, severe anaemia, , heart disease, lung disease, renal disease, and hepatic disease. †Denominator 274 985; excludes Japan, those with before labour, mode of delivery unknown, induced termination of pregnancy and laparotomy for ectopic; 95·3% received prophylactic uterotonics. ‡Denominator 313 030. §Maternal near miss:one maternal death. ¶Embolic disease, cancer, heart disease, lung disease, renal disease, or hepatic disease. Data are from Souza and colleagues30, Vogel and colleagues54, Sheldon and colleagues55, Abalos and colleagues56, Lumbiganon and colleagues57, and Dragoman and colleagues.58

Table : Association between maternal mortality and severe morbidity from the WHO Survey on Maternal and Newborn Health between 1·0% and 26·3% of post-partum women in pregnancy or from the incremental effects of repeated LMICs experienced depressive disorders. pregnancies. Many individual studies on the con- Increases in programmatic attention to newborn sequences of one pregnancy affecting maternal health in babies26 and stillbirths64 during the past decade have also subsequent pregnancies exist, but no large-scale brought greater consideration to maternal conditions. comparisons have been done. Consequences of previous The link between sexually transmitted infections in pregnancy can be physical (eg, fistulae), mental pregnancy and increased risks of pre-term delivery, for (eg, and depression), and socioeconomic (eg, example, has been understood for many years, and health-related debt, loss of productivity, and stigma of improved detection and treatment through antenatal repeated pregnancy loss or perinatal death), and borne by care would bring many benefits.2 Findings from the the woman, her offspring, household, or community.48 WHO Multi-Country survey54 show 20–30% of maternal The spatial diversity in maternal mortality reported complications coincide with stillbirths and early neonatal earlier in this paper can be expected to be broadly similar deaths, and data from country-specific studies suggest for life-threatening morbidity. The triple impact of high this estimate is conservative.65 A re-examination of fertility, poor maternal health, and low perinatal survival approaches for prediction of risks in pregnancy is needed in sub-Saharan Africa is clear. Southern Asia shows given the relevance to both maternal and newborn similarly high levels of as does outcomes.26 For mortality risks, the period around sub-Saharan Africa, but much lower rates for maternal childbirth is crucial whereas, for morbidity outcomes, disability-adjusted life-years and deaths to women of the window of opportunity for detection and management reproductive age—emphasising the varying patterns extends before, during, and after pregnancy (appendix). between maternal and newborn outcomes. Although A further area of renewed attention is nutrition. Rising population projections show a fall in total fertility rates levels of undernutrition and overnutrition in women of in all world regions, demographic momentum will reproductive age and in have major ensure high levels of growth through to 2050 in sub- implications for maternal, newborn, and child health.21 Saharan Africa. Of the 21 high-fertility countries, 19 are Overall, obesity (body-mass index ≥30 kg/m¯) has in this region.1 increased in LMICs in the past 15 years. However obesity Differential access to and thus uptake of interventions levels vary by region: wealthier women are most affected also contributes to the wide variation in the prevalence of in the poorest regions, women in middle-income life-threatening complications. Some differences in quintiles are most affected in South America, and women prevalence reflect variations in biological, genetic, or from all socioeconomic backgrounds are affected equally lifestyle disposing factors, such as for eclampsia or in the wealthiest regions. Obesity is associated with diabetes. However, access to and quality of care affect increased rates of ,66 diabetes,67 caesarean both primary prevention, as in the case of puerperal section,68 antenatal and postnatal depression,69 and infections,75 and secondary prevention through prompt adverse newborn outcomes.70–74 care for potentially life-threatening conditions, such as Long-term consequences for women’s health can arise post-partum haemorrhage. Provision of transport to from a life-threatening episode in the most recent health facilities in Ethiopia, for example, has been www.thelancet.com 13 Series

10 highest MMR countries 15–44 years, and the diversity of causes between Ratio highest:lowest populations has also increased—consistent with our 10 lowest MMR countries 250 observations. Earlier GBD analyses explored national 800 patterns in the burden of disease in relation to Gini coefficients, observing the link between key risk factors and poverty, and noted that many countries in sub- 600

200 MMR ratio Saharan Africa are being left behind.82 000 livebirths

400 What is the evidence for divergence between countries? 150 Maternal deaths are strongly clustered in LMICs, with

MMR per 100 200 the highest levels of maternal mortality found in the sub- Saharan African region but large numbers of deaths also 0 100 occur in south Asia. Furthermore, the global distribution 1990 1995 2000 2005 2010 (table 1) shows an upward trend in the proportion of Year deaths occurring in sub-Saharan Africa, from 42% in 1990 to 66% in 2015—a notable increase given that this is Figure : Relative difference in pooled maternal mortality ratios in ten countries with highest level* to ten countries with lowest level†, by year, not the most populous LMIC region. Fertility momentum 1990–2013 is a relevant driver here, which has implications for Data are from GBD 2013 Mortality and Causes of Death Collaborators.50 maternity services,22 and for coverage of other key MMR=maternal mortality ratio. *10 highest MMR countries (in one or more years): interventions along the continuum of care.83 From 2015 Afghanistan, Botswana, Burma (Myanmar), Burundi, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Equatorial Guinea, Eritrea, Ethiopia, Guinea, to 2050, half the world’s population growth is projected Guinea-Bissau, Liberia, Malawi, Mauritania, Papua New Guinea, Rwanda, Sierra to occur in nine countries,1 highlighting the acute Leone, South Sudan, and Zimbabwe. †10 lowest MMR countries (in one or more challenges facing countries in the central and west years): Australia, Austria, Canada, Denmark, Estonia, Finland, Greece, Ireland, Israel, African regions with high fertility, high maternal Italy, Montenegro, Norway, Singapore, Slovenia, Spain, Sweden, and Switzerland. mortality, and weak health systems.8 Figure 3 shows a steady increase over time in the associated with substantially decreased maternal relative difference of pooled MMRs for the ten countries mortality.76 Differences in effective coverage of care thus with the highest levels to the ten countries with the play a major part in the explanation of health and lowest, using annual estimates provided by the GBD mortality inequities between and within populations. study.50 Notwithstanding some fluctuations as specific countries dropped in and out of the 10 highest and Divergence in the burden of poor maternal health 10 lowest groups, the relative difference increased Acknowledgment that poor maternal health is unevenly steadily over the period, confirming divergence. The distributed is important so that programmatic efforts can relative difference increased from over a 100 times be prioritised and progress can be judged. The way difference in 1990, to over 200 times in 2013. Continued burden clusters is a reminder of the social determinants divergence would not only compromise the target for of health,18 reflecting inequities in wealth, rights, and 2030 of an MMR of 70, but would also imply the lack of a access to care. Improvements in average levels of rapid catch-up by the most health-disadvantaged maternal health problems can mask increases in relative countries which is essential for grand convergence. and absolute inequities between and within populations. Goli and Arokiasamy84 explored differential progress in This disparity is acknowledged in the strategic maternal and child mortality in 187 countries. An overall frameworks to accelerate progress in women’s and divergent trend was shown since 1990 but with some children’s health post-2015,5,6 and in the broader case to deceleration since 2000, a pattern attributed to reduced achieve equity in health or grand convergence.77 variance and skewness in rates of progress between The concept of grand convergence was proposed in countries. Goli and Arokiasamy84 also noted that some The Lancet’s Commission on Investing in Health 2035,73 countries are converging into clusters, defined by similar postulating that the next two decades provide a unique levels of mortality, with the largest cluster comprised of opportunity for investment to bring a substantial shift in countries with MMRs less than 300. In other words, global . Health-disadvantaged countries divergence and convergence of the burden can co-exist— would need to rapidly improve in the areas of child some clusters of countries converge to lower mortality, mortality, HIV, and tuberculosis. Since publication in late while others show little or no progress, and thus diverge. 2013, discussion has occurred on whether global health Strategies to prevent maternal and child mortality therefore data78 and projected trends show signs of convergence or need to focus not just on tracking of overall change, but divergence for particular world regions79 and for specific also to specifically target countries that lag behind.5 Other conditions such as HIV/AIDS.80 The results of the latest analyses6,7 suggest this parallel track prevailed during the GBD report81 show divergence has increased in age-specific MDG5 reporting period, and that countries in sub-Saharan mortality between countries for men and women aged Africa might drive divergence during the SDG era.

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However, alongside increasing gaps between countries, the highlighting the crucial importance of women’s agency potential for growing inequities within countries also to their health and wellbeing.19 exists, spatially in terms of rural and urban areas or remote districts,19,85 and between population subgroups. Grand divergence: the case of vulnerable populations Finally, we will examine populations that show extreme Is there evidence for increasing inequities in the burden divergence in the burden of poor maternal health. We of poor maternal health among women? refer to this as grand divergence because of the large Burdens should be monitored at the individual level and scale and substantial implications of such inequity. The within geopolitical areas to achieve health equity goals for all major transitions—demographic, epidemiological or conditions. The availability of reliable data disaggregated by obstetric, socioeconomic, and environmental—imply important covariates or determinants, such as educational population-wide progression between stages over time. status and access to care, has improved in LMICs over the However, evidence on maternal mortality suggests that past three decades, in part due to large-scale, population- geographically defined populations can contain based surveys such as the Demographic and Health Surveys subgroups who experience little change over time and (DHS) and Multiple Indicator Cluster Surveys.86 However, in often with limited options for future progress. These the case of maternal health, these sources have limited subgroups can be likened to the clusters of countries capacity to link individual characteristics with mortality or defined by similar levels of mortality, mentioned earlier morbidity, but a few research studies87,88 do enable this. The in the paper.84 We will focus on populations who are at association between determinants and health outcomes has greatest risk of being left behind—who will not been a crucial lever for national and international advocacy experience the rapid catch-up necessary for grand and action for infant and child health, and this lesson should convergence.77 We describe these as vulnerable be heeded for maternal health.22,89 populations with some—but not all—residing in One proxy approach for assessment of differentials in countries fulfilling usual definitions of fragility. mortality or morbidity for individual women would be to Fragility is conventionally applied to two main assume similar inequities to those seen for the uptake or population groups: those afflicted by humanitarian crises coverage of maternity services.90 Comprehensive popu- and those vulnerable because of social class, wealth, lation-based evidence from Countdown to 201587 relates religion, or ethnicity. The specific term fragile state is women’s socioeconomic and demographic characteristics applied to countries based on a broader set of factors. to coverage for 75 LMICs. Rich–poor gaps in women’s The Fragile State Index,96 for example, ranks countries uptake of maternity services persist across rural and by their stability based on 12 indicators, including urban areas within countries, and across very different deterioration of public services, security threats, and national levels of maternal mortality.22 A study91 compared sharp economic decline. In view of the gendered nature intersurvey trends for 47 LMICs on wealth quintiles for a of many risks in these settings, such as composite coverage index, including antenatal care and and a lack of routine and emergency services, these skilled attendant at childbirth. The rich–poor gap populations of women are indeed vulnerable. A declined from 28% in 2000, to 19% in 2014, while substantial proportion of this vulnerability is found in subgroups of women experienced increasingly similar fragile states in sub-Saharan Africa (appendix). For access to maternity services over time. However, the women, there is a stacking-up of poor maternal health, extent to which this progress also reduces the burden of with high fertility and the natural risks faced during maternal mortality and morbidity, depends on the key every pregnancy compounded by an absence of services, mediating factor of the quality of care received—timely, economic functionality, and human rights. appropriate, effective, and respectful care is required.6 Vulnerability is not, however, peculiar to fragile states. Exploration of inequities in both coverage and quality is Goli and Ariokasamy84 highlight the pockets of not possible from existing population-based surveys, disadvantage that reside within countries showing such as the DHS.92 Data captured in facilities, conversely, positive signs of progress at a national level. Groups of often has selection biases, and routine sources frequently vulnerable women at increased risk of death clearly lack information on relevant socioeconomic charac- persist across the world despite global reductions in teristics. The WHO Multi-Country hospital-based maternal mortality. The key issue is whether the well- survey30 does, however, provide some important insights. emphasised SDG goal of greater equity—to leave no one Women with the least education were found to be twice behind—will reach these vulnerable groups who as likely to have a severe maternal outcome and nearly six experience a disproportionate fraction of the burden of times as likely to die compared with those with the poor maternal health. highest education. The greatest difference was seen in Many equity targets primarily focus on geography;5,6 countries with the poorest overall level of socioeconomic this focus is necessary but not sufficient to address development.93 Moreover, the poorest women often pockets of vulnerability within populations. Universal receive the poorest quality of services, including health coverage is the proposed core mechanism for disrespectful and abusive care during labour,94,95 achievement of SDG3.73 In view of the increasingly www.thelancet.com 15 Series

diverse burden of pregnancy-related health problems and Contributors increasing divergence in levels of maternal mortality, WG, SW, PB, VF, and GG conceptualised the paper. GG, SW, and VF did health systems will need to be re-engineered for the literature search. Data analysis was done by WJG, SW, PB, VF, GG, and SV. SV, SW, and GG drew the figures. All authors contributed to vulnerable groups rather than just improving coverage data interpretation. WG, SW, PB, VF, and GG wrote the paper, and all using current implementation strategies. As Walker and other authors commented on multiple versions. The authors alone are colleagues83 note, innovative approaches to deliver care responsible for the views expressed in this article and they do not can help bend the curve of coverage and accelerate necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. progress, and future improvements might be faster if Declaration of interest starting levels are low.85 Multisectoral approaches offer We declare no competing interests. potential: by acknowledgment of the broader roots Acknowledgments of vulnerability, such as gender , and We thank the co-coordinator of the Series, Oona Campbell, lead authors promotion of opportunities for empowerment, including of other papers, and the members of the Executive Steering Group. girls’ education, and emphasis of important infrastructural The Bill & Melinda Gates Foundation and the MacArthur Foundation interventions such as roads, and water and sanitation.97 provided a grant to undertake some of this work. Crucially, integration of women’s own perspectives will References be essential to address their expressed needs in the 1 United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 post-2015 era. Revision, Key Findings and Advance Tables. https://esa.un.org/ unpd/wpp/Publications/Files/Key_Findings_WPP_2015.pdf Conclusion (accessed Aug 19, 2015). 2 Singh S, Darroch JE, Ashford LS. Adding it up: the costs and The burden of maternal mortality and morbidity is benefits of investing in sexual and reproductive health 2014. dynamic, with shifts in the magnitude, causes, and New York: Guttmacher Institute & UNFPA, 2014. distribution over time. The outcomes and care experiences 3 United Nations Secretary General. The road to dignity by 2030: ending poverty, transforming all lives and protecting the of the estimated 210 million women who were pregnant planet. 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A global 2014; 133: 863–71. review of the key interventions related to reproductive, maternal, 74 Kanadys WM, Leszczyńska-Gorzelak B, Jedrych M, Oleszczuk J. newborn and child health. Geneva: PMNCH, 2011. Maternal pre-pregnancy obesity and the risk of : 91 Victora CG, Barros AJ, Axelson H, et al. How changes in coverage a systematic overview of cohort studies with meta-analysis. affect equity in maternal and child health interventions in Ginekol Pol 2012; 83: 270–79. 35 Countdown to 2015 countries: an analysis of national surveys. 75 Graham WJ, Dancer SJ, Gould IM, Stones W. Childbed fever: Lancet 2012; 380: 1149–56. history repeats itself? BJOG 2015; 122: 156–85. 92 Graham WJ, McCaw-Binns A, Munjanja S. Translating coverage 76 Godefay H, Kinsman J, Admasu K, Byass P. Can innovative gains into health gains for all women and children: the quality care ambulance transport avert pregnancy–related deaths? One–year opportunity. PLoS Med 2013; 10: e1001368. operational assessment in Ethiopia. J Glob Health 2016; 6: 010410. 93 Tunçalp Ö, Souza J, Hindin M, et al. Education and severe maternal 77 Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: outcomes in developing countries: a multicountry cross-sectional a world converging within a generation. Lancet 2013; 382: 1898–955. survey. BJOG 2014; 121: 57–65. 78 Byass P. A transition towards a healthier global population? 94 Kruk ME, Kujawski S, Mbaruku G, Ramsey K, Moyo W, Freedman LP. Lancet 2015; 386: 2121–22. Disrespectful and abusive treatment during facility delivery in 79 Mahbubani K. The great convergence. Asia, the West, and the logic : a facility and community survey. Health Policy Plan 2014; of one world. New York: Public Affairs, 2013. published online Oct 1. DOI:10·1093/heapol/czu079. 80 Piot P, Abdool Karim SS, Hecht R, et al. Defeating AIDS-advancing 95 Freedman LP, Kruk ME. Disrespect and of women in global health. Lancet 2015; 386: 171–218. childbirth: challenging the global quality and accountability 81 GBD 2013 Risk Factors Collaborators. Global, regional, and agendas. Lancet 2014; 384: e42–44. national comparative risk assessment of 79 behavioural, 96 Messner JJ, Haken N, Taft P, et al. Fragile State Index 2015. environmental and occupational, and metabolic risks or clusters Washington, DC: Fund for Peace, 2015. of risks in 188 countries, 1990–2013: a systematic analysis for the 97 Velleman Y, Mason E, Graham W, et al. From joint thinking to joint Global Burden of Disease Study 2013. Lancet 2015; action: a call to action on improving water, sanitation, and hygiene 386: 2287–323. for maternal and newborn health. PLoS Med 2014; 11: e1001771.

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Maternal Health 2 Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide

Suellen Miller, Edgardo Abalos, Monica Chamillard, Agustin Ciapponi, Daniela Colaci, Daniel Comandé, Virginia Diaz, Stacie Geller, Claudia Hanson, Ana Langer, Victoria Manuelli, Kathryn Millar, Imran Morhason-Bello, Cynthia Pileggi Castro, Vicky Nogueira Pileggi, Nuriya Robinson, Michelle Skaer, João Paulo Souza, Joshua P Vogel, Fernando Althabe

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too Published Online soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or September 15, 2016 http://dx.doi.org/10.1016/ unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and S0140-6736(16)31472-6 morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes This is the second in a Series of unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when six papers about maternal health used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition See Online/Comment that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is http://dx.doi.org/10.1016/ typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health S0140-6736(16)31534-3, inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal http://dx.doi.org/10.1016/ S0140-6736(16)31525-2, and health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a http://dx.doi.org/10.1016/ systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, S0140-6736(16)31530-6 categorising them as recommended, recommended only for clinical indications, and not recommended. We also See Online/Series present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and http://dx.doi.org/10.1016/ increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, S0140-6736(16)31533-1, http://dx.doi.org/10.1016/ evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and S0140-6736(16)31528-8, delivered in a manner that respects, protects, and promotes human rights. http://dx.doi.org/10.1016/ S0140-6736(16)31527-6, Introduction (TMTS), might offset the gains resulting from http://dx.doi.org/10.1016/ S0140-6736(16)31395-2, and 8 The maternal health community has focused on improvements in maternal and perinatal health. TLTL http://dx.doi.org/10.1016/ strategies to reduce maternal mortality in low-income and TMTS represent the clinical care aspect of the S0140-6736(16)31333-2 8 and middle-income countries (LMICs), with efforts to widening diversity and divergence in maternal health. Department of , address the direct causes of pregnancy-related deaths, We suggest that adherence to evidence-based clinical Gynecology, and Reproductive increased skilled birth attendance, promotion of facility- guidelines can help individual practitioners in facilities Sciences, University of California, San Francisco, CA, births, and assurance of universal access to basic to avoid TLTL or TMTS. We present results of a systematic USA (Prof S Miller PhD, 1,2 maternal health care. These strategies have been partly appraisal of high-quality global and national clinical V Manuelli MD); Centro successful. Globally, an estimated 303 000 maternal practice guidelines (referred to here as guidelines). This Rosarino de Estudios deaths occurred in 2015, a 44% reduction from 1990.3 review lists recommended and not recommended Perinatales (CREP), Rosario, (E Abalos MD, Over the same period, antenatal coverage increased from interventions, as well as recommended interventions M Chamillard MD, V Diaz MD); 35% to 52%.4 Skilled birth attendance in LMICs increased that are potentially harmful if overused, and interventions Institute for Clinical from 57% to 70%.4 By 2013, facility births accounted for with inconsistent or conflicting recommendations. We Effectiveness and Health 44% of deliveries in LMICs.5 Nonetheless, maternal also present data from MICs on interventions that are Policy, Buenos Aires, Argentina (A Ciapponi Msc, D Colaci MD, 9 10 mortality and morbidity have not declined as rapidly as either TLTL or TMTS (low-income and high-income D Comandé BIS, F Althabe MD); hoped, with most countries not reaching Millennium countries have been covered elsewhere). Although we Center for Research on Women Development Goals targets.6 Poor maternal quality of only address maternal health, each evidence-based and Gender, University of care limits gains for improved maternal and perinatal intervention will also affect fetal and newborn health, as Illinois, Chicago, IL, USA (Prof S Geller PhD); Department 7 outcomes. A push towards births in facilities that have mothers and babies are inextricably linked. Furthermore, of Public Health Sciences, inadequate staff, training, infrastructure, and com- newborn guidelines were recently addressed in The Karolinska Institutet, modities, as well as insufficient evidence-based clinical Lancet’s Every Newborn Series.11 Stockholm, Sweden practice, often results in poor quality care.7 We refer to (C Hanson PhD); Department of Disease Control, London School this care as too little, too late (TLTL). Conversely, the Too little, too late of Hygiene & Tropical Medicine, rapid increase in facility use has been accompanied by Despite reductions over the past two decades, rates of London, UK (C Hanson); widespread over-medicalisation of birth, particularly in preventable maternal deaths remain unacceptably high Maternal Health Task Force, middle-income countries (MICs). This excessive Harvard T H Chan School of in LMICs, particularly in sub-Saharan Africa and south Public Health, Boston, MA, USA medicalisation, which we term too much, too soon Asia.12 The causes are complex and often rooted in www.thelancet.com 19 Series

Key messages structural health-system deficiencies, such as insufficient equipment, supplies, and drugs, which prevent health- • Preventable maternal morbidity and mortality is associated with the absence of timely care providers (referred to here as providers) from access to quality care, defined as too little, too late (TLTL)—ie, inadequate access delivering even the simplest and most cost-effective to services, resources, or evidence-based care—and too much, too soon evidence-based interventions.13–20 Inadequate numbers of (TMTS)—ie, over-medicalisation of normal antenatal, intrapartum, and postnatal care. skilled providers, insufficient training,18,21–25 or an absence • Although many structural factors affect quality care, adherence to evidence-based of guidelines for evidence-based care can be a problem guidelines could help health-care providers to avoid TLTL and TMTS. even when commodities are available.26,27 A range of • TLTL—historically associated with low-income countries—occurs everywhere there are geographical, social, and economic barriers might 28 disparities in socio-demographic variables, including, wealth, age, and migrant status. prevent women from accessing available care. This Often disparities in outcomes are due to inequitable application of timely evidence-based situation has been the focus of multiple papers, studies, 1,9,29–31 care. programmes, and policies. Stark disparities have also been reported within • TMTS—historically associated with high-income countries—is rapidly increasing countries, in which the burden of maternal morbidity everywhere, particularly as more women use facilities for childbirth. Increasing rates of and mortality is often concentrated among vulnerable potentially harmful practices, especially in the private sector, reflect weak regulatory women.8,32 Women can be disadvantaged in access to capacity as well as little adherence to evidence-based guidelines. health care and have worse outcomes owing to poverty, • Caesarean section is a globally recognised maternal health-care indicator, and an example geography, little or no financial protection, age, and of both TLTL and TMTS—with disparate rates between and within countries, and higher marital or migrant status.33–35 These differences have rates in private practice and higher wealth quintiles. Caesarean section rates are highest in been linked to insufficient (or providers’ differential middle-income countries and rising in most low-income countries. Although researchers adherence to) evidence-based care.36–38 Even in countries partly attribute the increase and variable rates to a shortage of clear, clinical guidelines and in which most of the population has access to well- little adherence to existing guidelines, multiple factors—economic, logistical, and resourced services, such as most high-income countries cultural—affect caesarean section rates. (HICs), many marginalised subpopulations continue to 10,39,40 • Quality clinical practice guidelines need to be developed that reflect consensus among experience a range of inequities in maternal health. guideline developers, using similar language, similar strengths of recommendation, and In 2010, black women in New York City were more likely 41 agreement on direction of recommendations. to die in childbirth (56 of 100 000) than were women in MICs such as North Korea (54 of 100 000)42 and Vietnam • Strategies for enhanced implementation and adherence to guidelines need multisectorial (54 of 100 000).42 Migrant status is an exemplar of TLTL in input and rigorous implementation science. HICs10 and LMICs. Recognition of the vulnerabilities of • A global approach that supports effective and sustained implementation of refugee and migrant women is a pressing concern, with respectful, evidence-based care for routine antenatal, intrapartum, and postnatal care unprecedented global numbers of internally and is urgently needed. externally displaced women—notably the millions fleeing Syria.38,43–45 Migration affects maternal care in sending countries (LMICs) and receiving countries Caesarean section rates (often other LMICs), and frequently results in increased 70 LIC maternal mortality and morbidities. Indigenous women MIC HIC within non-indigenous majority populations have higher 60 maternal mortality than do non-indigenous women46–50 (appendix, p 1). 50 Evidence-based care should apply to all women,

40 regardless of background. It should include respect for women’s circumstances, rights, and choices, as well as 30 close attention to screening for diseases or conditions, which might be more prevalent among refugee, migrant, 20 marginalised, or indigenous groups.51 Deliveries by caesarean section (%) 10 Too much, too soon Although TLTL remains a global public health problem, 0

73 73 73 73 61 79 76 76 61 76 79 79 79 76 79 79 80 81 82 83 75 76 84 77 78 the rapid increase in facility births has introduced new challenges. In many facilities, over-medicalisation of

USA (2014) childbirth is common practice, and can include excessive JapanFrance (2005) (2012) UK (2013–14) China (2011) Egypt (2013) (2013) Nigeria (2013)Malawi (2010) Sweden (2012) Turkey (2012) Tanzania (2010) India (2008–12) Spain (2006–12) ArgentinaGermany (2011) (2010)Lebanon (2008) Norway (2008–12) Canada (2006–12) Mexico (2006–12) or inappropriate use of interventions. For some of these DR Congo (2013–14)Malaysia (2006–12) Sri Lanka (2006–12) New Zealand (2006–12) interventions, no evidence of benefit exists, or there is Dominican Republic (2013) evidence of harm (eg, continuous electronic fetal Figure: Country-specific caesarean section rates in high-income, middle-income, and low-income countries monitoring,52 ,53 or enemas on admission for LIC=low-income country. MIC=middle-income country. HIC=high-income country. labour).54 TMTS also includes interventions that improve

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outcomes in some contexts, but are potentially harmful Respectful maternity care (Prof A Langer MD, and costly when used inappropriately or routinely. For Evidence-based maternal care in facilities should include K Millar MPH); University of Ibadan, Ibadan, Nigeria example, although induction and augmentation can be care that is humane and dignified, and delivered with (I Morhason-Bello MD); London effective (or even life-saving) procedures when indicated, respect for women’s fundamental rights. International School of Hygiene & Tropical their overuse (without a clear medical indication) has maternal-health organisations have increasingly highlighted Medicine, London, UK been associated with uterine rupture, perineal (I Morhason-Bello); lacerations, anal sphincter injury, and uterine prolapse.55,56 Unnecessary use of interventions can be costly for health Panel : Caesarean sections systems—a particular problem in LMICs in which Inequalities in caesarean section rates within and between countries are substantial, reflecting resources for maternal health are often scarce. These TLTL and TMTS. Low (<9%) caesarean section rates—indicators of TLTL—have been associated costs can be compounded if overuse of interventions with increased maternal and perinatal mortality and morbidity.71 Low caesarean section rates causes avoidable harm57 or increases the need for are found in LICs, particularly those with low rates of facility births, deficiencies in transport, additional interventions. surgical facilities, surgical and anaesthesia personnel and equipment, and blood transfusion In many HICs and a growing number of LMICs passing capacity, and a shortage of skilled attendants.29,73,85–88 Overuse of caesarean section for through the obstetric transition—shifting from high to non-medical indications—TMTS—has been associated with increased rates of maternal and lower maternal mortality, and from direct to indirect causes newborn adverse outcomes in a WHO multicountry survey.89 Additionally, unnecessary of maternal mortality58—trends towards excessive, un- caesarean sections add financial costs for health systems and individuals, and create barriers to necessary, or inappropriate use of obstetric interventions in universal health coverage.61 health facilities are a cause for concern. Examples include unnecessary ultrasound examinations,59 routine continuous Globally, caesarean section rates are rising in nearly every country and region, with 40·5% of all cardiotocography,52 routine ,53,60 non-medically births being by caesarean section in Latin America and the Caribbean, and increases in some 90 indicated caesarean sections,61 and high rates of labour LICs in sub-Saharan Africa (figure). However, national caesarean section rates obscure wide 91,92 induction and augmentation.62,63 In Brazil, longitudinal ranges within countries, as well as variations within facilities by providers. When stratified 93,94 95–100 29,73,86 studies have reported a temporal association between both by insurance status, public or private financing, and wealth quintile, these rates can increased labour inductions (from 2·5% to 43·0%) and differ widely (appendix, pp 2–4), and disparities exist in multiple factors, including providers’ increased caesarean section rates (from 27·6% to 43·2%) practice differences at facility and individual levels, financial incentives (private providers), and 101 with increased preterm birth rates (6·3% to 16·2%), inadequate adherence to clear evidence-based guidelines. For example, although Nigeria without any concomitant improvement in neonatal and India have overall low coverage of caesarean section (<10%), indicating TLTL, they have mortality.64 Evidence shows that women are frequently not the highest ratios between wealth quintiles, suggesting TMTS for wealthy women. informed of the risks, nor have they given informed Furthermore, hospital-level variations in caesarean section rates within countries have been 102 consent to use of these interventions.65 High rates of found, even within the same socio-demographic or economic groups. These differences induction of labour are strongly suggestive of TMTS.5,66 In a might reflect a failure to adhere to—or absence of—clear evidence-based guidelines at the 101 study conducted in LMICs, induction rates in facilities individual or facility level. ranged from 8·7% (Tanzania) to 37·9% (Benin).67 In a What is the appropriate caesarean section rate at the population level, avoiding TLTL and World Health Organization (WHO) survey, induction rates TMTS? In 2015, WHO published a statement on caesarean section based on systematic reviews ranged from 1·4% (Niger) to 35·5% (Sri Lanka).56,63 of ecological studies, noting that when population-based caesarean section rates increase Caesarean section is a globally monitored maternal above 15%, neither maternal or neonatal mortality rates improve.71,103,104 Another review health-care indicator and an example of an intervention slightly extends the limit of observed benefit to 19%.105 that can be TLTL or TMTS, with disparate rates between In 2010, an estimated 3·5–5·7 million unnecessary caesarean sections were done in HMICs, and within countries.68–70 Low-income countries (LICs)— whereas 1–3·5 million caesarean sections were needed, but not performed in LICs61—an especially in sub-Saharan Africa—have historically had indication of global extremes (figure). However, this range might not be relevant to facilities in very low caesarean section rates, probably reflecting which the case mix varies.71 WHO identified the Robson classification106 as a useful tool for inadequate availability,71–73 whereas HICs generally have assessment of caesarean section rates nationally and at health facility levels.72,103,107 A 2015 WHO higher caesarean section rates, indicating overuse.74 The paper proposed a mathematical model to generate expected caesarean section rates for highest caesarean section rates globally are seen in MICs: individual health facilities and systems. The C-model108 is based on clinical-obstetric Mexico (46·9%),75 Turkey (48·0%),76 Egypt (51·8%), Brazil characteristics, providing a reference for adequate or excessive use of caesarean section. Such a (56·7%),77 and the Dominican Republic (58·9%)78 tool could potentially help facilities and individual providers to optimise caesarean section use. (figure). High rates are often seen in LMICs in private practice and among women in upper wealth quintiles Although there are a multitude of social, economic, and health-system factors associated with (panel 1; appendix, pp 2–3), and might be masked in caesarean section use, we focus only on clinical interventions to address caesarean section national averages that seem reasonable if rates in other rates, such as trials of vaginal birth after caesarean section. Global organisations are creating 91,109–113 groups of women are very low. guidelines for interventions to reduce caesarean section rates, but the evidence is 92 Globally, caesarean section rates are rising, and medically insufficient for most strategies. More research is urgently needed on interventions for unnecessary caesarean sections are prevalent.61,114 According appropriate labour management to reduce unnecessary caesarean section and increase vaginal to WHO, 18·6% of women globally were giving birth by birth after caesarean section rates, thus avoiding TMTS. 90 caesarean section by 2016, with rates in many LMICS TLTL=too little, too late. TMTS=too much, too soon. LICs=low-income countries. HMICs=high-income and middle-income countries. rising precipitously, particularly in urban areas. www.thelancet.com 21 Series

GLIDE Technical Cooperation and Research, Ribeirão Preto, Panel : Interventions recommended for use SP, Brazil (C P Castro PhD, V N Pileggi MSc, Antenatal period • Advise about healthy lifestyle, including exercise for Prof J P Souza PhD); Department Early detection and treatment for complications and diseases maintenance of fitness, abstention from drinking alcohol, of Pediatrics (C P Castro, • Assess maternal health status by maternal weight smoking cessation or reduction, dental care, and mental V N Pileggi) and Department of Social Medicine (Prof J P Souza), measurement and body-mass index at admission, and health Ribeirão Preto Medical School, clinical screening for deep vein thrombosis and maternal • Provide information about consumption of well cooked meat, University of São Paulo, oedema at each antenatal visit drinking water and food preparation hygiene, washing hands Ribeirão Preto, SP, Brazil; • Assess the presence of fetal heartbeats at each antenatal visit after gardening and handling of animals (cats), to prevent Harbor-UCLA Medical Center, Los Angeles, CA, USA • Screen for mental health problems (including depression toxoplasma infection and other infectious diseases (N Robinson MD); and anxiety disorders), alcohol and drug misuse, and Organisation of antenatal care Safe Motherhood Program, psychosocial risk • Coordinate an integrated antenatal care plan with a group of San Francisco, CA, USA • Routinely test for ABO and D rhesus status, and screen for (M Skaer MPH); and UNDP/ professionals (including mental health) with whom the irregular red cell antibodies UNFPA/UNICEF/WHO/World mother is comfortable, ensuring that everyone involved in a Bank Special Programme of • Screen for pre-eclampsia by clinical risk assessment at woman’s care is trained and appropriately accredited for their Research, Development and admission, routine blood pressure measurement, and responsibilities Research Training in Human proteinuria at each antenatal visit Reproduction (HRP), • Provide women with normal course of pregnancy antenatal-care • Screen for intrauterine growth restriction by routine fundal Department of Reproductive models led by midwives, family doctors, trained nurses, or Health and Research, World height measurement of the at each antenatal visit professionals who specialise in maternal and perinatal care Health Organization, Geneva, • Screen for gestational diabetes by 50 g or 75 g 2-h oral • Establish the timing and number of antenatal care visits for Switzerland (J P Vogel PhD) glucose tolerance test at 24–28 weeks’ gestation low-risk pregnancies, in a safe environment, with a clear Correspondence to: • Request serological screening for maternal infections: HIV, Prof Suellen Miller, University of reference system for timely referral of women who require syphilis, hepatitis B, and rubella California, San Francisco (UCSF), additional care San Francisco, CA 94158, USA • Screen for asymptomatic bacteraemia by urine culture at • Use structured antenatal care records, informed consent [email protected] first visit procedures for interventions, and auditable records • Screen for anaemia with haemoglobin and haematocrit See Online for appendix obtained as part of a full blood assessment at first visit Intrapartum period • Screen for with smear test Respectful care and communication and birth companions • If available, offer a first trimester ultrasound for gestational • Offer women the possibility of being cared for by a midwife; dating provide one-to-one continuous supportive care • Offer, through an informed counselling process, the option of • Allow and encourage women to have a birth companion of a prenatal screening test for the most common clinically their choice significant fetal aneuploidies in addition to a second trimester • Treat every woman with respect, provide her with all ultrasound for dating, assessment of fetal anatomy, and information about what she might expect, ask her about her detection of multiples expectations, and involve her in the decisions about her care • Manage common symptoms during pregnancy, such as Assessments and monitoring of labour progress, and maternal and nausea and vomiting, heartburn, constipation, fetal health haemorrhoids, and back and pelvic pain • Perform vaginal examination every 4 h Disease prevention • Routinely assess the frequency of uterine contractions every • Prevent neural tube defects by supplementation with folic acid 30 min (400 µg/day) from preconception and until the 12th week of • Routinely assess maternal pulse every hour, maternal blood pregnancy pressure and temperature every 4 h, and frequently assess • Prevent pre-eclampsia by calcium supplementation passing of urine (at least 1 g/day) in women with low dietary calcium intake • Consider the psychological and emotional needs of the woman • Prevent spontaneous immunisation of Rh-negative women • Offer intermittent auscultation of the fetal heart rate to by anti-D immunoprophylaxis at 28 weeks women in established first stage of labour in all birth settings • Offer vaccines for influenza and tetanus (recommendations include frequency, timing, and recording) (or tetanus, diphtheria, and acellular pertussis) • Consider using a partograph; use a 4-h action line to monitor the progress of labour during second stage Health promotion • Document the presence or absence of substantial • Provide information about normal course of pregnancy, meconium-stained fluid when membranes rupture including breastfeeding if possible, by written material (waters break) (Continues on next page)

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(Panel 2 continued from previous page) Pain relief • Cord traction and palpation should be used after cord • Assess the labouring woman’s pain level and her desire for clamping in settings with skilled birth attendants non-pharmacological and pharmacological approaches to • Encourage women to have skin-to-skin contact with their pain relief babies as soon as possible after birth • Encourage women to adopt any upright position they find • Avoid woman–baby separation before the first hour comfortable throughout labour following birth, unless at the mother’s request; delay • Advise women that breathing exercises, immersion in water, postnatal routine procedures (eg, weighing, bathing, and and massage might reduce pain during first stage of labour, measuring); monitor the neonate’s condition during and that breathing exercises and massage might reduce pain skin-to-skin contact during second stage of labour • Encourage and support breastfeeding initiation within • Ensure the availability of opioids (eg, pethidine, first hour diamorphine) in all birth settings; inform women about their Postnatal period side-effects; if opioids are used for pain relief, provide Respectful care antiemetics in case of nausea or vomiting • Provide individualised, culturally and contextually appropriate • Ensure the availability of nitrous oxide (1:1 mixtures with care, responsive to changing needs, and based on individual oxygen) for pain relief in all birth settings; inform women care plan about its side-effects • In obstetric units, ensure the availability of regional During postnatal facility stay analgesia; inform women about risks and benefits and • Following an uncomplicated vaginal delivery, women are potential implications of epidural analgesia during labour; advised to stay at least 24 h in the facility provide regional analgesia for women who request it • Evaluate post-partum bleeding, maternal blood pressure, (including recommendations for drugs, dosing, and document urine void maintenance, co-interventions, and precautions); ensure • Evaluate perineal healing and look for signs of infection to intravenous access before initiation of analgesia identify and treat puerperal infection or sepsis (refer when necessary) Care during first-stage and second-stage labour • Provide pain relief • Routine hygiene measures taken by staff caring for women • Ask women about headache, assess bowel movements, and in labour, including standard hand hygiene and single-use promote early mobilisation to prevent thrombosis non-sterile gloves, are recommended to reduce • Facilitate rooming-in (mother and baby should stay in the cross-contamination between women, babies, and same room 24 h a day) and promote parent participation in health-care professionals educational activities related to newborn babies’ health • Allow and encourage women to drink water, juice, or isotonic • Anti-D immunoglobulin should be offered within 72 h to drinks, and eat light meals or snacks during labour every non-sensitised Rh-D-negative woman following • Encourage and help women to move and adopt any position miscarriage or birth of a positive baby they find most comfortable throughout labour and • Evaluate rubella immunisation and offer immunisation childbirth, except supine or semi-supine • Inform women that in the second stage they should be At discharge from health facility guided by their own urge to push • At time of discharge from health facility, provide information about danger signs for the mother and baby, and counsel Care during third-stage and fourth-stage labour women on adequate nutrition, hygiene, handwashing, • Inform women that active management of third stage and prevents post-partum haemorrhage • Provide iron and folic acid supplements for 3 months • (10 IU, intravenously or intramuscular) is the • Promote excusive breastfeeding from birth until 6 months of recommended drug for prevention of post-partum age; observe breastfeeding technique before hospital discharge haemorrhage • In malaria endemic areas, advise mother to sleep together • Ergometrine or 600 µg of oral misoprostol can be used as an with the baby under insecticide-impregnated bednets alternative if oxytocin is not available • Delayed cord clamping (done 1–3 min after birth) is Organisation and content of postnatal care after discharge recommended for all births while initiating essential • Recommend two to three post-partum visits after facility newborn care discharge • Early cord clamping (<1 min after birth) is not recommended • At each post-partum visit, provide information about danger unless the neonate is asphyxiated and needs to be moved signs for the mother and baby, and counsel women on immediately for resuscitation adequate nutrition, hygiene, handwashing, and safe sex (Continues on next page)

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(Panel 2 continued from previous page) • Ask about and resumption of , • Breastfeeding women between 6 weeks and 6 months and recommend pelvic floor exercises post partum opting for hormonal contraception can use • Assess mental health and wellbeing or post-partum progesterone-only oral contraceptives, progesterone-only depression using screening questions injectable contraceptives, and levonorgestrel and • Explore social support and assess for signs of domestic abuse etonorgestrel implants • Promote excusive breastfeeding from birth until 6 months • Breastfeeding women more than 6 months post partum of age; mothers should be counselled and provided with opting for hormonal contraception can use combined oral support for exclusive breastfeeding at each postnatal contact contraceptives • In malaria endemic areas, advise mother to continue to sleep • Women not breastfeeding less than 21 days’ post partum together with the baby under insecticide-impregnated should not use combined hormonal oral contraception; if bednets they have no risk factors for venous thrombosis, they can begin combined hormonal oral contraception after day 21; Family planning however if they are at risk for venous thrombosis, they • Provide family-planning counselling to all women during the should not begin combined hormonal oral contraception post-partum period until after day 42 • All women who are breastfeeding and less than 6 weeks post partum can use progesterone-only oral contraceptives and References given in appendix. levonorgestrel or etonogestrel implants

this approach, known as respectful maternity care.115–120 A showed that continuous companionship during labour systematic review121 for The Lancet’s Midwifery Series and childbirth was as low as 18%.126 However, 67% of identified that women value not only appropriate clinical women surveyed in Argentina expressed that they would interventions, but relevant, timely information and support have wanted a companion.127 Having a companion is not so they can maintain dignity and control. Respectful only a clinical intervention, but requires adaptations to application of evidence-based guidelines with attention to the labour wards to ensure all women privacy. women’s individual, cultural, personal, and medical needs is essential for universal access to quality maternal care. Clinical practice guidelines The need to promote and ensure respectful maternity Achievement of Sustainable Development Goal 3.1128—a care has evolved from growing recognition of mis- target of less than 70 maternal deaths per 100 000 livebirths treatment, abuse, disrespect, and of women by 2030—requires action on TLTL and TMTS. The global giving birth in facilities.122 Mistreatment and quality of increase in facility births presents an opportunity to clinical care are closely interlinked—many women who decrease maternal morbidity and mortality and reduce experience disrespect and abuse during childbirth might health inequities. To allow this opportunity to yield the also be subjected to poor standards of clinical care. largest effects, providers and women need universal Furthermore, women who experience mistreatment access to evidence-based interventions, so that effective, report they are less likely to return to facilities for future respectful care can be delivered. Evidence-based births.28 Guaranteed provision of respectful maternity interventions use the best available research to guide care requires efforts to respect and support providers as women’s and providers’ decision making and optimise well as women and families.123 Use of evidence-based maternal, fetal, and newborn outcomes. Guidelines based guidelines to tackle TMTS and TLTL needs to be coupled on this evidence, together with effective implementation with efforts to ensure that respect and dignity are integral strategies,129–131 have the potential to assist providers to parts of the good quality care that women should receive make the right decisions at the right time, and avoid the throughout pregnancy, childbirth, and the postnatal harmful extremes of TLTL and TMTS. period. These efforts need to be reflected in the health facility and systems as well as in guidelines. Guideline classifications For example, one indicator of respectful, evidence- We systematically reviewed evidence-based high-quality based care is for women in labour to be allowed and guidelines for routine maternity care to identify what encouraged to have a birth companion of their choosing,124 interventions and practices are promoted or discouraged which has been proven to improve maternal and for routine care of women at health facilities. We defined newborn health outcomes, and is strongly recommended intervention or practice as any practice, drug, device, by WHO.125 screening test, diagnostic test, therapy, or organisation of However, this practice is still not prevalent in publicly management of routine facility-based maternity care. funded maternity hospitals in most LMICs. Data from Details on the methods can be found in the appendix Argentina (City and Province of Buenos Aires) and Brazil (pp 5–6). Three groups of experts in antenatal, intra-

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partum, and postnatal care extracted recommendations on that a certain intervention should be used) and interventions for maternity care found in the recommended-against (the recommendation states that a highest-quality guidelines, and divided them into two certain intervention should not be used). Guidelines often groups: recommended-for (the recommendation states use different systems and terminology for development

Panel : Interventions recommended against use Antenatal period Disease prevention Early detection and treatment for complications and diseases • Prescriptions of medications such as antihypertensive drugs, • Routine prenatal breast examination is not recommended diuretics, heparin, nitric oxide donors, prostaglandin because no evidence supports its effectiveness in promotion precursors, progesterone, or coenzyme Q10 are not of breastfeeding, detection, or satisfaction recommended for pre-eclampsia prevention with antenatal care • Prescriptions of nutritional interventions such as dietary salt • Routine ultrasound after 24 weeks of pregnancy, routine restriction, fish oil, lycopene, or nutritional supplementation umbilical Doppler ultrasound, routine non-stress-test with folic acid, magnesium, vitamins C and E, or zinc are not cardiotocography, routine biophysical profile, and routine recommended for pre-eclampsia prevention fetal movement monitoring using specific alarm limits in • Hypocaloric diets for weight loss or weight maintenance in low-risk women with normal pregnancies are not pregnant women who are overweight or exhibiting recommended because they have no associated maternal or excessive gain during pregnancy are not recommended perinatal benefit because they have not been found to have any beneficial • Serological tests such as placental growth factor, inhibin A, effect on maternal health and might cause fetal damage soluble Fms-like tyrosine kinase, vascular endothelial • Nutritional and dietary supplemental strategies for the growth factor, soluble endoglin or serpin, urinary prevention of fetal growth restriction are not effective and albumin–creatinine ratio, or Doppler ultrasound velocimetry are not recommended of the uteroplacental circulation are not recommended for • Replacement of iron and folic acid with multivitamins to prediction of pre-eclampsia, until such screenings have been reduce maternal anaemia during pregnancy is not shown to improve pregnancy outcomes recommended in normal pregnancy • Routine screening for preterm delivery with tests such as • Vaccination of pregnant women against hepatitis B to serum chorionic gonadotropin, serum C-reactive protein, prevent infection in the neonate is not recommended; levels of cervicovaginal fetal fibronectin, measurement of vaccination of pregnant women with viable vaccines such as cervical length by transvaginal ultrasound or by repeated chickenpox is not recommended because the adverse effects digital cervical screening (pelvic examination) has no proven of live attenuated virus have not been sufficiently studied effects in prediction of the risk of preterm delivery in • Immunoprophylaxis with anti-D immunoglobulin in an pregnant women with normal pregnancies RhD-negative women with an RhD-negative partner is not • Screening for gestational diabetes with 75 g 1-h oral glucose required, provided that paternity has been ensured by tolerance test is not recommended because no established a private interview with the woman criteria exist for the diagnosis of diabetes based on the 1-h Health systems management post-load value • Routine involvement of obstetricians or gynaecologists in • Maternal age alone should not be used as a basis for the care of women with normal course of pregnancy is not recommendation of invasive testing when non-invasive recommended for improvement of perinatal results prenatal screening for aneuploidy is available. First • An antenatal care programme with a reduced number of trimester nuchal translucency should not be offered as a visits (fewer than five) is not recommended because it is screen without biochemical markers in singleton associated with increased perinatal mortality pregnancies • Routine screening for infections such as bacterial vaginosis, Intrapartum period chlamydia trachomatis, cytomegalovirus, parvovirus B19, Assessments and monitoring of labour progress, and maternal and or intestinal parasitism is not recommended for low-risk fetal health asymptomatic pregnant women • Do not carry out a speculum examination if membranes • Routine treatment of periodontal disease is not have certainly ruptured recommended to reduce the incidence of preterm birth, • Do not perform cardiotocography on admission for low-risk low birthweight, restriction of fetal growth, or premature women in suspected or established labour in any birth rupture of membranes setting as part of the initial assessment • Rutosides are not recommended during pregnancy to • Do not perform routine fetal pulse oxymetry improve symptoms of haemorrhoids • Do not make any decision about a woman’s care in labour • Monitoring of pregnant women for anti-A and anti-B on the basis of cardiotocography findings alone immune antibodies is not recommended

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(Panel 3 continued from previous page) Pain relief • Do not perform routine perineal shaving or enemas • Do not offer transcutaneous electrical nerve stimulation to • Do not perform perineal massage in the second stage of labour women in established labour • Do not carry out a routine episiotomy during spontaneous • Do not offer lidocaine spray to reduce pain in the second vaginal birth stage of labour • Do not perform Kristeller manoeuvre • Do not offer or advise aromatherapy, yoga, acupressure, Postnatal period acupuncture, or hypnosis, or water papules for pain relief • Palpation or measurement of uterus in absence of abnormal • Do not offer either H2-receptor antagonists or antacids bleeding is not recommended routinely to low-risk women • Routine use of antibiotics in low-risk women with a vaginal Care during first and second stage delivery for endometritis prophylaxis is not recommended • Do not offer or advise clinical intervention if labour is • Aspirin for thromboprophylaxis is not recommended progressing normally and the woman and baby are well • Vitamin A supplementation for the prevention of maternal (including amniotomy and oxytocin augmentation, even in and infant morbidity and mortality is not recommended women with epidural analgesia) • Discourage the woman from lying supine or semi-supine in References given in appendix. the second stage of labour

and formulation of recommendations, therefore we We categorise interventions as recommended-for or classified all extracted recommendations based only on recommended-against. We also refer to conflicting recom- direction, regardless of other factors (such as the strength mendations—ie, interventions that are inconsistently of the recommendation or quality of supporting evidence). recommended-for or recommended-against even in high- quality guidelines. The final category is recommended-for, but potentially harmful (if overused or used without clinical Induction of Augmentation Caesarean section Episiotomy labour with oxytocin indication)—this category describes interventions, such as induction of labour, which can be life saving, but increase East Asia and Pacific risk if used routinely. We have not conducted any critical China 7·0% (2010–11), 1·1% (2007–08) 27·0% (2007–14), 44·9% (2002), appraisal of the evidence supporting the interventions 6·4% (2007–08) 47·2% (2010–11) 82·0% (2001) recommended in the selected guidelines, as this was not Indonesia 25·5% (2006) 18·3% (2006) 12·9% (2012) 53·5% (2005) within the scope of the review. Laos ·· ·· 3·7% (2012) ·· Malaysia ·· ·· 16·0% (2006–12) 46·0% (2005) Intervention recommendations for women in facilities Mongolia 12·8% (2010–11) ·· 23·4% (2013), ·· 25·9% (2010–11) Three groups of expert reviewers identified Philippines 3·8% (2010–11), 25·0% (2007–08) 10·0% (2013), 63·7% (2005) 51 high-quality evidence-based guidelines from 163 4·3% (2007–08) 24·7% (2010–11) guidelines from 2010–15, described with their composite Samoa ·· ·· 12·8% (2009) ·· AGREE II scores in the appendix (pp 7–12). The selected Solomon Islands ·· ·· 6·2% (2007) ·· guidelines included recommendations for antenatal Thailand 6·1% (2010–11), 7·1% (2004–05) 32·0% (2012), 91·8% (2005) (25), intrapartum (15), and postnatal (19) care. Seven 8·3% (2007–08) 39·1% (2010–11) guidelines were issued by WHO and one jointly by Timor–Leste ·· ·· 2·1% (2009–10) ·· WHO, the International Federation of Gynecology and Vietnam 10·6% (2010–11), 4·4% (2007–08) 27·5% (2014), ·· Obstetrics (FIGO), and the national obstetrics and 5·7% (2007–08) 41·6% (2010–11) societies of the USA, Canada, UK, and Europe and central Asia Germany. The remaining guidelines were developed by Albania ·· ·· 34·1% (2013) ·· governmental and non-governmental organisations Armenia ·· ·· 23·8% (2013) ·· from HICs and MICs (Argentina, Australia, the Basque Azerbaijan ·· ·· 17·0% (2013) ·· Country, Brazil, Canada, Colombia, Ecuador, Italy, Japan, Belarus ·· ·· 26·6% (2013) ·· New Zealand, Norway, Scotland, Spain, UK, and the Bosnia and ·· ·· 24·1% (2013), ·· USA). We found no guidelines meeting our criteria that Herzegovina 13·9% (2012) were developed by LICs. Bulgaria ·· ·· 36·0% (2013) ·· We extracted 78 individual or groups of interventions Georgia ·· ·· 37·1% (2013) 17·4% (2003) recommended for use in routine antenatal (25), Kazakhstan ·· ·· 15·1% (2013) ·· intrapartum (28), and postnatal (25) care in low-risk Kyrgyzstan ·· ·· 9·2% (2013) ·· women attended at health facilities (panel 2). Macedonia ·· ·· 22·2% (2010) ·· 14 recommended-for interventions for antenatal care (Table 1 continues on next page) were related to assessments and diagnostic and screening procedures of maternal and perinatal

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pregnancy complications, four were for prevention of specific pregnancy complications, three for health Induction of Augmentation Caesarean section Episiotomy promotion, and four for organisation and content of labour with oxytocin antenatal care. For intrapartum care, we identified three (Continued from previous page) interventions for respectful care, seven for assessment Moldova ·· ·· 9·1% (2005) ·· and monitoring of the progress of labour and maternal Montenegro ·· ·· 23·6% (2010) ·· and fetal health, six for pain relief, and 12 for specific Romania ·· ·· 40·1% (2013) ·· care of the different stages of labour. For postnatal care, Serbia ·· ·· 26·8% (2012) ·· we identified one recommended-for intervention for Tajikistan ·· ·· 4·6% (2012) ·· respectful care, eight for assessment and care of the Turkey ·· ·· 50·3% (2013) ·· mother and the baby during postnatal stay at health Turkmenistan ·· ·· 6·6% (2012) ·· facilities, four for care at discharge, seven for Ukraine ·· ·· 16·9% (2013) ·· organisation and content of postnatal care visits, and five Uzbekistan ·· ·· 11·0% (2013) ·· for family planning. Latin America and the Caribbean We identified 37 individual or groups of interventions Belize ·· ·· 28·9% (2011) ·· which guidelines recommended were not used in routine Bolivia ·· ·· 19·5% (2008) ·· maternity care (panel 3). Of 19 recommended-against Brazil 38·6% (2010–11) ·· 56·7% (2013) ·· antenatal care interventions, ten concerned assessments Colombia ·· ·· 43·4% (2012) ·· and diagnostic and screening procedures of maternal Costa Rica ·· ·· 21·9% (2013) ·· and perinatal complications, seven were for prevention Cuba 20·0% (2004–05) ·· 12·2% (2004–05) ·· of specific pregnancy complications, and two were for organisation of antenatal care. Of 14 recommended- Dominican Republic ·· ·· 58·9% (2013) ·· against interventions for intrapartum care, four inter- Ecuador 12·2% (2010–11) ·· 45·4% (2010–11) ·· ventions regarded assessment and monitoring of the El Salvador 22·6% (2006) 18·8% (2006) 29·8% (2013) ·· progress of labour and maternal and fetal health, four Guatemala ·· ·· 16·3% (2008) ·· were for pain relief, and six were for specific care in the Guyana ·· ·· 13·7% (2009) ·· different stages of labour. We identified four recom- Honduras 10·5% (2006) 32·3% (2006) 19·4% (2011–12) ·· mended-against interventions for postnatal care. Jamaica ·· ·· 21·2% (2011) ·· Some interventions had conflicting recommendations Mexico 10·4% (2010–11), ·· 46·9% (2014) ·· 11·8% (2004–05) among different guidelines (appendix, p 14), and were Nicaragua 13·4% (2010–11), 4·5% (2007–08), 29·7% (2011–12), ·· recommended-for in some guidelines and recommended- 17·1% (2006) 32·1% (2006) 43·1% (2010–11) against in other guidelines—even when the guidelines Panama ·· ·· 27·7% (2013) ·· were concurrently published, albeit in different countries. Paraguay 1·8% (2010–11), ·· 46·3% (2010–11), ·· 7·2% (2004–05) 33·1% (2008) Coverage rates of interventions in MICs Peru 5·2% (2010–11), ·· 26·5% (2013), ·· To determine levels of underuse (TLTL) or overuse 5·0% (2004–05) 41·0% (2010–11) (TMTS), we searched for national, regional, or popu- Suriname ·· ·· 19·0% (2010) ·· lation-based MIC coverage rates of six intrapartum Middle East and north Africa interventions that are recommended, but potentially Algeria 6·8% (2004–05) 15·3% (2004–05) 16·3% (2012), ·· harmful if overused or used routinely (table 1). We 9·1% (2004–05) obtained coverage data for induction of labour Egypt ·· ·· 55·5% (2014) ·· (24 countries, range 1·8–71·0%), augmentation with Iran 71·0% (2011–12) 75·0% (2011–12) 47·9% (2009) 79·2% (2011–12) oxytocin (15 countries, 1·1–78·9%), routine amniotomy Iraq ·· ·· 22·2% (2011) ·· (Iran, 83·3% [data not shown in table]),132 caesarean ·· ·· 29·9% (2012) ·· sections (81 countries, 2·1–58·9%), and episiotomy Lebanon ·· ·· 23·2% (2004) ·· (11 countries, 17·4–91·8%). We found no data for Morocco ·· ·· 16·0% (2011) ·· continuous cardiotocography. Tunisia ·· ·· 26·7% (2012) ·· We searched for data for two recommended-against Yemen ·· ·· 4·8% (2013) ·· postnatal interventions as evidence of TMTS: routine South Asia administration of oral uterotonics after the third stage of Bangladesh ·· ·· 17·1% (2011), ·· labour and routine administration of antibiotics after normal 11·2% (2005–11) vaginal birth (appendix, p 13). Only six countries had national Bhutan ·· ·· 12·4% (2010) ·· level data for routine postnatal uterotonics (range India 11·8% (2010–11), 78·9% (2011), 19·2% (2010–11) 45·0% (2003) 17·5–92·0%). Rates of routine postnatal antibiotic use were 12·8% (2007–08) 2·3% (2007–08) available from five countries (1·2–60·6%). Maldives ·· ·· 41·1% (2011) ·· We searched for coverage rates of four interventions (Table 1 continues on next page) recommended for routine intrapartum and postnatal care www.thelancet.com 27 Series

Intervention recommendations and coverage Induction of Augmentation Caesarean section Episiotomy labour with oxytocin Our overview of high-quality, evidence-based guidelines for routine care of women in antenatal, intrapartum, (Continued from previous page) and postnatal care identified 78 recommended-for and Pakistan 10·7% (2010–11) ·· 15·9% (2012–13), ·· 34·6% (2010–11) 37 recommended-against interventions. In general, we Sri Lanka 35·2% (2010–11), 2·9% (2007–08) 31·0% (2007–14), ·· found many examples of interventions in these 35·5% (2007–08) 30·5% (2012) high-quality guidelines aiming to go beyond TLTL and Sub-Saharan Africa TMTS, as well as recommending respectful care and Angola 6·6% (2010–11), 5·9% (2007–08) 12·7% (2010–11) ·· communication. Respectful care included recom- 5·0% (2004–05) mendations to treat women with respect, ask them Cameroon ·· ·· 4·4% (2011) ·· their expectations, provide them with clear, concise Democratic Republic ·· ·· 5·9% (2011–12) ·· information to support decision making, and involve of the Congo them in decisions about their care. Among recom- Côte d’Ivoire ·· ·· 3·1% (2011–12) ·· mended-against interventions, several have been Gabon ·· ·· 10·5% (2012) ·· shown to cause avoidable harm if overused, or are Ghana ·· ·· 11·4% (2011), 17·4% (2003) simply unnecessary and dis respectful to women. 6·4% (2008) Examples of these include routine use of non-stress- Kenya 8·6% (2010–11), 3·6% (2007–08) 23·2% (2010–11), ·· test cardio tocography, bio physical profiles, ultrasounds 3·9% (2004–05) 6·7% (2008–09) after 24 weeks, and routine umbilical Doppler Lesotho ·· ·· 7·0% (2009) ·· ultrasounds; routine screening for infections (such as Mauritania ·· ·· 9·6% (2011) ·· bacterial vaginosis); absence of offers or advice on Namibia ·· ·· 15·1% (2013) ·· clinical interventions if labour is progressing normally Nigeria 5·4% (2010–11) 4·5% (2007–08) 2·2% (2013), 20·0% (2001) 19·7% (2010–11) and the baby is well (including amniotomy and oxytocin São Tomé and Príncipe ·· ·· 5·8% (2008–09) ·· augmentation); and routine use of antibiotics in women Senegal ·· ·· 5·7% (2014) ·· with a vaginal birth. South Africa ·· ·· 24·7% (2014) 63·3% (2003) Although scarce, available data for the coverage of interventions for TMTS in MICs are concerning. Sudan ·· ·· 6·6% (2010) ·· A population-based study134 of 186 548 births in five LMICs Swaziland ·· ·· 12·3% (2010) ·· found 52% (n=96 622) of women received maternal Zambia ·· ·· 4·4% (2013–14) ·· antibiotics in labour. Despite a wide range of variation— Data shown are coverage percentage and years of study. References given in appendix. indicating problems of TLTL and TMTS—we found national-level evidence of rising rates of interventions that Table : Coverage of selected interventions recommended only when clinically indicated during intrapartum care could be harmful if overused. These interventions included caesarean section, induction or augmentation, and routine episiotomy. One country—Iran—had an 83% (table 2). The interventions were breastfeeding initiated amniotomy rate.132 All high rates are indications of TMTS, within first hour (77 countries, range 17·4–98·4%), a birth which can carry harmful risks. Over-medicalisation of companion (42 countries, 0·1–56·7%), skin-to-skin contact labour and childbirth is clearly increasing—a complex (nine countries, 2·1–82·0%), and keeping the mother and problem which is being reported.29,135 An additional baby together (Brazil, 69·0% [data not shown in table]).133 complication is that TLTL and TMTS can coexist within countries and facilities; this distinction is often obscured Discussion by limited data that does not stratify by demographic or Importance of a move beyond TLTL and TMTS socioeconomic quintiles or other measures of inequity The maternal health field has long focused on TLTL, but (panel 1). This coexistence can be seen in caesarean TMTS can also produce harm.10 As facility births increase section rates stratified by public and private facilities and and the aetiologies of maternal morbidity and mortality by wealth quintiles (appendix, pp 2–4). shift in LMICs, TMTS becomes a global threat to Finally, as discussed in detail in this Series10 (and maternal, fetal, and newborn wellbeing. Coverage data previously explored in the Lancet’s Midwifery Series121), for national level implementation of maternal-health the lowest-cost option for care with the best outcomes interventions and recommendations are rare. None- and lowest rates of interventions could be with midwives theless, evidence shows increasing overuse of potentially as care providers and midwifery-led services (whether harmful interventions—especially caesarean section, hospital sited or free standing), with access to emergency inductions, and aug mentations—in facility births in services.121 LMICs. Improvements in development, dissemination, and strategies to globally increase adherence to clearly Problems in guideline implementation written guidelines might help providers move beyond Although development and dissemination of TLTL and TMTS. high-quality, clear guidelines are necessary, they are not

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sufficient to ensure evidence-based care. Adherence to regional levels were insufficient. Although numerous guidelines remains an enormous problem globally in all facility-based studies exist,132,145 few are representative of fields of health care. A large body of literature examines practices across the whole country, or their methods rely the failure of implementation of guidelines and the 19,136,137 so-called know–do gap. Individual studies and Immediate skin-to- Breastfeeding initiated Birth companion systematic reviews show that guideline imple mentation skin contact within first hour can be enhanced and sustained through multifaceted East Asia and Pacific approaches—including targeting of providers—such as China ·· 59·9% (2007–08) ·· dissemination of educational materials, audit and Indonesia ·· 49·3% (2012) 2·3% (2012) feedback, and targeted educational interventions Laos ·· 39·0% (2009–13) ·· (ie, simulations, continuing professional development, Mongolia ·· 77·5% (2005) ·· drills, and financial incentives).130,131,138 New technologies Philippines ·· 49·7% (2013), 39·9% 24·0% (2013) on the horizon, such as simple, low-cost vital-sign (2007–08) 139 140 monitoring devices or point-of-care diagnostics Samoa ·· 88·0% (2009–13) ·· might help to improve adherence. However, strategies Solomon Islands ·· 75·0% (2009–13) ·· that only target providers are likely to have limited Thailand ·· 52·6% (2007–08) ·· 141 effect. Improvement of adherence to guidelines Timor–Leste ·· 67·7% (2009–10) 47·6% (2009–10) requires a systems approach, with engage ment of Vietnam ·· 50·0% (2011), 63·9% 9·5% (2002) women and communities. Increased docu mentation of (2007–08) successful and unsuccessful approaches can improve Europe and central Asia guideline adherence in mater nity care, and allow these Albania ·· 41·1% (2008–09) 0·4% (2008–09) lessons to be shared. New approaches to implementation Armenia ·· 32·4% (2010) 0·0% (2010) merge social, political, and organisational strategies to Azerbaijan ·· 36·9% (2007) 0·6% (2006) help providers and women to mutually develop and Belarus ·· 21·1% (2005) ·· implement quality respectful care. Bosnia and Herzegovina ·· 56·7% (2006) ·· Georgia ·· 36·6% (2005) ·· Guideline inconsistencies and their consequences Kazakhstan ·· 67·8% (2010–11) ·· Guideline inconsistencies included recommendations for Kyrgyzstan ·· 82·5% (2014) 0·1% (2012) and against the same interventions—eg, routine screening Macedonia ·· 26·6% (2005) ·· for hepatitis C or gestational diabetes. Conflicting recom- Moldova ·· 66·7% (2005) 0·1% (2005) mendations might simply reflect differences in settings Montenegro ·· 25·2% (2005–06) ·· and contextual adaptation.142 However, this finding Serbia ·· 17·4% (2005–06) ·· highlights the absence of international consensus on the Tajikistan ·· 50·2% (2012), 60·9% 2·6% (2012) benefits and harms of routinely used interventions. (2005) Conflicting recommendations can confuse guidelines Turkey ·· 39·0% (2009–13) ·· 143 users, and create uncertainty as to why differences exist. Turkmenistan ·· 19·3% (2000) 0·5% (2000) Inconsistencies in just one recommendation can cast Ukraine ·· 41·5% (2007) 0·2% (2007) doubt on the entire set of guidelines or even on the use of Uzbekistan ·· 67·1% (2006) ·· guidelines completely. Use of different systems for grading Latin America and the Caribbean of evidence and different terminology can also create Belize ·· 50·6% (2006) ·· confusion for users and policy makers. Bolivia ·· 62·4% (2008) 22·5% (2008) Brazil 28·2% (2011–12), 44·5% (2011–12), 69·8% 18·8%* (2011–12) Guidelines from LICs 67·7% (2008) (2004–05) We identified no high-quality maternal-health guidelines Colombia ·· 64·1% (2010) 2·0% (2010) from LICs, which was of great concern, although our review Costa Rica ·· 60·0% (2009–13) ·· did not consider activities or efforts in adaption and Cuba ·· 70·2% (2006), 89·2% ·· implementation of international guidelines to local settings. (2004–05) Although guideline development requires substantial Dominican Republic ·· 45·0% (2013) 0·4% (2013) resources and methodological expertise, increased invest- Ecuador ·· 20·1% (2004–05) ·· ment and support is urgently needed for LICs to develop El Salvador ·· 31·2% (2002–03) ·· and implement locally specific, evidence-based maternal- Guatemala 22·6% (2010–13) 75·9% (2010–13), 55·5% ·· health guidelines. New tools, such as the ADAPTE (2008–09) Collaboration,144 might help LICs to move forward. Guyana ·· 57·8% (2009) 5·6% (2009) Honduras ·· 63·2% (2011–12) 2·3% (2011–12) Data for coverage rates Jamaica ·· 62·3% (2005) ·· Representative data for the coverage of interventions (Table 2 continues on next page) selected to demonstrate TLTL and TMTS at national or www.thelancet.com 29 Series

not useful for accurate measurements of the use of Immediate skin-to- Breastfeeding initiated Birth companion skin contact within first hour facility-based interventions because respondents might not know what interventions were performed or have (Continued from previous page) recall bias,148 with accuracy declining over time.149 Data for Mexico ·· 45·5% (2004–05) ·· the implementation of recommended-against inter- Nicaragua ·· 68·9% (2004–05) 7·9% (2001) ventions were particularly scarce. We could not find any Paraguay ·· 49·5% (2004–05) ·· national or regional data for recommended-against Peru 64·1% (2012) 62·8% (2012), 54·4% 4·6% (2012) (2012) antenatal care interventions such as routine vitamin C Suriname ·· 45·0% (2009–13) ·· and E supplementation, routine screening for bacterial Middle East and north Africa vaginosis, routine cardiotocography, routine umbilical Algeria ·· 44·7% (2004–05) ·· artery Doppler, or routine antibiotic prophylaxis to improve pregnancy outcomes. Similarly, data for Djibouti ·· 54·9% (2006) ·· recommended-against interventions for postnatal care Egypt 56·5% (2008) 27·4% (2014) 0·7% (2014) were scarce. We found only two cross-sectional studies— Iran 82·0% (2011–12) 96·0% (2011–12) ·· one of 336 facilities in one state in India145 and one of Iraq ·· 43·0% (2009–13) ·· 66 facilities in Syria150—on routine administration of oral Jordan ·· 19·4% (2012) 0·3% (2012) uterotonics during the postnatal stay (not for routine Morocco ·· 51·3% (2003–04) 14·9% (2003–04) prophylaxis). A multicountry study134 included five Syria 32·4% (2006) ·· countries (Pakistan, Guatemala, India, Kenya, and Tunisia ·· 40·0% (2009–13) ·· Zambia) and looked at both routine oral uterotonics and Yemen ·· 30·3% (2006) ·· routine postnatal antibiotic administration. South Asia Although many surveys document coverage of Bangladesh ·· 45·9% (2011) 56·7% (2011) emergency obstetric and neonatal care interventions, Bhutan ·· 59·0% (2009–13) ·· evidence about the content of routine maternity care is India 29·6% (2010–13) 83·6% (2010–13,) 65·8% 15·8% (2005–06) scarce, which makes determination of whether care (2007–08) was in accordance with recommended guidelines Maldives ·· 60·1% (2009) 0·1% (2009) difficult.9 We found limited data for the coverage of Pakistan 2·1% (2010–13) 17·7% (2012–13), 23·4% 5·7% (2012–13) (2010–13) recommended interventions. An exception was Sri Lanka ·· 88·5% (2007–08) ·· prevention of post-partum haemorrhage through Sub-Saharan Africa uterotonic prophylaxis immediately after the birth—a Angola ·· 98·4% (2004–05) 14·8% (2006–07) topic of research, implementation campaigns, and international advocacy. We found wide variation Cameroon ·· 33·6% (2013) 22·1% (2011) (17·7–98·4%) in adherence to the strongly recom- Democratic Republic of the ·· 23·1% (2011–12) 3·8% (2011–12) Congo mended practice of breastfeeding within the first hour, Côte d’Ivoire ·· 30·6% (2011–12) 16·7% (2011–12) despite 42 (55%) of 77 countries reporting rates higher Gabon ·· 32·8% (2012) 5·7% (2012) than 50%, and 12 (16%) reporting rates higher than Ghana ·· 46·8% (2008) 7·7% (2008) 75%. The data were from a variety of sources which Kenya 25·1% (2010–13) 82·1% (2010–13), 55·2% 21·1% (2008–09) might not be representative of the total population. We (2008–09) found similar variation in one of the major components Lesotho ·· 49·8% (2009) 23·2% (2009) of respectful care—a birth companion during Mauritania ·· 62·1% (2000–01) 15·2% (2000–01) intrapartum care. Although the range was 0·0–56·7%, Namibia ·· 70·2% (2013) 5·9% (2013) only five (11·9%) of 42 countries had rates greater than Nigeria ·· 33·6% (2013), 78·3% 22·1% (2013) 20%, indicating TLTL in respectful care. (2004–05) São Tomé and Príncipe ·· 40·8% (2008–09) 2·9% (2008–09) Research priorities Senegal ·· 29·9% (2014) 21·6% (2014) Our systematic review identified several issues regarding South Africa ·· 61·0% (2009–13) ·· maternal-health guidelines and appropriate use of specific Swaziland ·· 58·7% (2006–07) 15·4% (2006–07) recommendations that warrant future research. Metho- Zambia 23·4% (2010–13) 91·6% (2010–13) 14·6% (2013–14) dological research on ways to improve the quality of guidelines is a broad topic that affects all areas of health. Data shown are coverage percentage and years of study. References given in appendix. *An additional 56·7% had a companion at some point during the hospital stay including admission and post-partum. However, maternal health-care guideline developers should be at the forefront of guideline methodology and Table : Coverage of selected interventions recommended for routine care quality, ensuring that guideline development is not only rigorous, but that recommendations are formulated and on providers’ self-reports.82,146,147 Furthermore, most popu- disseminated in ways that facilitate understanding and For more on the DECIDE Collaboration see http://www. lation-based data for maternal health in LMICs are application by end users. For example, the DECIDE decide-collaboration.eu obtained via household surveys; these surveys are largely Collaboration has conducted research and developed tools

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to improve implementation of evidence-based recom- screening for prevention, early detection, and early mendations by different target audiences, including treatment during antenatal care. Guidelines should also providers, policy makers, and the public.151 Although consider the need to minimise TMTS care, which might standardisation of maternal-health guideline development not improve outcomes, and could cause avoidable harm might be desirable for guideline developers and users, and increase health-care costs and inequities. differences in recommendations could be a long-term Individual providers, professional associations, facilities, reality owing to differences in contextual factors (such as and health-care systems can seek a path beyond TLTL and disease burden, organisation of national health systems, TMTS through implementation of and adherence to clear, and health-care financial arrangements), regional appropriate, evidence-based guidelines for routine differences in the values and preferences of women and maternal health care. Guidelines do not exist in a vacuum providers, and the acceptability and feasibility of using and many other aspects of quality care need attention in different interventions. However, global maternal-health order for mothers and newborn babies to have positive organisations and professional associations can provide outcomes. However, without consistent guidelines with leadership, evidence, and forums to reach consensus on clear, comprehensible steps to implementation, mother- the use of specific interventions. Studies exploring reasons hood cannot be safe. Multisectorial, multifactorial, and for conflicting recommendations in different countries multidisciplinary methods for creation, maintenance, and could also drive overall improvements in guideline quality, continued improvement of guidelines in conjunction with and better define research agendas on specific inter- social, economic, and political change are all necessary to ventions where insufficient evidence exists. go beyond TLTL and TMTS for improved maternal Scarce coverage data for the use of specific recom- health for all. mendations makes assessment of TLTL and TMTS rates Contributors difficult. However, available data strongly suggest an SM, FA, EA, SG, AL, JPV, JPS, CH, and KM contributed to the urgent need for more research to assess levels, ranges, and conceptualisation. MS, KM, AC, DCol, DCom, MC, VD, CH, VM, IM-B, trends in the appropriate use of these interventions. This CPC, VNP, NR, and JPS did the literature research. MS, SM, FA, KM, EA, JPS, and DCol contributed to the data analysis. MS, KM, AC, and DCom research should not be conducted in isolation, but linked provided the figures. SM, FA, SG, AL, CH, KM, JPV, JPS, NR, and EA wrote to quality improvement measures that allow health-system the manuscript. All authors contributed to data interpretation and stakeholders to assess current practices and respond commented on drafts of the manuscript. accordingly with evidence-based implementation efforts Declaration of interests for all levels of care. As countries move through the We declare no competing interests. obstetric transition,58 and the focus of maternal health care Acknowledgments shifts from direct aetiologies of maternal mortality toward The Bill & Melinda Gates Foundation and The John D and Catherine T MacArthur Foundation partially supported this work. indirect aetiologies (such as non-communicable diseases Their individual institutions supported each of the authors. We would or risk factors including obesity, hypertension, diabetes, like to thank Lenka Benova, Clara Calvert, and Kerry Wong of the cardiac diseases, and infectious diseases such as malaria London School of Hygiene & Tropical Medicine for access to data, and HIV),8 greater emphasis is needed on prevention and Ruwani Ekanayake for assistance on preparation of the tables, Julia Ofman of the Harvard School of Public Health for assistance with early identification of risk factors in antenatal care. Two the review of abstracts for coverage data, Ingvild Odsbu of the Karolinska such efforts are the publications on mapping of antenatal- Institutet for assistance with translation of guidelines, and the Maternal care guidelines152 and barriers to integration of screening Health Task Force at the Harvard School of Public Health. into antenatal care.153 This shift in the aetiology of obstetric References complications needs to also be reflected in routine 1 Campbell OMR, Graham WJ. 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Informe técnico maternal and neonatal mortality in the 21st century: a worldwide preliminar sobre resultados de la investigación “Caracterización de population-based ecological study with longitudinal data. la atención del embarazo en el sector público de la Provincia de BJOG 2015; 123: 745–53. Buenos Aires y Ciudad Autónoma de Buenos Aires. Encuesta 105 Molina G, Weiser TG, Lipsitz SR, et al. Relationship between Perinatal 2008: resultados en hospitales públicos de la Provincia de cesarean delivery rate and maternal and neonatal mortality. Buenos Aires y Ciudad Autónoma de Buenos Aires”. Buenos Aires: JAMA 2015; 314: 2263–70. Ministerio de Salud de la Provincia de Buenos Aires, 2009. 106 Robson M, Hartigan L, Murphy M. Methods of achieving 128 Open Working Group of the General Assembly on Sustainable and maintaining an appropriate caesarean section rate. Development Goals. Report of the Open Working Group of the Best Pract Res Clin Obstet Gynaecol 2013; 27: 297–308. General Assembly on Sustainable Development Goals. New York: 107 Betrán AP, Vindevoghel N, Souza JP, Gülmezoglu AM, Torloni MR. United Nations General Assembly, 2014. A systematic review of the Robson classification for caesarean 129 Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and section: what works, doesn’t work and how to improve it. PLoS One efficiency of guideline dissemination and implementation 2014; 9: e97769. strategies. Health Technol Assess 2004; 8: 1–72. 108 Souza J, Betran A, Dumont A, et al. A global reference for caesarean 130 Pronovost PJ. Enhancing physicians’ use of clinical guidelines. section rates (C-Model): a multicountry cross-sectional study. JAMA 2013; 310: 2501–02. BJOG An Int J Obstet Gynaecol 2015; 123: 427–36. 131 Althabe F, Bergel E, Cafferata ML, et al. Strategies for improving 109 American College of Obstetricians and Gynecologists, Society for the quality of health care in maternal and child health in low- and Maternal-Fetal Medicine. Safe prevention of the primary cesarean middle-income countries: an overview of systematic reviews. delivery. Obstet Gynecol 2014; 123: 693–711. Paediatr Perinat Epidemiol 2008; 22 (suppl 1): 42–60. 110 Hoesli I, El Alama-Stucki S, Drack G, et al. Guideline Césarienne. 132 Pazandeh F, Huss R, Hirst J, House A, Baghban A. An evaluation Berne: Société Suisse de Gynécologie et d’Obstétrique, 2015. of the quality of care for low risk women: the use of evidence-based 111 Sentilhes L, Vayssière C, Beucher G, et al. Delivery for women with practice during labour and childbirth in four public hospitals in a previous cesarean: guidelines for clinical practice from the French Tehran. Midwifery 2015; 31: 1045–53. College of Gynecologists and Obstetricians (CNGOF). 133 Moreira MEL, Gama SGN da, Pereira APE, et al. Práticas de atenção Eur J Obstet Gynecol Reprod Biol 2013; 170: 25–32. hospitalar ao recém-nascido saudável no Brasil. Cad Saude Publica 112 National Collaborating Centre for Women’s and Children’s Health 2014; 30: S128–39. (UK). Caesarean section: November 2011, NICE clinical guideline. 134 Dhaded SM, Somannavar MS, Vernekar SS, et al. Neonatal London: Royal College of Obstetricians and Gynaecologists, 2011. mortality and coverage of essential newborn interventions 113 International Confederation of Midwives. ICM position statement. 2010 – 2013: a prospective, population-based study from low-middle Appropriate use of caesarean section. The Hague: International income countries. Reprod Health 2015; 12 (suppl 2): S6. Confederation of Midwives, 2011. 135 Centers for Disease Control. Births—method of delivery. 2013. 114 Souza JP, Gülmezoglu A, Lumbiganon P, et al. Caesarean section http://www.cdc.gov/nchs/fastats/delivery.htm (accessed Feb 22, without medical indications is associated with an increased risk of 2016). adverse short-term maternal outcomes: the 2004–2008 WHO Global 136 Mohanan M, Vera-Hernández M, Das V, et al. The know-do gap in Survey on Maternal and Perinatal Health. BMC Med 2010; 8: 71. quality of health care for childhood diarrhea and pneumonia in 115 International Federation of Gynecology and Obstetrics, rural India. JAMA Pediatr 2015; 169: 349–57. International Confederation of Midwives, White Ribbon Alliance, 137 Grol R, Wensing M. What drives change? Barriers to and International Pediatric Association, WHO. Mother-baby friendly incentives for achieving evidence-based practice. Med J Aust 2004; birthing facilities. Int J Gynaecol Obstet 2015; 128: 95–99. 180: S57–60. 116 Freedman LP, Kruk ME. Disrespect and abuse of women in 138 Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. childbirth: challenging the global quality and accountability An overview of reviews evaluating the effectiveness of financial agendas. Lancet 2015; 384: e42–44. incentives in changing healthcare professional behaviours and 117 WHO. The prevention and elimination of disrespect and abuse during patient outcomes. Cochrane Database Syst Rev 2011; 6: CD009255. facility-based childbirth. Geneva: World Health Organization, 2014. 139 Nathan HL, de Greeff A, Hezelgrave NL, Chappell LC, 118 PMNCH. PMNCH Knowledge Summary #23 Human Rights and Shennan AH. An accurate semiautomated oscillometric blood Accountability. Geneva: The Partnership for Maternal Newborn and pressure device for use in pregnancy (including pre-eclampsia) in Child Health, 2013. a low-income and middle-income country population: the Microlife 119 Respectful Maternity Care Advisory Council, White Ribbon Alliance 3AS1-2. Blood Press Monit 2015; 20: 52–55. for Safe Motherhood. Respectful maternity care: the universal rights 140 Peeling RW, Mabey D. Point-of-care tests for diagnosing of childbearing women. Washington, DC: White Ribbon Alliance infections in the developing world. Clin Microbiol Infect 2010; for Safe Motherhood, 2011. 16: 1062–69. 120 Maternal Health Task Force. Respectful maternity care. 2015. 141 Grimshaw J, Eccles M, Thomas R, et al. Toward evidence-based http://www.mhtf.org/topics/respectful-maternity-care/ quality improvement. Evidence (and its limitations) of the (accessed Sept 14, 2015). effectiveness of guideline dissemination and implementation 121 Renfrew MJ, McFadden A, Bastos MH, et al. Midwifery and quality strategies 1966–1998. J Gen Intern Med 2006; 21 (suppl 2): S14–20. care: findings from a new evidence-informed framework for 142 WHO. WHO Handbook for Guideline Development, 2nd edn. maternal and newborn care. Lancet 2014; 384: 1129–45. Geneva: World Health Organization, 2014.

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143 Piso B, Reinsperger I, Winkler R. Recommendations from 149 Souza JP, Cecatti JG, Pacagnella RC, et al. Development and international clinical guidelines for routine antenatal infection validation of a questionnaire to identify severe maternal morbidity screening: does evidence matter? Int J Evid Based Healthc 2014; in epidemiological surveys. Reprod Health 2010; 7: 16. 12: 50–61. 150 Matar HE, Almerie MQ, Alsabbagh M, et al. Policies for care during 144 The ADAPTE Collaboration. The ADAPTE process: resource the third stage of labour: a survey of maternity units in Syria. toolkit for guideline adaptation. Version 2.0. 2009. http://www.g-i-n. BMC Pregnancy Childbirth 2010; 10: 32. net/document-store/working-groups-documents/adaptation/ 151 Treweek S, Oxman AD, Alderson P, et al. Developing and adapte-resource-toolkit-guideline-adaptation-2-0.pdf evaluating communication strategies to support informed decisions (accessed March 11, 2016). and practice based on evidence (DECIDE): protocol and preliminary 145 Stanton CK, Deepak NN, Mallapur AA, et al. Direct observation of results. Implement Sci 2013; 8: 6. uterotonic drug use at public health facility-based deliveries in four 152 Abalos E, Chamillard M, Diaz V, Tuncalp Ö, Gülmezoglu AM. districts in India. Int J Gynaecol Obstet 2014; 127: 25–30. Antenatal care for healthy pregnant women: a mapping of 146 Altaweli RF, McCourt C, Baron M. Childbirth care practices in interventions from existing guidelines to inform the development public sector facilities in Jeddah, Saudi Arabia: a descriptive study. of new WHO guidance on antenatal care. BJOG 2016; 123: 519–28. Midwifery 2014; 30: 899–909. 153 de Jongh TE, Gurol-Urganci I, Allen E, Jiayue Zhu N, Atun R. 147 Khayat R. Hospital practices in maternity wards in Lebanon. Barriers and enablers to integrating maternal and child health Health Policy Plan 2000; 15: 270–78. services to antenatal care in low and middle income countries. 148 Casey R, Rieckhoff M, Beebe SA, Pinto-Martin J. Obstetric and BJOG 2016; 123: 549–57. perinatal events: the accuracy of maternal report. Clin Pediatr (Phila) 1992; 31: 200–04.

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Maternal Health 3 The scale, scope, coverage, and capability of childbirth care

Oona M R Campbell, Clara Calvert, Adrienne Testa, Matthew Strehlow, Lenka Benova, Emily Keyes, France Donnay, David Macleod, Sabine Gabrysch, Luo Rong, Carine Ronsmans, Salim Sadruddin, Marge Koblinsky, Patricia Bailey

Published Online All women should have access to high quality maternity services—but what do we know about the health care available September 15, 2016 to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers http://dx.doi.org/10.1016/ S0140-6736(16)31528-8 and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, This is the third in a Series of and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on six papers about maternal health where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers’ See Online/Comment skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to http://dx.doi.org/10.1016/ link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just S0140-6736(16)31534-3, emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated http://dx.doi.org/10.1016/ regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the S0140-6736(16)31525-2, and http://dx.doi.org/10.1016/ models we observe, and consider changes that might improve services and accelerate response to future challenges. S0140-6736(16)31530-6 Areas that need attention include minimisation of overintervention while responding to the changing disease burden. See Online/Series Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to http://dx.doi.org/10.1016/ implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth S0140-6736(16)31533-1, without risk to her life, or that of her baby. http://dx.doi.org/10.1016/ S0140-6736(16)31472-6, http://dx.doi.org/10.1016/ Introduction indicators and benchmarks used (appendix). In the new S0140-6736(16)31527-6, The Millennium Development Goal (MDG) to reduce era of Sustainable Development Goal (SDG) targets, the http://dx.doi.org/10.1016/ maternal mortality did not recommend specific shortcomings of use of unidimensional and limited S0140-6736(16)31395-2, and http://dx.doi.org/10.1016/ configurations of maternal health-care services, but metrics to characterise complex services should be S0140-6736(16)31333-2 aimed implicitly, as reflected in its tracking indicators, to redressed. In this Series paper, we focus on intrapartum London School of Hygiene & ensure high coverage of skilled birth attendant at delivery care. In the appendix, we briefly describe the status of Tropical Medicine, London, UK and antenatal care. Underlying these choices were family planning, abortion, antenatal, and postnatal (O M R Campbell PhD, assumptions that high coverage of skilled birth attendant services. The continuum of care is important, but we C Calvert PhD, A Testa MSc, L Benova PhD, D Macleod MSc, and antenatal care would put women and their babies in chiefly address childbirth services because they are more C Ronsmans DrPH); Stanford contact with professionals who could manage uneventful complex to provide, and because good intrapartum and University School of Medicine, pregnancy, labour, and birth, and either prevent, detect immediate reduce maternal, fetal, and Stanford, CA, USA and treat, or appropriately refer complications. neonatal deaths, and promote health, wellbeing, and (M Strehlow MD); FHI 360, 5 Durham, NC, USA Additionally, antenatal care sessions provide an opport- enhance child development. (E Keyes MSPH, P Bailey DrPH); unity to arrange appropriate childbirth care. A useful starting point for this Series paper is to lay out Tulane University School of The end of the MDG era showed progress: from pathways that could theoretically lead individual women Public Health, New Orleans, LA, 1990 to 2013, global coverage of births occurring with to receive adequate intrapartum care with skilled birth USA (F Donnay MD); Institute of Public Health, Heidelberg skilled birth attendants increased from 57% to 74%, one attendants (figure 1). Informed by this framework, we University, Heidelberg, or more antenatal visits from 65% to 83%, and four or present a multifaceted characterisation of the main Germany (S Gabrysch PhD); more antenatal care visits from 37% to 64%.1,2 However configurations of childbirth services currently used by National Center for Women and Children Health, Chinese some countries continue to have high maternal mortality women in low-income and middle-income countries Disease Prevention Control ratios, despite high coverage of skilled birth attendants (LMICs), with some data presented on high-income Center, Beijing, China and antenatal care. Such sustained maternal mortality countries (HICs) for comparison. We begin with the (L Rong MM); West China could arise because such indicators track contacts with prevailing patterns of where, and with whom, deliveries School of Public Health, Sichuan University, Chengdu, care and not the content of care; a quality gap might take place. We then detail the levels of facilities, and 3,4 China (C Ronsmans); World remain despite increases in coverage. Furthermore, facility and staff capabilities, and touch on other aspects Health Organization, Geneva, features beyond skilled birth attendant and antenatal of quality, followed by a section on strategies to link Switzerland (S Sadruddin PhD); care coverage are likely to be influential. For example, a women to such intrapartum services. Financing and USAID, Office of Health, Infectious Diseases and high population density and short travel times should innovations, also essential for improvements to access 6 Nutrition, Maternal and Child facilitate access to emergency obstetric care (EmOC), and and quality, are addressed by Koblinsky and colleagues. Health, Washington, DC, USA women’s health profiles and life circumstances might Finally, we discuss whether current models of service (M Koblinsky PhD) also drive health outcomes. delivery are likely to be fit-for-purpose, and indicate the Comparative tracking of maternal health-care provision scope for future change. We make recommendations for across different countries has been minimal, apart from data collection for improved planning, provision, and the two aforementioned MDG indicators, with only a few tracking.

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Correspondence to: Key messages Oona M R Campbell, London School of Hygiene & Tropical • Facility and skilled birth attendant deliveries are increasing; failing should be remedied as a matter of priority; childbirth Medicine, Keppel St, this investment should yield multiple benefits, reduce should only be promoted in facilities that can guarantee at London WC1E 7HT, UK maternal and perinatal mortality, and improve maternal least a basic emergency obstetric care standard [email protected] and neonatal wellbeing • Low-income and middle-income countries could promote • Progress is not as great as expected; phrases such as skilled births in comprehensive emergency obstetric care facilities, See Online for appendix birth attendant and emergency obstetric care can mask as most high-income countries have done; however, such poor quality care; we need to ensure skilled providers for models can be associated with unnecessary intervention routine and emergency childbirth care, along with timely and high costs; to support normal birth, provision of access to such care alongside midwifery-led units can be a good choice for • National health plans need to ensure women, especially the many women, such units have the additional advantage most remote or vulnerable, can reach intrapartum services in that they eliminate the need for inter-facility emergency a timely way: this requirement will entail understanding of transfer, although they do not address bottlenecks around the current use of routine and emergency transport, and initial access patterns of relocation (before the start of labour) to stay near • The current indicator of skilled birth attendant coverage is a the planned childbirth locale (maternity waiting homes) unidimensional and limited metric with which to • It is unethical to encourage women to give birth in places with characterise complex services; a more diverse range of low facility capability, no referral mechanism, with unskilled indicators is needed to capture the nature and content of providers, or where content of care is not evidence-based: this care being provided; these data are readily available

Our exploration of childbirth services presents evidence level and higher-level facility births (eg, Mali 2008–12), to from 50 countries. We drew on academic literature, those where doctors prevail (eg, Ukraine 2003–07). In particularly reviews, and, for a subset of 29 LMICs, we some countries, lower-level facilities births are conducted our own analyses (methods detailed in the predominantly with midwives or nurses, while hospital appendix). births are with doctors (eg, Indonesia 2008–12). Countries with mostly hospital births (figure 3) vary in their Where do births take place, and with whom? dominant skilled birth attendant cadre. As well as increases in skilled birth attendant coverage, some countries have increased facility deliveries at Are staff skilled? astonishing rates (appendix). The intersection between Skilled staff are essential to provide high quality where births take place and with whom captures the intrapartum care to each woman and newborn, are a endpoint of the paths women take in a given context determinant of facility capability, and a requirement for (figure 1). A provider’s designation (eg, midwife or adequate home-based childbirth care (figure 1). Skills obstetrician) should indicate skills, while a facility’s include the ability to communicate in a caring, respectful designated level (eg, hospital, health centre, or health manner, plus the knowledge and technical skills to give post) should signal its capability to provide certain appropriate, well-timed care.8,9 Unfortunately, in many elements of care (eg, comprehensive EmOC, basic settings women receive neither; systematic reviews8–13 EmOC, or routine-only care), and whether a facility is show substantial disrespect and abuse, and numerous obliged to refer complications elsewhere for treatment.7 studies show low levels of provider skills and confidence. Many unstandardised terms are used to describe provider For example, a study10 of nine sub-Saharan African cadres and facility levels. For example, freestanding countries showed most did not train skilled birth midwifery units or private midwife’s clinics generally attendants to manually remove placentas. Some resemble health centres, to the extent that they might be countries designate cadres as skilled birth attendants, 12,14 expected to provide basic EmOC (eg, MgSO4), but not despite them lacking requisite midwifery skills. aspects of comprehensive EmOC (caesarean section and Staff numbers matter too. 90% of maternal deaths blood transfusion). Figure 2 shows these childbirth care happen in 58 countries with only 17% of the world’s configurations for 50 countries, with nearly as many midwives and doctors.15 Data compiled from 132 countries patterns as countries. Providers range from no one, to revealed 64 did not meet the minimum critical threshold non-skilled birth attendants, to midwives, to doctors; of 23 midwives, nurses, and doctors per 10 000 population settings include those where births occur mostly at home needed to implement primary care programmes, (eg, Chad 2000–04), predominantly at lower-level health including intrapartum care (appendix).16 Shortages of facilities (eg, Senegal 2010–14), or almost entirely at other key providers such as anaesthetists also exist.17 hospitals (eg, Jordan 2008–12). The main cadre of birth Furthermore, providers are often poorly distributed (eg, attendant in facilities varies (figure 3), from countries concentrated in urban areas or in the private sector). where midwives or nurses attend the majority of lower- Low-density settings (remote and rural) are particularly www.thelancet.com 37 Series

Woman entering labour (at home or in a maternity waiting home) Routine transport pathways

1 2 3

4

Home Facility Facility Facility Routine care only Routine care and BEmOC Routine care and CEmOC (with or without AMU) 4 3 2

Emergency transport pathways

Requirements for each pathway and option for routine and emergency care

Routine transport at start Provision of quality care Emergency transport Provision of quality care of labour for routine childbirth for complications for complications (EmOC)

Options to Woman/family: Facility has adequate: Attendant: Facility has adequate: ensure SBA delivery • Makes decision on • Staff cadres and skills for • Recognises need for • Staff cadres and skills to intended place of childbirth routine childbirth emergency care manage complications • Has ability to reach • Staff numbers • Can identify and reach • Staff numbers intended location, • Equipment, drugs, and CEmOC facility (eg, using • Equipment, drugs, and (transport and supplies emergency medical supplies communication) including • 24/7 opening times and service) • Blood supply by relocation to a MWH basic infrastructure • 24/7 opening times and basic infrastructure

Facility with routine 1 Woman travels from home/ Uncomplicated childbirth at Travel not required; if in Complicated childbirth care & CEmOC MWH to CEmOC facility CEmOC facility, potentially AMU, move to emergancy managed at CEmOC facility in an AMU care located on the same site

Facility with routine 2 Woman travels from home Uncomplicated childbirth at 2 Woman who cannot be care and BEmOC or MWH to BEmOC facility BEmOC facility managed at BEmOC facility travels to CEmOC facility

Facility with routine 3 Woman travels from home Uncomplicated childbirth at 3 Woman travels from routine- care only or MWH to routine-only routine-only facility only facility to CEmOC facility facility

Home with SBA 4 SBA travels to woman’s Uncomplicated childbirth at 4 Woman travels from home home home to CEmOC facility

Figure : Conceptual framework of pathways leading to adequate childbirth care options Skilled birth attendance for uncomplicated childbirth and access to emergency obstetric care to manage complications, and the requirements for each pathway and option to be successful. SBA=skilled birth attendant. EmOC=emergency obstetric care. BEmOC=basic emergency obstetric care. CEmOC=comprehensive emergency obstetric care. 24/7=24 h a day, 7 days a week. AMU=alongside midwifery-led unit. MWH=maternity waiting home.

challenging to provision; providers prefer to work in What capability do facilities have? teams and sometimes resist placements without To give high-quality intrapartum care, skilled staff amenities such as schools.18–20 Location and facility size require an enabling environment, and facilities that often correlate with resources available for hiring, receive women at any time of day. Specialist back-up care training, supervision, and retention. With insufficient should be part of the plan, via transfer to another facility staff, some women cannot get timely care, and end up if needed. Figure 1 designates facilities as capable of delivering alone or with non-skilled birth attendants, providing comprehensive or basic EmOC, or routine care such as cleaners, despite being in facilities.21 only. Routine care is included for completeness because

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MMR (2015) Ethiopia, 2007–11 353 Chad, 2000–04 856 Bangladesh, 2007–11 176 Madagascar, 2004–09 353 Nepal, 2007–11 258 Nigeria, 2009–13 814 Haiti, 2008–12 359 India, 2001–06 174 Kenya, 2004–09 510 Tanzania, 2006–10 398 Sierra Leone, 2009–13 1360 Mali, 2008–12 587 Mozambique, 2007–11 489 Uganda, 2007–11 343 Morocco, 1999–2004 121 Indonesia, 2008–12 126 Zambia, 2009–14 224 Rwanda, 2006–10 290 Ghana, 2010–14 319 Malawi, 2006–10 634 Ecuador, 1999–2004 64 Senegal, 2010–14 315 Turkey, 1999–2003 16 DR Congo, 2009–13 693 Cambodia, 2010–14 161 Netherlands, 2013 7 Peru, 2008–12 68 Egypt, 2010–14 33 Namibia, 2009–13 265 Mexico, 2007–11 38 China, 2008 27 South Africa, 2008 138 New Zealand, 2014 11 Germany, 2014 6 Brazil, 2002–06 44 England, 2015 9 Jordan, 2008–12 58 Canada, 2006–07 7 Mongolia, 2009–10 44 Russia, 2011 25 Malaysia, 2011 40 USA, 2013 14 Sri Lanka, 2002–07 30 Norway, 2010 5 Cuba, 2012–14 39 France, 2010 8 Argentina, 2013 52 Ukraine, 2003–07 24 Japan, 2005 5 Sweden, 2010 4 0 20 40 60 80 100 Distribution of deliveries (%)

Home : alone Home : no detail Lower unit : no detail Facility : nurse or midwife Home : non-SBA Facility : alone or non-SBA Hospital : nurse or midwife Facility : doctor or GP Home : non-SBA or alone Lower : nurse or midwife Hospital : doctor Facility : no detail Home : SBA Lower : doctor Hospital : no detail Elsewhere : other

Figure : Distribution of births by childbirth location and provider attending birth MMR=maternal mortality ratio. SBA=skilled birth attendant. facilities should at a minimum be able to manage some antibiotics (one of six basic functions) and caesarean complications, stabilise women, and guarantee transfer section (one of two comprehensive functions).23 Facilities to a hospital (ie, be capable of basic EmOC), as well as to designated as hospitals or even comprehensive EmOC care competently and empathetically for routine, facilities, vary widely in their actual capability to provide uncomplicated births.22 such care. Measurement of signal functions frequently Researchers have evaluated the capability of facilities to extends to include neonatal resuscitation, but we avoided provide EmOC across many settings using eight signal reporting this function because we concur with those functions including, for example, provision of parenteral who would expand emergency neonatal care beyond just www.thelancet.com 39 Series

Ukraine India USA 8% 8% 1% Namibia 100 16% 4% 0% 20% 23% Bangladesh 9% 71% 32% Morocco 1% 64% 10% 1% 0% 18% 92% 90 89% 92% 3% 84% 30% 0% 47% 5% 77% 50% Jordan Kenya 95% 70% 0% 80 81% Nigeria 0% Ghana 22% 2% 0% 2% 0% 22% 42% 24% 30% 32% 70% 10%12% 78% 8%7% 70 57% 78% 84% 78% 66% 73% Uganda 1% 60 19% 1% Ethiopia 5% 1% 50 94% Cambodia 6% 17% 80% 0% 45% 0% 77% 55% Indonesia 3% 39% 40 1% 20% 60% 97% Facility births in hospitals (%) Facility 6% 22%

72% 30 Madagascar 79% 1% Mali Senegal 1% 22% 8% 1% 43% 2% 21% 20 30% 4% 2% 28% 57% 69% 94% 70% Delivery attendant 10 77% Doctor 71% Nurse/midwife/auxiliary midwifery staff Non-SBA or alone 0 0 10 20 30 40 50 60 70 80 90 100 Births in any facility (%)

Figure : Percentage of births in facilities, by facility level and cadre of attendant, for selected countries SBA=skilled birth attendant. Percentages do not add up to 100 due to rounding. Outer ring represents hospital births and inner ring represents lower-level facility births.

resuscitation.24 Unfortunately, we lacked data for a high-volume facilities (≥10 000 deliveries per year), and broader definition. In nine LMICs, we explored the one study26 reported some facilities conduct as many as volume of deliveries, the actual capability of facilities to 25 000 deliveries per year. provide emergency and routine childbirth care, and whether facilities had basic infrastructure. Emergency obstetric care capability Facility capability to deliver EmOC was often poor Volume of deliveries (figure 4A). For example, in Kenya only 16% of facilities Facilities of different levels usually have different could provide EmOC, illustrated in green in column I. numbers of beds, providers and provider skill mixes, and Taking into account that more functional facilities had a different volumes of deliveries handled. Variations across higher volume of deliveries shifted the balance favourably countries reflect differences in geography and population (figure 4A, column II). In Kenya, 43% of facility deliveries densities, philosophies and policies for childbirth, and were in EmOC-capable facilities. However, even this health-care systems, but the size and number of facilities more favourable picture demonstrated that in four of also reflect potential difficulties in organisation, eight countries evaluated, most births were in facilities provision, and access to care. incapable of providing five basic EmOC functions—a Across eight sub-Saharan African countries and China, vital gap in maternal health care provision. Facilities in more than 70% of facilities conducting deliveries were China were considerably more likely to provide EmOC low-volume (<500 births per year), and only conducted a than were those in sub-Saharan Africa. small proportion of all facility births (appendix). For example, in Namibia, 86% of facilities were low-volume, Routine childbirth care and conducted only 17% of all facility births. Across the Despite the skilled birth attendant strategy that nine countries, 17–47% of facility births were in essentially promotes facility birth, little attention is paid low-volume facilities. Among HICs, few countries have to routine intrapartum care in facilities. Signal functions more than a fifth of births in low-volume facilities, and for routine care, capturing of selected aspects of many had none.25 The nine LMICs also had some very monitoring and prevention (eg, infection prevention,

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A 100 CEmOC/CEmOC-1 BEmOC/BEmOC excluding AVD 80 BEmOC-2 BEmOC-4 Lowest/ 60 substandard

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20

facility deliveries (%) or II facility of I facilities Percentage 0 IIIIII IIIIII IIIIII IIIIII

B 100 All 3 routine functions 2 routine 80 functions 0–1 routine functions 60

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facility deliveries (%) or II facility of I facilities Percentage 0 IIIIII IIIIII IIIIII IIIIII

C 100 All 3 elements of basic infrastructure 24/7 and 80 electricity or water 24/7 only Electricity and 60 water Electricity or water None 40

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facility deliveries (%) or II facility of I facilities Percentage 0 IIIIII IIIIII IIIIII IIIIII Rwanda, Uganda, Namibia, Kenya, Ethiopia, Ghana, Mozambique, China, 2007 2007 2009 2010 2008 2010 2012 2011 Country, year

Figure : Percentage facility capability by weighting The left hand columns (I) are percentage of facilities; and in the right hand columns (II), percentages are weighted by number of deliveries in each facility, by country, and are thus representative of all deliveries in all facilities: (A) EmOC capability; (B) routine childbirth care capability (infection prevention, partograph, & routine administration of uterotonic); and (C) basic infrastructure. Differences in definitions drive some between-country differences (appendix). EmOC=emergency obstetric care. BEmOC=basic emergency obstetric care. CEmOC=comprehensive emergency obstetric care. AVD=assisted vaginal delivery. CEmOC-1=CEmOC excluding AVD. BEmOC-2=BEmOC excluding two signal functions. BEmOC-4=BEmOC excluding four signal functions. 24/7=service 24 h a day, 7 days a week. partograph, and routine administration of uterotonic), (figure 4). In Mozambique for example, around half of and signal functions for basic infrastructure were first facility deliveries were in EmOC-capable facilities proposed 15 years after those for EmOC.24 In six LMICs (figure 4A, column II), but over 75% were in facilities with relevant data, we showed facilities were generally capable of all routine care signal functions better equipped to provide routine care than EmOC (figure 4B, column II). Nevertheless, an unacceptably www.thelancet.com 41 Series

high proportion of births occurred in facilities incapable maternity waiting homes) late in pregnancy, before they of providng adequate quality routine care. enter labour. For emergencies, referral systems and coordinated emergency transport are needed to transfer Basic infrastructure patients and communicate critical health records to Results of a national study27 in Tanzania showed that 56% receiving hospitals.52–55 of facilities conducting deliveries lack water and Emergency transport is divided into formal and sanitation, and the results of a systematic review28 showed informal systems. Most HICs, and increasing numbers 66% of hospitals in sub-Saharan countries lack electricity. of LMICs, have formal emergency medical services Figure 4C shows many facilities were open at all times, systems providing ambulance transport and care for but lacked both water and reliable electricity. patients with all types of emergencies. Four main emergency medical services models exist: no defined Quality of intrapartum care at the individual level formal system, basic life support, advanced life High quality care also requires that all components of support, and on-scene physicians providing advanced routine and emergency care be provided consistently, life support.56,57 Most LMICs lack formal emergency respectfully, in a timely fashion, and affordably to all medical services systems, or operate basic life support women who need it. Individual women’s care can be very systems. By contrast, HICs typically use advanced life poor, even when providers and facilities are capable of support (eg, USA and UK) or on-scene physicians providing it.29 However, with some exceptions,30 coverage providing advanced life support (eg, Germany and of specific elements of care is rarely available at national- France) systems. Although evidence suggests that on- level in LMICs, because of the challenges in gathering of scene physicians providing advanced life support is such individual-level data from health management superior for severely injured trauma patients, limited information systems, non-electronic medical records, or research has failed to show significant differences in surveys. outcomes between basic, advanced, and on-scene physicians providing advanced life support for other What does it take to access care? emergency patients, and no controlled trials specifically Access to health services remains a challenge for evaluating emergency obstetric patients have been women in many countries; in 2013, met need for skilled done.58–61 birth attendant delivery worldwide was 74%.1 A 2015 Emergency medical technician training should at a systematic review31 of met need for EmOC, an indicator minimum include emergency resuscitation and pre- that signposts women’s use of facilities for hospital decision skills, such as who should be allowed in complications (assuming 15% of all pregnancies will the ambulance, and whether in instances with only one require such care), estimated that the percentage of provider, the ambulance driver should pull over to help women with complications who actually attended manage an emergency requiring two sets of hands, or EmOC facilities was 21% in low-income settings and keep driving. For emergency conditions such as major 32% in middle-income settings. Economic and cultural trauma and acute myocardial infarction, bypassing of barriers play a part in attendance, but an additional lower-level facilities for higher ones is appropriate reason is the lack of nearby EmOC facilities; few because additional transport time is outweighed by countries meet the benchmark of five fully functioning improved services and care at higher levels.52,62 Because (as defined by the performance of all signal functions) of the risk to both mother and baby, and the time needed EmOC facilities per 20 000 births.32 Another reason is to set inter-facility referral in motion,63 women who the lack of transport to link women to care. The spatial cannot be managed in situ are likely to be better off being distribution of women entering into labour, in relation transferred directly to the nearest functioning com- to the location of facilities of a given level, determines prehensive EmOC facility. distance. Distance, along with mode-of-transport and Functional emergency medical services systems are difficulty of travel (road infrastructure, road quality, resource intensive and demand a coordinated call-centre traffic, and safety), then determines travel time, and and ambulance response team. Mature emergency affects the timeliness of obtaining routine and medical services systems in HICs operate single toll-free emergency childbirth care.33 access numbers, managed by call-centres whose agents dispatch appropriate ambulance services; thus, Strategies to link women to services ambulances are located to optimise response time and Strategies connecting women to routine services (eg, resources.56,64 The number of ambulances required per antenatal or childbirth care) frequently differ from those population varies depending on local factors, such as linking them to emergency services (panel 1). Access to road conditions, population density, distance, and routine intrapartum care requires that women in labour culturally acceptable response times.65 be transported to health facilities, or that staff and In LMICs, ambulance numbers are increasing rapidly; supplies are transported to women’s homes (figure 1). however, a lack of system-wide coordination compromises Alternatively, women can move close to services (eg, to their reach and impact (appendix). Unlike in HICs, many

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Panel : Routine transport systems and maternity waiting homes: getting women to routine childbirth services Routine transport delineate the entire picture; multiple factors, including Emergency complications that cannot be managed in situ perceived low-quality service, lead women and families to generally require women to reach high-level facilities rapidly, but bypass smaller local facilities for more emergency obstetric even routine transport for women in labour has to be relatively care-capable facilities further away.40,45 The impact and swift.34,35 Scarcity of reliable transportation hampers timely appropriateness of obstetric patients without known care-seeking, with rural populations spending substantial travel complications who bypass services is poorly studied, but time, and incurring high transport costs.36–39 bypassing can indicate dysfunction at lower levels, and cause Readily available transport and short travel times have a dysfunction at higher levels, via overcrowding. dramatic impact on facility delivery.40 In high-income countries, Maternity waiting homes rural areas have higher rates of motorised vehicle ownership In hard-to-reach areas, women in labour setting out for a than do urban locales.41 By contrast, many low-income and distant facility might deliver on route, particularly in low- middle-income countries have very low rates of motorised income and middle-income countries where air transport of vehicle ownership in rural areas, which further exacerbate women (or skilled birth attendants) to a childbirth site is not disparities in access to high-quality obstetric care. For example, available or financially viable.46 One solution is for women to in Kenya a very small proportion of households within move and stay adjacent to health facilities towards the end of Demographic and Health Surveys clusters owned any form of pregnancy, reducing travel times in labour. These locales can be motorised vehicle (appendix). Phone ownership, which formal health-sector maternity waiting homes, patient hotels, facilitates communication, was higher than for vehicles, private hotels, hostel accommodation, or the homes of relatives particularly in urban areas, but was still low in sparsely or friends, sometimes referred to as informal maternity waiting populated areas. homes. Maternity waiting homes are recommended To improve transport, countries such as India, Nepal, and South interventions, although the evidence is weak.47 Little is known Sudan have established fully or partially subsidised transport for about the scale of maternity waiting homes provision, or the women seeking routine obstetric care.42–44 Provision of formal proportion of women using them, although some countries transport services should increase the rate of facility births, reportedly make considerable use of this approach (eg, especially among rural and low-income women, but further Mongolia,48 Cuba,49 and Peru50). In Canada in 2006–07, 5·8% of study of these programmes’ designs (eg, staffing, costs, and women travelled more than a day before birth to another city, sustainability) is needed. Travel times to facilities alone do not town, or community to give birth.51

LMICs rely on facility-based ambulances, and lack single emergency transport, they do not resolve issues around access phone numbers, providers trained in pre-hospital routine transport of women in labour, especially from care, or ideal accessibility (appendix). Facility-based remote locations. ambulances allow providers a dual role, providing both Other types of fragmentation hinder linkages as well. pre-hospital and in-hospital care. This dual provision In some countries (eg, Indonesia), hospitals and health reduces staffing needs, but the absence of designated centres fall under different government departments ambulance providers results in the ambulances with little direct relationship. Subnational administrative themselves being underused. Placement of ambulances boundaries, decentralised funding, and multiple public- at remote, lower-level facilities (health centres), further sector and private-sector funding streams can complicate strains limited staffing resources. Finally, provision of care for women. Referral protocols that do not recognise community-based emergency vehicles has shown some the urgency of many obstetric complications to reach the initial success, but sustainability, cost, and scale-up are nearest comprehensive EmOC facility can fatally delay poorly studied.66 The Cambodian experience provides a care. good case study (panel 2). Discussion Alongside midwifery-led units The MDG5 indicators of skilled birth attendant and Alongside midwifery-led units, which co-locate the antenatal care coverage are insufficient to characterise equivalent of lower-level facilities on hospital sites, are an the maternal health-care systems of countries, or indicate approach to allow women to deliver in lower-capability the likelihood of achieving good outcomes. Unless other units while eliminating travel-time to comprehensive aspects linked to quality and timeliness, ensuring of EmOC facilities if transfer is needed.76,77 Such models are respectful care and other elements of coverage are used in South Africa78 (known as onsite midwife-led birth addressed, achievements towards improving maternal units) and the UK. However, although such units might health could be overestimated. Policy makers need address high hospital costs, overcrowding, and over- information to contextualise their countries along a intervention, and obviate the need for inter-facility number of potentially successful pathways to high www.thelancet.com 43 Series

Panel : Emergency transport systems in Cambodia Improvements • National policies require trained staff to accompany patients • Cambodia’s maternal mortality ratio has dropped from during transport, a practice used in three-quarters of 1020 per 100 000 livebirths in 1990, to 484 per 100 000 in referrals by health centres. However, the accompanying staff 2000, to 161 per 100 000 in 2015, meeting the MDG5 is frequently a midwife or nurse without emergency medical target.67,68 technician training. • In 2014, 83% of births occurred in facilities, and 89% were Ambulances assisted by an SBA, compared with 22% in facilities and 44% • In 2015, China donated 200 new ambulances to Cambodia assisted by an SBA, in 2005. that were distributed to public facilities across the country, • Related services also improved: by 2014, 95% of women had bringing the estimated total number of functional at least one antenatal visit, 76% had more than four ambulances nationwide to more than 400—about one antenatal visits, and 85% received postnatal care within 2 ambulance for every 35 000 people. days of birth. Modern contraception increased to 39% and • Recommendations for LMICs range from one ambulance per unmet need was down to 13%. Induced abortion is legal up 20 000 population to one per 100 000·65,73 to 12 weeks’ gestation. The government-backed EmONC • Ambulances remain primarily hospital-based and improvement plan (2010–14) and finances to provide hospital-administered. services,69 coupled with efforts to expand and strengthen • No centralised access number or dispatch system exists, financial schemes that assist low-income patients to use leading to vast underuse of ambulances, protracted services, have been instrumental in Cambodia’s progress.70,71 response times, and vehicles falling into disrepair. Gaps in care • Obstetric emergencies are among the most common • Despite this forward momentum, and the fact that most of reasons for seeking of emergency transport, with fees being the population reside within 2 h of a health centre, reimbursed by government, and donor-backed low-income significant gaps remain in the number and distribution of assistance programmes.74,75 functional EmONC services across Cambodia, with 2·35 • Unfortunately, rates charged to patients vary widely, and EmONC-capable facilities and 1·31 comprehensive reimbursements often fail to cover the entire cost of EmONC-capable facilities per 500 000 population. Global transport.74 Taken together, these challenges have led to a benchmarks require five EmONC-capable facilities and one lower than expected number of referrals and unnecessary EmONC-capable facility per 500 000 population. delays in care. • Only around 24% of all births occurred in functional EmONC Quality improvements facilities; EmONC services are highly concentrated in urban • Multiple quality improvement efforts are underway to centres, leaving rural areas without essential services.69,72 improve linkages between facilities in Cambodia. • Most designated EmONC facilities not achieving functional • Quarterly Midwifery Coordination Alliance Team meetings status were health centres incapable of assisted vaginal have successfully brought together health centre midwives, delivery, manual removal of placenta, or provision of operational district administrators, and local and provincial parental anticonvulsants or neonatal resuscitation. referral hospital staff to review referrals, discuss Referral systems improvement opportunities, and conduct education on key • Referral systems linking patients to available emergency maternal care practices. obstetric care services remain a challenge in Cambodia. • Additionally, current efforts to standardise referral Although nearly all health centres have a phone service and guidelines and promote provincial-level obstetric care are located within 2 h of higher-level care, and hospitals hotlines will help Cambodia continue its progress in have functional on-site ambulances, breaks in the referral advancement of maternal health. system persist. SBA=skilled birth attendant. EmONC=emergency obstetric and neonatal care. • Very few health centres have their own emergency LMICs= low-income and middle-income countries. transport, and 60% of health staff report routinely helping patients arrange private transport.69

quality and effective services, to identify breaches in Our conceptual framework (figure 1) illustrates that for these paths, and review their direction of travel. childbirth, the essential features to explore are the birth The SDG era provides an opportunity to review, refine, location and its capability, the skills of the birth attendant, and plan carefully to ensure health-system developments and the ability of women to access routine and emergency better meet the needs of pregnant and delivering women care. A clear understanding of these features, coupled and their babies, as well as the needs of women who with an appreciation of the geography and other require other reproductive and general health services. contextual factors of a setting, is needed to compre-

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hensively illustrate the current situation of maternal care Irrespective of attendant, home births need emergency for multi-country or sub-national comparisons, and to medical services options to get women to hospitals develop evidence-informed options. Great variability is should complications arise. This need is a bottleneck, seen in these maternal health-system features across with few national-scale emergency transport schemes in countries, some of which achieve good results, and LMICs. For example, in Ethiopia (2007–11), where 90% of others which do not. women delivered at home, household ownership of motorised vehicles was low, a universal access telephone What existing patterns tell us about home births number was not available for emergency medical Among the 50 countries we examined for this Series services, and few patients were transported by paper, home births ranged from 0·1% to 90%. The ability ambulance. Although Ethiopia is redressing low to achieve safe and respectful care for home births coverage—its national survey (2010–14) shows 16% depends on who attends, and how successfully home facility birth,87 and others show 43%88—such a config- births are integrated into effective formal-sector services, uration cannot, and does not, achieve low maternal including via emergency medical services. In general, mortality (Ethiopia’s maternal mortality ratio is 353 per the higher the home birth percentage, the lower the 100 000 livebirths).67 Many women in many countries live percentage of births that were with skilled birth far from EmOC-capable facilities, and motorised attendants (eg, in Ethiopia in 2007–11, 90% of births were transport is inaccessible or unaffordable in some rural at home, of which only 0·4% were with skilled birth areas. In urban areas, traffic can delay arrival. Emergency attendants). Most home births in LMICs were either with transport innovations, including those instigated by traditional births attendants (eg, 89% in Bangladesh in women’s groups, have been proposed but not scaled-up.89 2007–11), with relatives or family (eg, 61% in Ethiopia in India might provide a pragmatic future model via its 2007–11), or alone (eg, 34% in Rwanda in 2006–10). emergency medical service innovations.42,43 Inappropriate When non-skilled birth attendants attend home births, decisions made by families can also delay seeking of potential interventions include birth preparedness and emergency care and also needs to be addressed. complication readiness,79,80 and links to the formal health- In summary, where home-based models of care system.79,81 Generally, this configuration is associated with predominate, most women and family decision makers high maternal mortality and poor perinatal outcomes.7 are unable to navigate the pathways to care, as evidenced When skilled birth attendants attend substantial by the low proportion of expected emergencies that proportions of home births (eg, in Indonesia, Sierra actually arrive at facilities,31 and the resultant high Leone, and Cambodia), women need ways to call them maternal mortality ratios (figure 2). when labour starts and attendants might need transport to get to the birth. For such models to yield low maternal What existing patterns tell us about facility births mortality, midwives and doctors should be competent in Global expansion of skilled birth attendant coverage has provision of routine care and emergency first-aid; they occurred largely via increased facility delivery, which is also need to be integrated into formal systems of now almost universal in some LMICs, and most HICs. training, supervision, and skills retention, even if they In the 50 countries analysed for this Series paper, facility work privately. In HICs, home births were less than 5%, births ranged from 10% to 99% of all births, with except in the Netherlands (15% in 2013) and, when hospitals comprising 17–100% of all facility births. Yet, planned, were mostly with skilled birth attendants. given that facility births constitute formal-sector Evidence-based UK guidelines show home births with provision, it is deplorable that many facilities fail to midwives are safe for multigravida with uncomplicated provide skilled, high-quality, respectful care. Most pregnancies.82 Planned out-of-hospital births in the USA facilities we studied in sub-Saharan Africa, but not have worse perinatal outcomes, but nearly a quarter had China, were ill-equipped to provide EmOC, especially no skilled birth attendant and more than a third lacked lower-level facilities. Similar unacceptable findings are insurance compared to less than 1% of planned hospital reported elsewhere.90,91 Moreover, many facilities could births.83 Comparable clarity for LMICs is lacking. not even provide routine childbirth care or lacked Historical examples of success with skilled birth necessities such as electricity or water. Such functions attendant-attended home births exist, for example in should be improved to enable high quality and respectful Malaysia.7,84 However, evaluation of the national care, and to improve patient and provider satisfaction. Indonesian midwifery programme showed that although Some women report delivering in facilities without a skilled birth attendants for home births increased, skilled birth attendant: 0–5% of facility births in most maternal mortality remained high, even among women LMICs, but in Senegal (2009–14), for example, as high as who received professional care.85,86 These findings 28% of births in lower-level facilities and 8% in hospitals. suggest home-based midwifery care can fail, possibly Other studies report that providers classified as skilled because midwives were in sufficiently trained or skilled, birth attendants are not actually skilled,11 and that care was not well-timed, and access barriers to EmOC numbers of staff deployed are frequently too low, remained, or even widened. exacerbating low facility capability.92 Women in many www.thelancet.com 45 Series

settings leave facilities quickly, without discharge inequality and condemns many women and newborns to checks.93 These findings beg the question as to why death. women are encouraged to deliver in such circumstances The Lancet’s 2006 Maternal Survival Series promoted with low facility capability, poor provider skills, and childbirth in lower-level facilities capable of basic EmOC inadequate lengths of stay, and these issues should be provision, ideally staffed with midwives, for LMICs.22 remedied as a matter of priority. These facilities were promoted because of shorter travel The imperative for countries that have achieved demand times, reduced cost, and reduced likelihood of over- for facility birth, and ensured some form of access, is to intervention. Some countries appear to have adopted improve quality, including EmOC capability, and inter- this model (eg, Senegal and Uganda); however, in view facility links and emergency medical services. Countries of our findings that health centres in many settings where nearly all deliveries occur in facilities have opted have suboptimal capabilities and are not capable of largely for births in hospitals with caesarean-section basic EmOC we question whether this model was capability. Trends in HICs have been towards centralisation actually adopted. Tanzania expects deliveries to occur at of health services, leading to fewer, larger-volume facilities, even lower levels: health posts and dis pensaries.105 Such and less rural provision. The changes in HICs are driven low-volume facilities are numerous, and of particular partly by desires to improve patient safety and cut costs, concern despite often being the closest facilities to and indirectly by challenges that remote facilities face in remote rural women; even if provisioned as childbirth recruitment and retention of providers, and by increased venues, their staff might have insufficient training or regulations reducing profitability of private-sector opportunities to practise and maintain competency in maternity services.94–99 However, a low number of units intrapartum care, and links to emergency medical erodes patient choice, and increases travel time,95 and very services are frequently poor.106,107 large hospitals can be difficult to manage. Mega-hospitals, with at least 10 000 births per year, which are seen in some What do we want for the future? countries can yield peculiar ecologies of non-evidence- Facility and skilled birth attendant deliveries are based childbirth practices, including high levels of aug- increasing, but in many LMICs, urban, and richer mentation, caesarean-section, crowding, and very short women use these services much more than rural and lengths of stay.29,100 poorer women.108 To serve women, and achieve universal Countries where hospital births are nearly universal coverage, this discrepancy needs to be remedied. More- are approaching, or are already below, the new over, governments and policy makers can no longer 2030 maternal mortality ratio target of 70 per pretend to provide life-saving care, using phrases such as 100 000 livebirths or less, irrespective of the front-line skilled birth attendant and EmOC to mask poor quality; cadre.101 The Lancet’s 2014 Midwifery Series102 provided skill and emergency care need to actually be provided, hypothetical evidence for midwives as the preferred main adequate numbers and training of staff should be skilled birth attendant and front-line provider. In ensured, capability and basic infrastructure of facilities countries where most facility births are in hospitals, the should be improved, timely referral should be ensured mix of cadres varies: in Morocco (2000–04) and Namibia where necessary, and women should get appropriate (2009–13), for example, midwives predominate, with a high quality content of care.29 non-trivial proportion of doctor-led births, whereas in Chronic underinvestment in the health workforce Ukraine (2003–07) and the USA (2013) doctors lead. We and the resultant global shortage of health-care workers have insufficient data on the front-line provider is well known and extends to skilled birth attendants, (particularly for HICs) to compare maternal and neonatal particularly in low-income countries.109 Ultimately, out comes in countries where different cadres pre- overburdened, underskilled, and underappreciated dominate (figure 2). health workers are compromised to deliver quality Some countries, such as Bangladesh and Haiti, have maternal health care, and lack resilience to shocks (eg, low coverage of skilled birth attendants and facility birth, as observed in the 2014 Ebola outbreak). 20,110,111 Un- but women who do get facility care are mainly in fortunately, we found few national examples in which hospitals (rather than lower-level facilities), and attended the skilled birth attendant workforce substantially grew by doctors. This pattern either reflects grossly unequal in a short timeframe.112 Initiatives to increase provider availability and accessibility in which only a privileged numbers have included training staff to work abroad minority access care, or alternatively could arise if (eg, Cuba113), recruitment of staff from others countries emergency referral functions, and hospital-based (eg, Cuban doctors in Brazil114 and Africa115), scaling up providers primarily attend women with complications.103 of training programmes to locally train sufficient In Bangladesh, travel times are short, so women with numbers (eg, in Indonesia and South Africa 116–119), and complications can reach hospitals quickly, possibly task shifting (eg, Mozambique120,121). The Lancet’s explaining why the country’s maternal mortality ratio is Commission on Health professionals for a new relatively low considering its low skilled birth attendant century,122 suggests ways to sustainably improve health coverage.104 In other settings, this pattern reflects sizeable worker education in general, and programmes exist in

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a number of countries (including e-health distance- Data needs: moving towards universal indicators for learning approaches in Rwanda, and modernisation of maternal health services curricula and development of continuing, in-service The data we collated and analysed show how previously education in Mozambique, Sudan, Thailand, and underused information can describe the configurations Yemen).123 However, evidence that these suggestions of maternal health services better. Our main sources achieve sustainable, long-term success is limited. were the Demographic and Health Surveys and health- Rollout of task-shifting programmes has been facility assessments. Together, data from these sources hampered by political, capacity, quality, and other enabled us to illustrate the diversity of maternal health resource challenges,119,124 and while task-shifting models across a range of LMICs, and to pinpoint some programmes increase health-care coverage in some common bottlenecks preventing women from receiving cases, success is not at a sufficient scale to improve high-quality routine or emergency childbirth care. These population-level maternal health outcomes, with some same sources can generate the same indicators at sub- notable exceptions.125,126 Teamwork, as recommended in national level. Complementary indicators, on GDP, The Lancet’s 2006 Maternal Survival series,18 is an health-expenditure, policies (such as the legality of alternative potential solution. abortion), and estimates of the extent of private-sector We support facility delivery, but not in facilities that fail coverage, content of antenatal care, caesarean-section to reach at least basic EmOC standards, unless countries rates, length-of-stay, postnatal care coverage, and unmet are explicit about how such places will cater for need for family planning, can round-off our emergencies. It could be argued that LMICs should understanding, particularly if tabulated by indices of emulate HICs, and opt for births in facilities capable of inequality, and coupled with health status indicators, comprehensive EmOC. However, such models are such as obesity, HIV prevalence, maternal mortality associated with high intervention rates in some HICs, ratios, severe morbidity, and fetal and neonatal mortality. and even higher intervention rates among wealthier Ultimately, strong national data systems need to be built women in poorly regulated LMIC health-systems.29,127 to inform policy, and focus investment and resources, Some HICs (eg, the UK) are increasingly encouraging ideally linked and aligned to similar processes for low-risk women to opt for home births with skilled birth newborns. attendants, or birth in lower-level free-standing, We acknowledge some data limitations in our analysis. midwifery-led units, or in alongside midwifery-led First, the facility designation and the cadre of the health units.128 professional are often recalled by women (eg, in the Average travel times to the lowest-level facilities are Demographic and Health Surveys) and are subject to generally shortest, but frequently these cannot even recall errors and can be an inaccurate reflection of the provide routine care, much less emergency care. To actual facility capability131 or providers’ actual skills.11,132 improve geographical access for women in labour and Second, some data were more than 10 years old, which is timeliness of care, governments could improve func- problematic when extensive changes occur (eg, Ethiopia tionality of lower-level facilities, or institute maternity or India). This limitation underlines the importance of waiting homes, or support routine transport to EmOC- relatively frequent data collection. Health management capable facilities. Either all women who enter into labour information systems, such as DHIS2,133 could rectify this should be within travelable distances to comprehensive limitation, provided they include private providers facilities, or if they can only reach lower-level facilities, (because these providers conduct many deliveries).134 these must have well-functioning maternal care, with Health management information systems are also excellent strategies for linkage to emergency medical advantageous because they provide subnational, district- services. level data. In this Series paper, we focused on the pathways In addition, we identified some critical data gaps. linking women to intrapartum services. Looking more Signal functions for routine maternal (and for newborn widely, we recognise the continuum of care129 and the care) need to be more widely adopted, collected via need to link across services, and develop new non- public-sector and private-sector facility assessments, traditional maternity services that respond to the and ideally, be updateable and in the public domain. obstetric transition being observed globally.130 Ensuring The ultimate challenge is to measure how many maternal health systems synergise with emerging women actually receive key elements of routine neonatal strategies and structures is also beneficial. childbirth care and whether all women who require Dickson and colleagues36 did a multi-country review of emergency care actually receive it, respectfully, and health system bottlenecks for newborns and identified promptly. Data also need to be captured for unnecessary solutions we further endorse for women, including interventions. This challenge requires investments to workforce planning to increase numbers and upgrade improve record-keeping and change health manage- specific skills, incentives for rural workers, financial ment information systems, as was done successfully in protection, and dynamic leadership such as innovation Ecuador.30 The maternal and newborn research com- and community empowerment. munities need to come to consensus on which www.thelancet.com 47 Series

coverage, quality, and timeliness indicators they can every woman can give birth without risk to her life, or effectively field at scale. These indicators need to be that of her baby. defined clearly and implemented consistently to Contributors compare across countries. OMRC, CC, AT, MS, FD, MK, and PB conceptualised the series paper. Parallel investments in development of tools for OMRC, CC, AT, MS, SG, MK, and SS did the literature search. CC, LB, EK, DM, CR, LR, and PB did the data analysis. Figures were done by CC, planning, monitoring, and advocacy are also vital. For LB, SG, EK, DM, LR, and PB. All authors contributed to data example, consensus on the numbers of births a full- interpretation. OMRC, CC, AT, MS, EK, and PB wrote the review and all time midwife can do per month, and tools enabling other authors commented on multiple versions. managers to accurately calculate staffing requirements Declaration of interests overall, and on a daily basis, would support more We declare no competing interests. 135 effective planning, deployment, and cost-savings. Acknowledgments Improvements to existing planning tools, such as the The Bill & Melinda Gates Foundation and the MacArthur Foundation OneHealth Tool, would extend reach, and help countries supported this work. We thank the Ghana Health Services for access to the Ghana 2010 Assessment data; the Mozambique Ministry of Health achieve human resource plans for maternal, fetal, and and National Institute for Health for access to the Mozambique 2012 5,136 newborn care. Similarly, more sophisticated use of assessment data; the Ethiopia Federal Ministry of Health for access to mathematical and geographical models now available the Ethiopia 2008 assessment data; the Demographic and Health Survey have great potential to inform improved service Program for access to Service Provision Assessments and surveys; 64 Robert Scherpbier, Sufang Guo, and Xiaona Huang from UNICEF, configurations. For example, a study in Ethiopia China, and Hu Wenling from the National Center for Women and modelled the effect on coverage of adding vehicles and Children Health, Chinese Disease Prevention Control Center, Beijing, communication capability or upgrading strategically for access to facility assessment data from China; Luisa Kunz for help located facilities, and changing the configuration of accessing German data; Masao Iwagami, Kazuyo Machiyama, and Sean Duffy (London School of Hygiene & Tropical Medicine, London, UK) for referral networks, and found that the optimal strategy help accessing and interpretation of Japanese data; Kerry Wong for reduced mean travel time from 2 h to 1 h. preparing figure in appendix on telephone and motorised vehicle ownership in Kenya; and Jerker Liljestrand (Bill & Melinda Gates Conclusion Foundation, Louisiana, WA, USA) and Kevin Quigley (School of African and Oriental Studies, London, UK) for comments on a draft. The A powerful body of data is available to examine current authors alone are responsible for the views expressed in this article and configurations of childbirth care, and to begin to they do not necessarily represent the views, decisions, or policies of the evaluate whether maternal services meet the needs of institutions with which they are affiliated. women. In view of the enormous range of contexts, we References cannot recommend one configuration of care. These 1 WHO. World health statistics 2015. Geneva: World Health Organization, 2015. decisions need to be made locally and nationally. 2 United Nations Inter-agency and Expert Group on MDG Indicators. However, we can reiterate that facility deliveries only The Millennium Development Goals Report 2014. New York: make sense if they can provide safe routine services, as United Nations, 2014. 3 Hodgins S. Achieving better maternal and newborn outcomes: well as basic EmOC and referral capability to guarantee coherent strategy and pragmatic, tailored implementation. women with complications are appropriately managed Glob Health Sci Pract 2013; 1: 146–53. in a timely manner (at a minimum). We note a number 4 Kinney MV, Kerber KJ, Black RE, et al. Sub-Saharan Africa’s of missed opportunities to generate evidence: data for mothers, newborns, and children: where and why do they die? PLoS Med 2010; 7: e1000294. routine care, maternity waiting homes, transport, and 5 de Bernis L, Kinney MV, Stones W, et al. Stillbirths: ending inter-facility transfers are particularly limited. preventable deaths by 2030. Lancet 2016; 387: 703–16. Considerable investments are needed to enable the 6 Koblinsky M, Moyer CA, Calvert C, et al. Quality maternal care for every woman, everywhere: a call to action. 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Maternal Health 4 Drivers of maternity care in high-income countries: can health systems support woman-centred care?

Dorothy Shaw, Jeanne-Marie Guise, Neel Shah, Kristina Gemzell-Danielsson, KS Joseph, Barbara Levy, Fontayne Wong, Susannah Woodd, Elliott K Main

Published Online In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been September 15, 2016 largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the http://dx.doi.org/10.1016/ S0140-6736(16)31527-6 main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and This is the fourth in a Series of six papers about maternal health place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in See Online/Comment high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear http://dx.doi.org/10.1016/ prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource S0140-6736(16)31534-3, shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, http://dx.doi.org/10.1016/ such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and S0140-6736(16)31525-2, and http://dx.doi.org/10.1016/ practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and S0140-6736(16)31530-6 disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of See Online/Series excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all http://dx.doi.org/10.1016/ the facility’s women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by S0140-6736(16)31533-1, women’s experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with http://dx.doi.org/10.1016/ S0140-6736(16)31472-6, integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight http://dx.doi.org/10.1016/ areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman- S0140-6736(16)31528-8, centred care and the best outcomes without high costs is required to provide an impetus for change. http://dx.doi.org/10.1016/ S0140-6736(16)31395-2, and http://dx.doi.org/10.1016/ Introduction Series paper presents the main drivers of the models of S0140-6736(16)31333-2 Global efforts to end preventable maternal and newborn maternity and childbirth care in 14 HICs, and their Department of Obstetrics and mortality have appropriately focused on addressing of influences on outcomes. Drivers are factors that cause a Gynaecology (D Shaw MBChB, known risks associated with pregnancy and birth. This particular phenomenon to happen or develop. This Series K S Joseph PhD), Department of approach has been the great success of medical paper also includes mechanisms and research direction to Medical Genetics (D Shaw), and School of Population and intervention in high-income countries (HICs), resulting promote evidence-based change and woman-centred care. Public Health (K S Joseph), in very low maternal mortality (12 deaths per To explore potential drivers, including cost, we compared University of British Columbia, 100 000 livebirths) and neonatal mortality (four deaths available national data from 14 representative HICs. We Vancouver, BC, Canada; BC per 1000 livebirths).1,2 HICs virtually guarantee antenatal also draw on the scientific literature, particularly reviews, Women’s Hospital and Health Centre, Vancouver, BC, Canada care and a skilled birth attendant, and generally have to identify additional potential drivers (methods are shown (D Shaw); Departments of institutional births, which can provide appropriate in the appendix). Obstetrics and Gynecology, emergency care for complications. Medical Informatics and The new era of Sustainable Development Goals (SDGs)3 Health system and epidemiological drivers Clinical Epidemiology, Public Health and Preventive brings HICs under the accountability lens, providing an Health system drivers of maternal health outcomes Medicine, and Emergency opportunity for timely reflection on the status of maternal include birth setting (home, free-standing birthing centre, Medicine, Oregon Health and health and its drivers in these countries. Although hospital-sited midwifery-led birthing unit, or hospital), Science University, Portland, mortality is generally low, the picture is far from perfect. cost of models of care, and size and location of facilities OR, USA (J-M Guise MD); Beth Israel Deaconess Medical Care varies greatly, not all care is evidenced based, and (rural and remote). Epidemiological drivers of maternal Center, Harvard T H Chan some care might actually be harmful. In some settings, health outcomes include maternal mortality and morbidity School of Public Health, fear prevails among subsets of women and providers, surveillance and audits, and the changing epidemiology of Cambridge, MA, USA driving increased and inappropriate intervention. Medical women giving birth. Evaluation of data for these health (N Shah MD); Division of Obstetrics and Gynecology, liability costs are enormous, human resource shortages system drivers can provide evidence for necessary change. Department of Women’s and are common, and costs of provision can be very high. Children’s Health, Karolinska Outcomes are not equitable, and disadvantaged sub- Care delivery models in high-income countries: Institute, Stockholm, Sweden (K Gemzell-Danielsson PhD); The populations can face substantially elevated risks. New birth setting Children’s and Women’s challenges linked to changing epidemiology, such as older Hospital births Hospital of British Columbia, age at birth and increased obesity are also present. At the Most women in HICs have access to antenatal care, and BC, Canada (K S Joseph); same time, examples of excellence and progress are postnatal care, including settings where postnatal care George Washington University evident, from clinical interventions to models of care. This includes home visits by midwives and health visitors.

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Home births are infrequent in most HICs, other than the Netherlands (table 1). In most HICs, women with Key messages high-risk and low-risk pregnancies deliver in the same • Women should be offered care that supports the safe physiological process of labour place, a hospital. These facilities are well optimised for with the lowest level of intervention possible, to reduce overintervention, and support high-risk women, with technology and staffing for close woman-centred care. Countries, care systems, and providers need to consider how monitoring and expeditious access to interventions. they will promote this. Conversely, these facilities might not be optimised for • High-income countries (HICs) with a combination of lowest intervention rates, best low-risk women, and staff monitor and intervene more outcomes, and lowest costs have integrated midwifery-led care through different than is necessary for the overwhelming majority of models, including team-based care in maternity hospitals, low-risk units alongside women. The consequences of overintervention include full-scope maternity hospitals, and freestanding or home-based midwifery. Such avoidable harms to women and newborns, such as rapidly experiences in HICs are informative for countries where maternal mortality is rising incidence of placenta accreta linked to previous decreasing, and transitions in care models are occurring. caesarean section, while driving escalating, unsustainable • Most HICs lack robust surveillance systems for ascertainment of maternal deaths, and costs. In some settings, hospital-sited midwifery-led for accurate identification of the underlying cause of death and instances of birthing units are an attempt to optimise care for low-risk preventable death. State, provincial, or national level audits of maternal death are women. Such units have lower rates of medical needed, with results collated, analysed, and disseminated, along with interventions during labour, and higher satisfaction recommendations for prevention. Data should specifically be disaggregated by levels, with no increased risk to mothers or babies.4 vulnerable populations. • Maternal safety programmes are recognising the importance of protocols, drills, and Birth centres and home births team training in a simulation environment, to address preventable causes of mortality Midwives attending births at home or in free-standing and morbidity, such as massive obstetric haemorrhage. birthing centres are another way to optimise birth for • HICs experience variation in practice that is not evidence-based nor attributable to size of low-risk women. These centres are typically clustered facility, providing opportunities for improvement of quality of care, and outcomes. around urban centres, with easy transfer to hospital • Malpractice liability might pose a barrier to optimal maternity care in North America, when appropriate.5 especially the USA, by reducing the number of obstetricians willing to pay high Research on planned hospital versus planned home premiums and by contributing to overuse of services based on fear. Some countries births in the UK indicates that home birth services with manage to overcome liability barriers by state support provision for those infants born collaborative med ical backup should be established and with serious neurological . Research from other countries suggests that offered to women with low-risk pregnancies in all state support should be in conjunction with implementation of safety programmes at jurisdic tions.6 The National Institute for Health and Care the facility level. Excellence (NICE) 2014 guidelines recommend that all birth settings should be available to women at low risk of birth-associated complications, and home birth should Some elements of increased spending improve School of Medicine, generally be considered a safe option, although an outcomes, particularly for premature infants, although Washington, DC, USA (B Levy MD); Uniformed increased risk of adverse outcomes for the baby for support of extremely preterm infants with neonatal Services University of the nulliparous women compared with birth in a midwifery- intensive care is a significant expense in HICs. Increasing Health Sciences, Washington, led unit is noted.7 A 2015 US study8 showed a higher numbers of caesarean sections and inductions of labour DC, USA (B Levy); Women’s perinatal mortality (3·9 vs 1·8 deaths per 1000 deliveries) are additional cost drivers in the USA, UK, and Canada; Health Research Institute, BC Women’s Hospital and Health in planned out-of-hospital births but did not highlight vaginal delivery is the least expensive, and unplanned Centre, Vancouver, BC, Canada 10 important factors, including lack of insurance in 34·5% caesarean is the most expensive mode of delivery. (F Wong BA); London School of of the women (vs 1·0% for planned hospital birth) and no Several studies from HICs,11–14 including the Netherlands, Hygiene & Tropical Medicine, skilled attendant in 23·1% of the planned out-of-hospital show lower resource use and costs at home and birth London, UK (S Woodd MBBS); and California Maternal Quality births (vs <0·2% for planned hospital birth). A 2015 centres than hospitals, especially in urban or academic Care Collaborative, 9 Canadian study that compared planned hospital births medical centres. San Francisco, CA, USA with home births, attended by licensed midwives, found (E K Main MD) no difference in serious neonatal adverse outcomes, and Size and location: rural and remote Correspondence to: noted that Canadian midwives are well integrated into The trend over the past two decades in HICs towards Prof Dorothy Shaw, Departments of Obstetrics and Gynaecology the health-care system. closure of smaller facilities providing maternity care and Medical Genetics, University means women travel further to receive care, especially of British Columbia, Vancouver, Costs of models of care and outcomes for labour and delivery, and can involve relocation to BC V6H 3N1, Canada The cost of childbirth is disproportionately expensive in maternity waiting homes.15 Access costs in many cases [email protected] the USA compared with all other HICs within the are borne by women. Smaller hospitals have lower See Online for appendix Organization for Economic Co-operation and Develop- rates of obstetric intervention and improved neonatal ment (OECD; table 1). Similar trends in higher costs can outcomes among low-risk women.5,16 A Canadian be seen in Australia and other HICs. Cost increases over study17 showed that travel to access maternity care in time are largely attributed to use of interventions large hospitals is associated with adverse perinatal (appendix). outcomes for infants. German18 and Norwegian19 www.thelancet.com 53 Series 2013–14 Year of data of Year Overall Overall health expenditure GDP) of (% 2014 Cost of Cost caesarean section US$) (2015 $2477 $4896 10·08% 2012 $6775499 $10 9·03% 2011/2012/2014 $3931 $3931 9·27% 2010/2011 $2303 $2909 9·44% 2010/2011/2012 $3025 $6025 9·36% 2008/2010/2014 $2784 $4561 8·85% 2008/2010/2013 Cost of Cost vaginal birth (2015 US$) None $2741 $4604 9·32% 2010/2013–14 None (facility US$10 fee day) per NoneNone (can $1434 pay privately) $3801 9·07% 2010 None (can pay privately) No net cost N/A $3676 $6686 11·63% 2010/2012 None (facility fee €17) None $2930 $5420 11·18% 2002–03/ 2011–12/ None $2517 N/A 11·15% 2005/2010–12 Cost to Cost patient None (can pay privately) Salary Salary Salary Salary Salary Fee for serviceFee None $2889 $5618 11·96% 2010/2012/2013 Government-set Government-set fee for service Salary Salary (hospital) N/A $2592 $4253 11·06% 2010/2013 Salary Government-set Government-set fee for service Salary remuneration type for physicians Salary obstetrician consultant role obstetrician consultant role obstetrician obstetrician obstetrician/GP obstetrician consultant role obstetrician obstetrician obstetrician obstetrician GP/midwife obstetrician Main care provider Most common obstetrician 10–50% Midwife/ 16% Midwife– Epidural in labour (%) 19·4%/ 20·1% Episiotomy of rate (% vaginal births) 24·6%, 26·1% Caesarean- section rate (%) 77·9% 22·1% 4·9% N/A Midwife/ 73·9% 75·4%, 74·7% 25·3% 12·0% 24·7% Midwife/ 75·0% 25·0% 43·0% N/A Midwife/ 72·9% 27·1% 17·0% 58·7% Obstetrician/FP/ 67·8% 32·2% 14·4% 71% Obstetrician for service Fee N/A232 $10 591 $15 17·85% 2012/2014 79·0% 21·0% 26·9% 82% Midwife/GP/ 67·7% 32·3% 15·6% 29·9% Midwife/GP/ 82·9% 17·1% 6·6% 34·4% Midwife– 82·9% 17·1% 18·8% 28% Midwife/ 83·0% 17·0% 30·3% 11·3% Midwife– 83·2% 16·8% 24·1% 49% Midwife/ 80·8% 19·2% N/A 68·7% 31·3% 27·7% <10% Midwife/ Vaginal Vaginal birth rate (%) Birth centre birth rate (%; free-standing) 2% 2·3% 1·1% N/A 0·91% 0·43% Home birth rate (%) USA UK (England, Wales) SpainSweden N/A N/A <1% N/A* Norway 0·8% 0·5% New Zealand 3·3% 10·1% Netherlands 20·0% 11·4% GermanyJapan 0·0% N/A France 0·0% N/A DenmarkFinland 1·2% N/A 0·6% N/A Canada 1·2% N/A Australia 0·4% 2·2% References in appendix. GP=general practitioner. FP=family practitioner. N/A=not available. *Sweden’s only birth centre is now closed. *Sweden’s N/A=not available. FP=family practitioner. GP=general practitioner. in appendix. References to birth and cost comparisons in selected high-income countries related in interventions Variations : Table

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studies, show smaller maternity hospitals have higher women aged 15–54 years to pregnancy-related hospitali- rates of neonatal death. More research is needed to sations and those within 1 year after the end of pregnancy clarify these issues and to identify how low-risk (includes 98% of births).26 Mortality based on vital maternity care in rural areas can be delivered safely registration data reveal an increasing trend, whereas the and acceptably. more accurate rates based on hospitalisation data do not show any significant change.26,27 Need for health system responses to prevailing epidemiological burden The need for maternal death and severe maternal Maternal mortality surveillance in HICs morbidity audits Most HICs have experienced declines in maternal Enhanced data is needed to drive practice improvement— mortality since 1990, although the rate varies (figure 1).1 especially in terms of an information system that is The UK Confidential Enquiry into Maternal Deaths is possibly the finest existing surveillance system for maternal death.20 This legislated and comprehensive A examination of clinical circumstances and context relies 20 Australia Germany Spain Canada Japan Sweden on information from midwives, obstetricians, coroners, 18 Denmark Netherlands UK members of the public, the media, vital statistics records, Finland New Zealand USA France Norway and linked birth–death records. The UK vital registration 16 system only identified 53% of the deaths in the most 14 recent inquiry.21 Deaths from direct causes (such as pre-eclampsia and eclampsia) decreased from 1985–87 to 12 2009–11, whereas rates of maternal death from indirect 000 livebirths) causes (such as cardiac causes) increased.21 A substantial 10 000 number of deaths from influenza emphasises the need to 8 use influenza vaccine in pregnant women.20 Cardiovascular

disease was the largest single cause of death in 2010–12, MMR (per 1 6 similar to rates in Australia and the USA.20 4

Maternal mortality in Canada and the USA 2 Global assessments of maternal mortality ratios in 2013 revealed some disappointing trends: the ratio was 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 increased in 19 countries, including Canada and the Year USA.20,22 However, both countries had reduced their ratios in 2015: Canada at six deaths per 100 000 livebirths, B 2 24 California and the USA at 14 deaths per 100 000 livebirths. The 22·0 USA USA has moved from having one of the lower maternal 21 19·3 mortality ratios among HICs, to having the highest in 16·9 19·9 25 years.23 This rise in ratio might be a result of an ageing 18 15·5 16·6 15·1 16·9 14·6 maternity population with increasing comorbidities and 14·0

000 livebirths 15 13·1 ever-rising body-mass indices,24 as well as overuse 12·7 10·9 11·6 12 10·0 13·3 (increasing interventions), underuse (lack of risk- 9·9 9·9 12·1 11·8 11·7 9·2 appropriate care), and lack of access to care. Mortality 11·1 9 9·8 9·7 7·4 7·3 data can be based on modelling (figure 1A) or vital 8·9 6 7·7 registration (figure 1B). Additionally, improved 6·2 surveillance (eg, introduction of a pregnancy checkbox deaths per 100 Maternal 3 HP 2020 Objective: 11·4 deaths per 100 000 livebirths on death certificates) could be an important contributor 0 to the relatively high rate and temporal increase in 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 maternal mortality rates in the USA (appendix). Year Identification of the true state of maternal mortality will take careful correlation of case reviews with vital record Figure : Maternal mortality ratio per 100 000 livebirths from 1990–2015 for selected countries (A)1 and coding for both direct and indirect maternal deaths. maternal mortality rate in California and USA between 1999–2013 (B) Data source for part B was the State of California, Department of Public Health, California Birth and Deaths Statistical Routine reporting of maternal mortality in Canada master files 1999–2013. Maternal mortality for California (deaths ≤42 days post partum) was calculated using uses vital registration, but the most recent comprehensive International Statistical Classification of Diseases and Related Health Problems 10th Revision cause of death report in 200425 showed that vital registration only classification (codes A34, O00-O95, O98-O99). US data and HP2020 Objective use the same codes. US maternal mortality data is published by the National Centre for Health Statistics (NCHS) through 2007 only. US maternal identified 41% of maternal deaths between 1997 and mortality rates from 2008 through 2013 were calculated using CDC Wonder Online Data based accessed at http:// 2000. More recently, the Canadian Perinatal Surveillance wonder.cdc.gov/ on March 11, 2015. Produced by California Department of Public Health, Center for Family Health, System has linked data from all hospital deaths among Maternal, Child and Adolescent Health Division, March 2015. MMR=maternal mortality ratio. www.thelancet.com 55 Series

feasible (low burden and low cost), timely, reliable, and hypertension, obesity, and other complicating conditions actionable. Comprehensive details on the social of pregnancy.40 More disturbingly, the overwhelming circumstances and clinical context surrounding each majority of childbirth in black Americans occurs in a maternal death are important in view of the small concentrated set of hospitals that experience higher rates number of heterogeneous maternal deaths that occur in of severe maternal morbidity.41 HICs. The lesson learnt from the UK Enquiry is that Reforms to the US maternal health system are maternal death audits and severe maternal morbidity underway. Concerted efforts have been made to improve surveillance are complementary activities informing surveillance, audit, and feedback of important birth policies and quality improvement activities to reduce outcomes.42,43 Payment reforms to reduce unnecessary preventable mortality.20 interventions, including a hard stop that eliminates payment for early elective inductions of labour, have had Case study countries early success,44 although evidence is conflicting on USA increases in stillbirth rates.45,46 The Affordable Care Act Most women give birth in hospitals, under the care of has improved access to care, recent measures to ensure obstetricians. In many rural areas of the USA, women appropriate resources are available for the types of high- must travel long distances to access obstetric care.14 risk care in which the USA excels.47 Nonetheless, the Compared with all other OECD nations, maternal health USA has much room to improve maternal health-care care for the average woman is expensive, risky, and affordability and outcomes, particularly for the average inconsistent. Large out-of-pocket expenses for care during patient with a low-risk pregnancy. pregnancy are common.28,29 Despite high investment, important indicators of health system performance such Sweden as maternal and neonatal mortality, and preterm and low Sweden has one of Europe’s highest birth rates. Its weight births, significantly lag behind OECD averages.30 maternal mortality ratio in 20152 was four deaths per Equally concerning are large disparities within the USA 100 000 livebirths, one of the lowest in Europe. Sweden that exist along regional, socioeconomic, and racial lines. has sparsely populated mountainous areas and remote Maternity and newborn care constitutes the single islands, and long travel distances. Despite these obstacles, largest category of hospital payouts by both private and coverage is good, and all women have access to antenatal public insurers in the USA.31 25% of all hospital care and childbirth care. discharges are either a mother or a newborn baby after Antenatal care is organised mainly at primary levels, childbirth.32 Of concern, charges for childbirth in the provided by midwives for healthy women. Obstetricians USA tripled between 1996 and 2013.31 Payment models and midwives provide antenatal care to women with high- vary but fee for service is most common, which provides risk pregnancies at specialist units, with planned financial incentives for high use. Labour induction, programmes, and follow-up. All birthing facilities are epidurals, caesarean deliveries, and other childbirth located at hospitals, which are staffed by obstetricians and interventions have escalated in the past few decades in a midwives; midwives are responsible for births of healthy manner that appears to be largely independent of patient women. Birthing facilities are hospital-sited midwifery-led risks or preferences.33,34 birthing units, but all have access to skilled obstetricians Underlying the US payment system is a care-delivery and neonatologists. Less than 1% of all births are home model that is influenced by birth setting, workforce, births. Maternity care is publicly funded, and provided malpractice policies, and patient agency. Most of the mainly in public facilities, with some publicly funded care childbirth charge comes from the facility fee,35 which can in private facilities. Staffing does not differ by sector. vary ten fold between facilities.36 The facility fee reflects Labour induction for singleton pregnancies at more the hospital-based birth settings that 99% of Americans than 37 weeks’ gestation was 17·1% in 2014.48 Electronic choose; most of these settings have staffing ratios and fetal monitoring is used in all women at admission, equipment that closely resembles the intensive care continuously if indicated. Intravenous access is routine. unit.8,37–39 Relatively few women choose midwives over Pain relief in labour involves use of nitrous oxide (81% of obstetricians despite possible benefits for low-risk women) and minimal motor block epidural analgesia women with regard to cost and intervention rates.40 (53% of primiparas, 21% of parous women). Low-risk Even when birth setting, workforce, payment model, women are permitted to consume fluids in labour. and malpractice policies are held relatively constant, Skin-to-skin contact for the first hour is standard care. substantial unexplained variation persists in the The overall caesarean-section rate is approximately provision of maternal health care. Hospital caesarean 18%, of which 54% are planned (elective); rates are section rates vary from 6% to 70%; early elective delivery highly variable between hospitals (12–22%). Maternal rates from 0% to 83%, and third and fourth degree tears requested caesarean section is covered by national from 0·5% to 95%.34 Black Americans are significantly guidelines49 and comprises 17% of all caesareans. The more likely than are white Americans to experience caesarean section rate for multiple births is 58% and for preterm birth, neonatal and maternal mortality, as well as breech presentation is 91%.48

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Health facilities publish benchmarking data for world, followed by the Americas (WHO region), resulting quality indicators such as caesarean section rates and in a higher prevalence of alcohol dependence and complications.50 Women or their relatives, or health alcohol-use disorders than in other WHO regions facilities or staff can report unexpected outcomes to the (appendix).60 Health and Social Care Inspectorate. Economic support or compensation for adverse maternal or infant outcomes Trauma-informed practice is paid by insurance covering all publicly funded Woman experience a high prevalence of abuse and health care (Landstingens Ömsesidiga Försäkringsbolag). violence (one in three women), globally. from National data are collected for women’s experiences intimate partner violence is not currently included in during childbirth. Stipulations for maternity leave are maternal mortality data. Women who are young, integrated into parental-leave schemes.51 immigrant, Indigenous, and women who have a disability Complementary efforts to improve reproductive health are at increased risk of intimate partner violence;61,62 include free contraceptive counselling, and subsidised prevalence is especially high in those women who contraception for young women. These interventions continue to drink alcohol after discussion at the first have decreased teenage deliveries and abortions.52 prenatal visit. Trauma-informed practice is an approach Teenage delivery rates are among the lowest globally. to support all women in terms of providing safe care in Induced abortion is legal. the health system for women who experience violence. Women generally have good health status. However, Use of a trauma-informed conversation in which obesity has been increasing; in 2014, 13% of all mothers judgment is suspended and substituted with supportive were obese.48 About 6% of women smoke in early information and questions as suggested by the British pregnancy.48 Immigrant women, comprising more than Columbia Centre of Excellence for Women’s Health is 25% of women giving birth, use less antenatal care and designed to move towards greater safety and a harm less preventive care, such as cervical screening.48,53,54 reduction model when abstinence from alcohol is not Being foreign born is an independent risk factor for possible.61 induced abortion and migrant women requesting termination of pregnancy had lower contraceptive use Vulnerable women compared with Swedish-born women.55 Vulnerable populations (immigrant, Indigenous, or ethnic minorities) are associated with poor health Demographics of pregnant women outcomes, including high maternal mortality among Changes in the underlying epidemiology of who is giving African American women (at rates 3–4 times the rates for birth will affect care and outcomes. In Australia, the Hispanic and non-Hispanic whites),63 south Asian percentage of women 35 years and older was 22·7% of women (India and Pakistan) in the UK,64 Aboriginal and the total who gave birth, but accounted for 40% of the Torres Strait Islander women in Australia,65 and refugee total maternal deaths. In the UK, 74% of deaths occurred women in France and the UK. These women often have in women with pre-existing medical conditions.21 other adverse outcomes, including increased caesarean section rates, preterm birth, and low birthweight infants. Obesity Pregnant Canadian and Australian Indigenous women More than one in five pregnant women are overweight or have high rates of gestational diabetes and pre-existing obese globally, putting these women at increased risk of diabetes,65,66 and Torres Strait Islander women have an congenital anomalies (specifically neural tube and incidence of diabetes of 3–6 times the national average.67 abdominal wall defects), venous thrombo embolism, pre- High rates of micronutrient deficiency, alcohol, and eclampsia, gestational diabetes, post-partum haemor- tobacco use are also reported, and nutritional intake is rhage, and increased chance that an operative vaginal poor in a population with very low socioeconomic birth or a caesarean section will be required (appendix).56,57 indicators. As noted by Graham and colleagues in this Caesarean section rates are more than doubled with Series,68 The Lancet’s 2014 commission report on culture increased operative morbidity; successful vaginal birth and health concluded that the neglect of culture is the after caesarean section rates are decreased to 57·1% for single biggest obstacle to development of equitable women who weigh 90–135 kg, and 13·3% for women health care.69 who weigh more than 135 kg, compared with 81·8% success for women who weigh less than 90 kg.58 Preterm birth Additionally, hospital costs are increased for both Preterm birth remains the least well understood and maternal and neonatal indications in obese women. greatest contributor to poor perinatal outcomes globally, and is both stressful for families and costly to the health Tobacco and alcohol use system. Risk factors for preterm birth and its attempted Overall rates of smoking at the start of or during prevention and treatment also have implications for pregnancy vary between 5·5% and 23% for the selected maternal health, including extremes of maternal age HICs.48,59 Alcohol intake in Europe is the highest in the (both young and old), assisted reproductive technology, www.thelancet.com 57 Series

40 Australia interviewed supported high-tech hospital birth, including Canada use of electronic fetal monitoring. Primary caesarean Denmark section rates, where reported, are higher for women age Finland 35 80–83 France 35 years and older. However, maternal preference Germany caesarean rates vary across HICs and surveys typically 30 Japan Netherlands show physicians report higher maternal preferences New Zealand than women do themselves.84–86 25 Norway A multicountry systematic review found experiences Spain Sweden during childbirth were reported as unsatisfactory when UK (England) 20 they occurred in the absence of one or more of the USA following situations: quality care promoting wellbeing

15 with a focus on individual needs; unrushed caregivers who provide continuity of care and communicate effectively; involvement in decision making about care Percentage of births in women ≥35 years women ≥35 of births in Percentage 10 and procedures; and kindness and respect.87 Immigrant women gave worse ratings than did non-immigrant 5 women due to communication difficulties resulting from language barriers, unfamiliarity with how care was 0 provided, and experiences of discrimination87— 1982 1992 2002 2012 experience of birth from the perspective of immigrant Year women is particularly relevant to inform health system Figure : Percentage of births to women aged 35 years or older, in high income countries, 1982–2012 responses, in view of the current global migration trends.

multiple gestation, low maternal , Fear of pain in labour late or no , substance abuse, tobacco use, Pain relief options in labour and what is accessible in any bacterial vaginosis, and periodontal disease.70 In the given birthing environment depend on the culture, search for potentially modifiable risk factors for preterm woman’s preference, and availability of obstetric birth and infant health, gut and vaginal microbiomes are anaesthesia services. Existing data suggest wide important ongoing research areas.71,72 variations in the use of epidural analgesia with rates of 82% in France, 71% in the USA, 59% in Canada, and Drivers of clinical quality of care 10–50% in other countries (table 1). Comparative Biology in conflict information on availability of a mobile or minimal motor Drivers of clinical quality of care include women’s block labour epidural for analgesia is non-existent. autonomy, the role of the health-care provider and patient safety, as well as intersecting drivers such as social Maternity (or pregnancy) leave support, clinical evidence, fear, and medical liability. The International Labour Organization convention on Many women in HICs are delaying marriage and maternity leave stipulates at least 14 weeks of leave.88 reproduction until they complete higher education and Most OECD countries tie public income support find permanent work (figure 2). The consequences of this payments to taking of maternity leave for periods ranging delay are decreased fertility, a rising age at giving birth, from 6 weeks (Australia) to 39 weeks (UK); some and complications due to coexisting medical conditions integrate maternity leave into parental leave schemes that increase with age. Spain, Germany, and Japan have (appendix).51 The USA is the only OECD country that very low total fertility rates at 1·3–1·4 births per woman, does not provide paid maternity or parental leave89 and and all Nordic countries are under replacement levels at 30% of US women take no maternity leave.89 In Japan, 1·7–1·9 births per woman (appendix).73,74 qualification for paid child care leave is challenging, so only 4% of women in non-regular jobs can return to work Autonomy of women after leave.90 Mental health is a well-recognised health Women drive care because they have high expectations concern during pregnancy and post partum. Linked data for a positive birth experience and a healthy baby. Fear of in Europe (SHARE)91 suggest that a more generous pregnancy and childbirth is common, affecting as many maternity leave during the birth of a first child is as 25% of women in HICs,75 and can be so intense as to associated with a significantly reduced score of be termed tokophobia.76 Women are set up to feel 0·38 points in the Euro-D depressive symptom scale at inadequate and responsible if a perfect outcome is not later ages (over 50 years for a 16–25 years cohort). achieved, despite having little control over this mostly physiological process.77,78 The extent to which women Adolescents share in the general western valuation of technology is Adolescents are a special population whose re- revealed in a study79 in which more than 70% of women productive health needs are often suboptimally met.

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Teen pregnancy rates in the selected countries in this Fear of litigation and malpractice insurance Series paper have mostly declined, and birth rates for Many authors discuss the essential balance between fear adolescents have declined except for the USA, with and trust, as birth is becoming increasingly medicalised increased abortion rates in Finland, the Netherlands, due to domination of fear.104 Obstetric providers are often Sweden, and the UK. 92 In the UK and USA, teen sued, usually because of a neurologically compromised pregnancy rates are increased in the most socio- infant (table 2); despite the fact that as early as 1999, economically disadvantaged groups.93,94 an International Cerebral Palsy Task Force strongly suggested that most cerebral palsy was a result of Influence of the provider on maternity care multifactorial and mostly unpreventable causes during outcome either fetal development or the neonatal period.114 Models of care Fees for insurance liability coverage for obstetricians are Maternity care providers in HICs vary from single high in Canada and the USA.1108,109 The impact on the practitioners (family physician, general practitioner, obstetric provider goes beyond the cost of indemnity midwife, or obstetrician) to group practices of single payments, including time and stress, and can reduce provider cadres, to shared care between midwives and availability of obstetricians.110 Insurance affordability or obstetricians, in both public, and private settings. availability was the reported reason for a 9·6% increase in A mixture of models of care is found in the UK, the number of caesarean deliveries between Jan 1, 2012 and Canada, Germany, Japan, and Australia (appendix).95–97 Dec 31, 2014, in the 2015 American College of Obstetricians In western Europe, Scandinavia, and New Zealand, and Gynecologists survey.110 States with relatively high midwives provide 70–80% of care during pregnancy and malpractice insurance premiums had higher rates of for low-risk births, leading to lower intervention rates. caesarean section and lower rates of delivery by vaginal A review98 of continuous care led by licensed midwives birth after caesarean section than did states with lower showed several benefits for mothers and babies, and premiums.111 Furthermore, caesarean section rates were identified no adverse effects compared with models of substantially reduced and vaginal birth after caesarean medical-led care or shared care. The main benefits of section rates were substantially increased in state-years, in midwifery-led care were reductions in epidurals, which caps on non-economic damages were in force. episiotomies, and instrumental births. The rate of Medical liability reforms that have been implemented or caesarean births did not differ. In France, the roles of suggested include a no-fault system—at least for the different types of health-care providers have changed, neurologically impaired infant, caps on non-economic with greater involvement of general practitioners, and damages, and legal safe harbours.111,112 A number of no-fault especially midwives.97 In Japan, midwives work at schemes exist throughout the world, including in New hospitals and clinics, provide care for low-risk women Zealand, Scandinavia, Japan, and parts of the USA.105,106,112,114 during pregnancy, labour, and post partum, and cooperate with physicians for women at risk. Quality and safety issues In North America, most births were assisted by High quality care should be safe, effective, woman physicians, with midwifery reintroduced over the last centred, timely, efficient, and equitable,107 and a good three decades. Births by certified nurse midwives and outcome should be defined as what is meaningful and certified midwives in the USA in 2013 represented 12·0% valuable to the individual woman.78 of all vaginal births, or 8·2% of all births.99 In Canada, Improvement of care quality is a priority in HICs clearly midwifery began to be regulated in 1991, and planned evidenced by findings from Confidential Enquiries in home births by regulated midwives were first introduced France, Netherlands, and the UK, showing that overall in 1994. By 2013, all but two of ten provinces or territories almost half of maternal deaths are associated with had enacted legislation to regulate midwives.100 substandard care.20,115 In countries such as France, the Enquiry and attendant remediation efforts have reduced Labourists—a potential solution? preventable maternal deaths due to suboptimal care by Labourists are obstetricians who only provide care for 10%.116 The substantial variation in HIC obstetric hospital labour and delivery and may be a possible solution to care raises concerns that clinical practice patterns rather high intervention rates by obstetrician-led care. Studies than medical indications are driving increasing find that care by full-time labourists was associated with intervention rates.116,117 These variations are not accounted 27% fewer caesarean deliveries,101 whereas care provided for simply by different levels of care in size and type of by teams of labourists and midwives showed a nearly facility. As noted by Miller and colleagues in this Series,118 50% reduction in both overall and nulliparous term overuse of technology refers to use that is not based on single vertex caesarean delivery rates.102 Other studies evidence, with multiple drivers including fear of adverse have found no difference in outcomes when labourists outcome, revenue generation, and women’s demand. are present. The lack of a consistent role and funding Electronic fetal monitoring and prenatal ultrasound model for labourists makes reliable conclusions about during pregnancy and labour are major contributors to this model problematic at present.103 intervention in maternity care. www.thelancet.com 59 Series

Confidential inquiry into Tort No fault system for severe Cap on damages Malpractice insurance Other maternal deaths or near system neurological birth injury fees/subsidies miss Australia105–107 No (has national maternal Yes No; partial funding for high No Government premium .. death report generated payouts subsidies, private from ad-hoc national indemnity insurance research dataset) required for private practice Canada106,108,109 No Yes Partial in 4 provinces Yes; $100 000 for Premiums $34 204–72 456; Losing party pays 2/3 of successful non-pecuniary losses in 1978, subsidies variable by party’s legal fees; health-care costs currently estimated at province; insurance covered by state; fees not based on $300 000 coverage at time of event physician’s record or claims history effective whenever claim made Denmark106,107 No (regional maternal and Yes Yes No Yes, the regions pay Health-care costs covered by state perinatal reviews annually) compensation in case of malpractice from Patientforsikringen Finland106,107 No Yes Yes (in principle); the Finnish Case-based cap Public hospitals cover all Health-care costs covered by state Patient Insurance Centre employees evaluates and covers; in cases of serious malpractice or misconduct the health-care provider can be charged but not for financial expenses France106 Yes Yes but Partial Not available Partial government subsidy .. tort- adverse system Germany106,108 No Yes No Yes, and no punitive damages Not available Alternate dispute resolution encouraged; health-care costs covered by state Japan106 Yes Yes Yes No Not available .. Netherlands106 Yes Yes No Yes; €1 250 000 per claim Not available .. New Zealand106 No (has Perinatal and No Yes Not available Not available Health-care costs covered by state Maternal Mortality Review Committee) Norway106,107 No Yes Yes Case-based cap NPE (governmental Health-care costs covered by state system) and private insurance for physicians in case claims not covered by NPE Spain106 No Yes No No No .. Sweden106.107 No (Maternal Mortality Yes Yes; patients eligible to Yes; $370 000 per claim Insurance of Health-care costs covered by state review by Swedish receive compensation if $300–600 annually Obstetrics and Gynecology suffered injury that could through; the Swedish Society) have been avoided Medical Association UK (England)106,107 Yes Yes Government sponsored No No fees for NHS physicians, Health-care costs covered by state indemnification of medical sliding scale if in private injuries (National Health practice Service Litigation Authority) USA106,107,110–113 No Yes No (in 2 states only) Non-economic in 28 states; No; base rates from .. federal legislation pending $16 240 to $214 999; must have current insurance when claim made

NPE=Norsk pasientskade-erstatning.

Table : Factors affecting medical liability in selected high-income countries

Lack of clear and respectful communication across the safety and quality of care in HICs include national care team is one of the most common root causes of quality or safety agencies (or both), accreditation reported maternal and perinatal sentinel events.119,120 programmes, subnational reporting, institution-specific This lack is further amplified in publications of women’s mechanisms, involvement of patients (women) and experience of care. Mechanisms to improve patient families in planning, assessment, and delivering of

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their own care, required competencies for postgraduate Appropriate use of technology training, and public reporting on key quality and safety Although technology is a major driver in high-resource indicators. settings, and might result in over-intervention, Key safety practices and tools include121 maternal safety technology such as telehealth might have even greater For more on maternal safety bundles, maternal safety early warning triggers, critical benefit when women are geographically isolated. In bundles see http://www. patient safety event reviews with root cause analysis, HICs, telehealth has been tested in diabetes care, safehealthcareforeverywoman. org severe maternal morbidity case review forms, team-based smoking cessation, alcohol cessation, influenza simulation for obstetric emergencies, and validated vaccination, and antepartum care with mostly positive communication tools. results (appendix). As electronic technologies become increasingly prevalent, their ability to transcend access Drivers for change barriers and optimise convenience is attractive; Opportunities realised from data understanding of where the value is worth the investment Efforts can be made to reduce interventions in HICs by is a critical question.127 E-health initiatives to improve increased understanding of potentially modifiable risk access to care, woman-centred care, and improved factors and identification of opportunities to address pregnancy outcomes warrant further randomised trials. such risk factors through education, professional guidelines, health policy, and quality improvement Group antenatal care in HICs initiatives. CenteringPregnancy, and similar models of innovative New opportunities are available to use data to inform group antenatal and postnatal care and education in the heath policy and practice. In the USA, efforts are USA, Canada, Sweden, and Australia seek to address the underway to reconstitute maternal mortality reviews in concerns of consumers and professionals about the every state to create a standard set of structured data shortcomings of traditional antenatal care.128 A Cochrane elements for maternity care and to facilitate more review129 of a limited number of studies concluded that accurate and timely collection of vital records and group antenatal care is positively viewed by women and performance indicators directly from the electronic is not associated with adverse outcomes for them or for medical record.122 their babies. Detailed reviews of maternal deaths from two of the largest US states, California and New York, led to the Conclusions development of state-wide pilot projects with best Models of maternity care in HICs are evolving; woman- practice toolkits and large-scale engagement within centred care, accompanied by evidence that increasing performance improvement collaboratives.24 These interventions raise costs but do not improve outcomes, collaboratives focused on haemorrhage and severe provides an opportunity to shift the balance in HICs, and hypertension, which account for more than 80% of to provide an example of best practice based on evidence. severe maternal morbidity cases in the USA. The most Large variations in practice are evident in all HICs in populous US state, California, with nearly 500 000 annual all sizes of facilities, and among providers within the births (1/8 of all US births), has a maternal mortality rate hospitals when either outcomes or processes of care are that is now half the national rate and is similar to other examined. HICs (figure 1). Data should drive health policy and currently too many Implementation of national guidelines from France for knowledge gaps exist in HICs. Outcomes beyond non-invasive prenatal detection of aneuploidy successfully mortality are required to comprehensively inform health decreased amniocentesis, especially among women aged policy, especially in view of the inequities that exist for 38 years and older (from 61% to 42%) showing that Indigenous, ethnic, or marginalised populations. professional recommendations are being followed.123 Indicator data should be disaggregated by ethnicity and Recent changes to the definition of the active phase of vulnerable groups, with inclusion of rural versus urban labour and redefinition of normal length of second stage of contrasts. Additionally, nationally consistent oversight is labour should inform professional and facility guidelines needed and could be achieved by audit or confidential to decrease interventions for arrested progress.124,125 inquiry for maternal mortality and near miss (severe morbidity) with nationally supported provision of Innovation to improve access to care comparable data. Addressing of inequalities in both access to care and Quality improvement initiatives driven by data, maternal outcomes is a priority requiring improved evidence, and women’s input are becoming standard in recognition of vulnerable women to allow more targeted health-care facilities of HICs, and are beginning to or appropriate services to be delivered. The UK NHS improve outcomes, including reductions in maternal Initiative to offer pregnant women a budget of up to mortality in the USA. Leadership from national £3000 to choose the care they receive is also intended to professional organisations is essential to support the increase safety, and requires evaluation with improved of best practice for quality, safety, and woman- data collection.126 centred care. Central to progress is the ability to change www.thelancet.com 61 Series

from a perception that the pregnant and labouring 8 Snowden JM, Tilden EL, Snyder J, Quigley B, Caughey AB, woman is a risk waiting to happen, to one where birth is Cheng YW. Planned out-of hospital birth outcomes. N Engl J Med 2015; 373: 2642–53. normalised to provide the best outcomes for most 9 Hutton EK, Cappelletti A, Reitsma AH, et al. Outcomes associated women, with services available in the event that with planned place of birth among women with low-risk complications develop. For women with existing or pregnancies. CMAJ 2016; 188: E80–90. 10 Allen VM, O’Connell CM, Baskett TF. Cumulative economic pregnancy-related medical problems, or with social implications of initial method of delivery. Obstet Gynecol 2006; circumstances that may require highly specialised care, 108: 549–55. coordinated team approaches in the pre-pregnancy and 11 Hendrix MJ, Evers SM, Basten MC, Nijhuis JG, Severens JL. antenatal period are needed, as well as post partum, to Cost analysis of the Dutch obstetric system: low-risk nulliparous women preferring home or short-stay hospital birth—a prospective optimise the management of pre-existing illness, and non-randomised controlled study. BMC Health Serv Res 2009; 9: 211. reduce morbidity from indirect causes. 12 Henderson J, Petrou S. Economic implications of home births and Different models of care by providers should continue birth centers: a structured review. Birth 2008; 35: 136–46. 13 Garcia FA, Miller HB, Huggins GR, Gordon TA. Effect of academic to be explored and evaluated in terms of their ability to affiliation and obstetric volume on clinical outcome and cost of meet women’s needs, and reduce interventions, and childbirth. Obstet Gynecol 2001; 97: 567–76. costs, while outcomes are improved. Women should be 14 Kozhimannil KB, Henning-Smith C, Hung P, Casey M, Prasad S. Ensuring access to high quality maternity care in rural America. involved in the process. With evolving evidence and Women’s Health Issues. 2016. http://www.whijournal.com/article/ guidelines to support low-risk women planning birth S1049-3867(16)00023-2/pdf (accessed April 22, 2016). at home or in hospital birth centres, a focus on 15 Arnold JL, de Costa CM, Howat P. Timing of transfer for pregnant woman-centred care by accrediting bodies, and women from Queensland Cape York communities to Cairns for birthing. Med J Aust 2009; 190: 594–96. resurgence of midwifery-led care by licensed midwives 16 Tracy S, Sullivan E, Dahlen H, Black D, Wang Y, Tracy M. Does size in HICs where it had disappeared or waned, the tide of matter? A population-based study of birth in lower volume intervention-oriented birthing might be turning. maternity hospitals for low risk women. BJOG 2006; 113: 86–96. 17 Grzybowski S, Stoll K, Kornelsen J. Distance matters: a population Contributors based study examining access to maternity services for rural DS conceptualised the paper. DS, FW, and J-MG did the literature women. BMC Health Serv Res 2011 11: 147. search. NS did the US case study and cost analysis and KG-D did the 18 Heller G, Richardson DK, Schnell R, Misselwitz B, Kunzel W, Swedish case study. DS, J-MG, FW, and NS did the tables. DS, FW, KSJ, Schmidt S. Are we regionalized enough? Early-neonatal deaths in and EKM did the figures. All authors contributed to data interpretation; low-risk births by the size of delivery units in Hesse, Germany DS wrote the paper, with contributions from J-MG, KSJ, NS, BL, and 1990–1999. Int J Epidemiol 2002; 31: 1061–68. EKM, and all authors commented on multiple versions. All authors are 19 Moster D, Lie RT, Markestad T. Relation between size of delivery able to take public responsibility for the work. unit and neonatal death in low risk deliveries: population based study. Arch Dis Child Fetal Neonatal Ed 1999; 80: 221–25. Declaration of interest 20 Kassenbaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. We declare no competing interests. Global, regional, and national levels and causes of maternal Acknowledgments mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 980–1004. The Bill & Melinda Gates Foundation and the MacArthur Foundation supported this work. We thank Oona Campbell and Tim Johnson 21 Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ, eds, on behalf of MBRRACE-UK. 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Appropriateness of liability/index.php (accessed April 22, 2016). elective caesarean deliveries in a perinatal network: a cross-sectional 107 Canadian Medical Protective Association. https://www.cmpa-acpm. study. BMC Pregnancy Childbirth 2014; 14: 135. ca/fees-and-payment (accessed April 22, 2016). 85 Torloni MR, Betrán AP, Montilla P, et al. Do Italian women prefer 108 Carpentieri AM, Lumalcuri JJ, Shaw J, Joseph GF. Overview of the cesarean section? Results from a survey on mode of delivery 2015 ACOG survey on professional liability. https://www.acog.org/-/ preferences. BMC Pregnancy Childbirth 2013; 13: 78. media/Departments/Professional-Liability/2015PLSurveyNationalSu 86 Fenwick J, Staff L, Gamble J, Creedy DK, Bayes S. Why do women mmary.pdf?dmc=1&ts=20160119T2152511981 (accessed April 22, 2016). request caesarean section in a normal, healthy first pregnancy? 109 Yang TY, Mello MM, Subramanian SV, Studdert DM. Relationship Midwifery 2010; 26: 394–400. between malpractice litigation pressure and rates of cesarean section 87 Small R, Roth C, Raval M, et al. Immigrant and non-immigrant and vaginal birth after cesarean section. Med Care 2009; 47: 234–42. women’s experiences of maternity care: a systematic and 110 Virginia birth-related neurological injury compensation program. comparative review of studies in five countries http://www.vabirthinjury.com/why-the-birth-injury-program/ BMC Pregnancy Childbirth 2014; 14: 152. (accessed April 22, 2016). 88 International Labour Organization. International labour standards 111 Drabsch T, NSW Parliamentary Library Research Service. No fault on maternity protection. Maternity protection convention. 2000. compensation. 2005. https://www.parliament.nsw.gov.au/prod/ http://www.ilo.org/global/standards/subjects-covered-by- parlment/publications.nsf/0/54B0D80E7B70C457CA256FF9000DC international-labour-standards/maternity-protection/lang--en/index. 9DA/$File/No%20Fault%20Comp%20and%20Index.pdf (accessed htm (accessed April 22, 2016). April 22, 2016). 89 Women’s Health USA 2011. Maternity leave. 2011. http://www. 112 OECD. OECD medical malpractice prevention insurance and mchb.hrsa.gov/whusa11/hstat/hsrmh/pages/233ml.html coverage options. Paris: OECD, 2006. http://www.keepeek.com/ (accessed April 22, 2016). Digital-Asset-Management/oecd/finance-and-investment/medical- 90 Maternity . The Japan Times. http://www.japantimes. malpractice_9789264029057-en#page1 (accessed April 22, 2016). co.jp/tag/maternity-harassment/ (accessed April 22, 2016). 113 Smith J, Isavoran MR. AHRQ medical liability & patient safety 91 Avendano M, Berkman LF, Brugiavini A, Pasini G. The long-run planning grant. Final progress report. http://www.oregon.gov/oha/ effect of maternity leave benefits on mental health: evidence from OHPR/PSDM/AHRQ_MLPS_Report.pdf (accessed April 22, 2016). European countries. Soc Sci Med 2015; 132: 45–53. 114 Committee on Quality of Health Care in America. Institute of 92 Sedgh G, Finer LB, Bankole A, Eilers MA, Singh S. Medicine. Crossing the quality chasm: a new health system for the Adolescent pregnancy, birth, and abortion rates across countries: 21st century. Washington, DC: National Academy Press; 2001. levels and recent trends. J Adolesc Health 2015; 56: 223–30. 115 Saucedo M, Deneux-Tharaux C, Bouvier-Colle M-H, for the French 93 Kost K, Henshaw S. U.S. teenage pregnancies, births and abortions, National Experts Committee on Maternal Mortality. Ten years of 2010: National and state trends by age, race and ethnicity. New York: confidential inquiries into maternal deaths in France, 1998–2007. Guttmacher Institute, 2014. Obstet Gynecol 2013; 122: 752–60. 94 Humby P. An analysis of under 18 conceptions and their links to 116 Betran AP, Torloni MR, Zhang J, et al. What is the optimal rate of measures of deprivation, England and Wales, 2008–10. London: caesarean section at population level? A systematic review of Office for National Statistics, 2013. http://www.ons.gov.uk/ons/ ecologic studies. Reprod Health 2015; 12: 5 7. dcp171766_299768.pdf (accessed April 22, 2016). 117 Main EK. Clues for understanding hospital variation among 95 Australian Government Department of Health. Provision of obstetric services. AJOG 2015; 213: 443–44. maternity care. http://www.health.gov.au/internet/publications/ 118 Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late publishing.nsf/Content/pacd-maternityservicesplan-toc~pacd- and too much, too soon: a pathway towards evidence-based, maternityservicesplan-chapter3 (accessed April 22, 2016). respectful maternity care worldwide. Lancet 2016; 388: 19–35. 96 Canadian Institute for Health Information. Giving birth in Canada. 119 The Joint Commission. Sentinel event data—root causes by event type Providers of maternity and infant care. https://secure.cihi.ca/free_ (2004–2015). 2015. https://www.jointcommission.org/assets/1/18/ products/GBC2004_report_ENG.pdf (accessed April 22, 2016). Root_Causes_by_Event_Type_2004-2015.pdf (accessed Aug 1, 2016).

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120 Lyndon A, Johnson MC, Bingham D, et al. Transforming 125 Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: oxytocin communication and safety culture in intrapartum care: a multi- augmentation for at least 4 hours. Obstet Gynecol 1999; 93: 323–28. organization blueprint. J Midwifery Womens Health 2015; 60: 237–43. 126 Women to be offered their own £3000 ‘birth budgets’. Feb 23, 2016. 121 Institute for Healthcare Improvement. Evidence-based care bundles. http://www.bbc.com/news/health-35634524 (accessed http://www.ihi.org/topics/bundles/Pages/default.aspx (accessed April 22, 2016) April 22, 2016). 127 HRSA. Telehealth. 2015. http://www.hrsa.gov/healthit/toolbox/ 122 Creanga AA, Berg CJ, Ko JY, et al. Maternal mortality and morbidity in ruralhealthittoolbox/telehealth/ (accessed April 22, 2016). the United States: where are we now? J Womens Health 2014; 23: 3–9. 128 Baldwin KA. Comparison of selected outcomes of centering 123 Blondel B, Kermarrec M. French National Perinatal Survey 2010. pregnancy versus traditional prenatal care. J Midwifery Womens Health Situation in 2010 and trends since 2003. Paris: Epidemiological 2006; 51: 266–72. Research Unit on Perinatal Health and Women and Children’s 129 Catling CJ, Medley N, Foureur M, et al. Group versus conventional Health, INSERM-U, 2011. antenatal care for women. Cochrane Database Syst Rev 2015; 124 Arulkumaran S, Koh CH, Ingemarsson I, Ratnam SS. 2: cd007622. Augmentation of labor mode of delivery related to cervimetric progress. Aust N Z J Obstet Gynaecol 1987; 27: 304–08.

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Maternal Health 5 Next generation maternal health: external shocks and health-system innovations

Margaret E Kruk, Stephanie Kujawski, Cheryl A Moyer, Richard M Adanu, Kaosar Afsana, Jessica Cohen, Amanda Glassman, Alain Labrique, K Srinath Reddy, Gavin Yamey

Published Online In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current September 15, 2016 state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the http://dx.doi.org/10.1016/ S0140-6736(16)31395-2 structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and This is the fifth in a Series of six papers about maternal health middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. See Online/Comment Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and http://dx.doi.org/10.1016/ the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. S0140-6736(16)31534-3, Research and policy will need to reflect the changing maternal health landscape. http://dx.doi.org/10.1016/ S0140-6736(16)31525-2, and http://dx.doi.org/10.1016/ Introduction health-system changes that will influence the profile of the S0140-6736(16)31530-6 The papers in this Series document substantial progress in pregnant woman, her community, and her health clinic See Online/Series the reduction of maternal mortality over the past several over the next 15 years. Although there are many potential http://dx.doi.org/10.1016/ decades and offer new ideas and technologies to improve shocks that could influence maternal health in the coming S0140-6736(16)31533-1, maternal health. The Series recognises that maternal years, we believe those likely to have the biggest impact are: http://dx.doi.org/10.1016/ S0140-6736(16)31472-6, health is a product of a wide array of factors from the the anticipated rise in domestic health financing in low- http://dx.doi.org/10.1016/ structures and resources of societies, to the function and income countries (LICs) and middle-income countries S0140-6736(16)31528-8, responsiveness of health systems. These societies and (MICs); shifts in governance for health; migration from http://dx.doi.org/10.1016/ health systems are experiencing a rapid change that can rural to urban areas; and strains on the health system from S0140-6736(16)31527-6, and http://dx.doi.org/10.1016/ reshape the possibilities of the future. An understanding infectious disease outbreaks, armed conflict, and severe S0140-6736(16)31333-2 of these larger forces is necessary to sustain gains and weather events associated with climate change. In this Department of Global Health reach the women still excluded from the recent context, we discuss some of the promising innovations and Population, School of improvements in maternal health. with the potential to change current maternal health Public Health, Harvard T H In this paper, we look outside of the field of maternal practice for the better, such as universal health coverage Chan, Boston, Boston, MA, USA (M E Kruk MD, J Cohen PhD); health to review the coming shocks and rapid societal and (UHC), insights from the field of behavioural economics, Department of Epidemiology, and the greater use of data and communication technology Mailman School of Public for health improvement. We conclude by laying out policy Health, Columbia University, Key messages implications of these shocks and innovations. NY, USA (S Kujawski MPH); Department of Learning Health • Maternal health in the next 20 years will be transformed by Sciences and Department of social, political, environmental, and demographic changes. External shocks Obstetrics and Gynaecology, • Future health systems must respond to the changing Economic growth and the potential for health convergence Medical School, University of Most maternal deaths occur in LICs and lower-MICs Michigan, Ann Arbor, MI, USA context of women’s lives: urbanisation, greater access to (C A Moyer PhD); School of information, and rising expectations for high-quality, whose limited resources have historically hindered their Public Health, University of woman-centred care. ability to provide good quality health care. Over the next Ghana, Accra, Ghana • Donor assistance for health will continue to decline and two decades, however, these countries are on course to (Prof R M Adanu MD); experience substantial economic growth, which will James P Grant School of Public countries need to increase domestic financing; potential Health, BRAC University, revenue sources are economic growth, taxes on alcohol and increase their fiscal space for health investments. Annual Dhaka, Bangladesh tobacco, and reduction of fossil fuel and other subsidies. growth in real gross domestic product from 2011 to 2035, (K Afsana MD); Center for Global Development, Washington, DC, • Rapid urbanisation has improved access to and quality of care for many, but not all, women; research is urgently USA (A Glassman MSc); Search strategy and selection criteria: Department of International needed on models of care for poor women in urban areas. Health, Johns Hopkins • Universal health coverage, with comprehensive maternal We identified data by searches of PubMed and references Bloomberg School of Public Health, Baltimore, MD, USA health services at its core, is a major opportunity for from relevant articles using the search term maternal health (A Labrique PhD); Public Health improving maternal health and reducing impoverishment. combined with each of the following search terms (using Foundation of India, Gurgaon, • Behavioural economics and the data revolution offer new AND): universal health coverage, urban health, urbanisation, India (Prof K S Reddy MD); and promising approaches for improving the effectiveness and behavioural economics, and mHealth. We only included Duke Global Health Institute, Durham, NC, USA (G Yamey MD) responsiveness of health care. articles published in English between 2006 and 2016.

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is projected to be about 4·5% in LICs and 4·3% in lower- gained.1 This outcome makes health an exceptionally Correspondence to: MICs—double that of high-income countries.1 There is good investment—a point that might resonate with Dr Margaret E Kruk, Department also tremendous scope to use new sources of domestic national finance ministers. of Global Health and Population, School of Public Health, Harvard T revenues, such as taxation of tobacco and alcohol, tourist H Chan, Boston, MA 02115, USA taxes, and redirection of fossil fuel subsidies to the health Shifts in governance for health [email protected] sector.1–3 Two trends in the governance of global health create If even a small portion of newly available revenues was challenges and opportunities for maternal health. The first harnessed for health, through publicly financed insurance, is the transition from the UN-sponsored Millennium and health system and infrastructure investments, the Development Goals (MDGs) that expired in 2015 to the monies could substantially improve health outcomes. The Sustainable Development Goals (SDGs). In the MDGs, Lancet Commission on Investing in Health1 assessed the maternal health was a stand-alone goal; however, it is one resources required to achieve a grand convergence in of many targets of the SDG on health: ensure healthy lives health—a reduction in avoidable infectious, maternal, and and promote wellbeing for all at all ages. The health MDGs child deaths to universally low levels by 2035.1 The focused on donor and domestic investments in maternal Commission estimated that the annual cost for LICs and health, which encouraged the reduction of maternal lower-MICs to achieve convergence would be about mortality ratio (MMR) in some countries.10,11 By contrast, US$70 billion annually from 2015 to 2035. In LICs, this the large number of health SDG subgoals might dilute the estimate means an additional $23 per person—roughly focus on maternal health. Nevertheless, the SDGs present double the health spending in 2015. In the 34 countries opportunities for the expansion of the maternal health labelled as LICs in 2015, this additional cost would prevent agenda, as we discuss in the UHC section.12 190 000 maternal deaths in 2035.2 A second trend relates to the ongoing fragmentation in The Commission’s modelling suggests that most governance and financing for maternal health and countries could fund health convergence themselves. introduction of related initiatives, such as those focused However, two dozen countries are still likely to be on newborn babies, adolescents, family planning, and classified as LICs by 2035, particularly the fragile and nutrition. The past decade has seen a proliferation of conflict-affected states, and these countries are likely to global efforts in maternal health with at least need development assistance for health (DAH).1 18 high-profile initiatives striving to mobilise greater Additionally, some MICs might need assistance since funding or to enhance provision of reproductive, they might lack the policy space or institutional maternal, and newborn health care in LICs and MICs. arrangements to (1) deliver certain politically sensitive Examples include Every Woman, Every Child; Women services, such as reproductive health care, or (2) reach Deliver; and Family Planning 2020. Each initiative has certain populations (eg, refugees) with maternal health slightly different goals and strategies. In 2005, the services.4 In this situation, a case can be made for targeted Partnership for Maternal, Newborn and Child Health international assistance.5 (PMNCH) was launched as an umbrella organisation to What is the likely future trajectory for DAH for foster strategic alignment among maternal, newborn, reproductive, maternal, newborn, child and adolescent and child health initiatives. However, a 2014 assessment health (RMNCAH)? Overall levels of DAH have stagnated noted that its mandate was unclear, and that PMNCH in recent years, at about $30 billion annually.6 should define their comparative advantage going Nevertheless, for RMNCAH there has been a gradual forward.13 These initiatives could be synergistic, but they upward trend from 2008 to 2012 in external assistance.7 create difficulties for rational priority setting and This trend could potentially be accelerated by the recent programming for maternal health, particularly as launch of the Global Financing Facility (GFF) in support funding and activities might be organised in a categorical of Every Woman, Every Child,8 which aims to mobilise manner that does not allow for reallocation or flexibility. more than $57 billion for RMNCAH from 2015 to 2030, Although the entry of new funders and programmes can from both domestic resources and by “attracting new yield new approaches to address maternal mortality, most external support and improving coordination of existing maternal health initiatives do not assess their impact.14,15 assistance.”8 However, details of how the GFF will be For example, pilot projects of innovative models of care funded have not been established. and incentives for service uptake have substantially Irrespective of income level, less future health increased. Many are donor-supported and few have been financing will come from donors. The political will to subjected to rigorous assessment—with demand-side increase national spending on health cannot be assumed; incentives, such as cash transfers, among the best studied.14 however, only seven countries in sub-Saharan Africa With the receding role of donors in national health fulfil the Abuja Declaration obligation to allocate 15% of systems, the effectiveness of health policies will be their budget to health.9 When the intrinsic value of health determined by state capacity, democratisation, and to individuals is included in national income, nearly a attention to women’s rights. An important trend that will quarter of the growth in full income between 2000 and influence the implementation of policy agendas is the 2011 has come from the value of additional life-years growth of government decentralisation in LICs and www.thelancet.com 67 Series

1·0 central tax revenues to the states along with greater freedom to choose how they spend it. The accompanying 0·9 cut in the federal health budget places greater 0·8 responsibility on the states to make appropriate policy 0·7 choices and allocate sufficient funds to health. 0·6 Evidence that members of the public are demanding High-income countries 0·5 Latin America and Caribbean better health care and taking a more active role in health- Sub-Saharan Africa system decisions is growing. Across different countries Proportion 0·4 North Africa and Middle East and health conditions, health-system users have 0·3 South Asia Southeast Asia, east Asia, preference for high-quality care, even with greater cost or 0·2 Oceania in convenience. For example, women frequently seek out 0·1 Central Europe, eastern Europe, central Asia more distant and costly providers and facilities that are 0 Global average more reputable for delivery,16,17 and active patients form 1970 1980 1990 2000 2010 2020 2030 2040 2050 active communities. Civil society is increasingly in- Year fluencing health-care policies and reform. In many Latin Figure : Urban and rural birth projections American countries, community participation has grown Proportion of births in urban areas by region, 1970–2050. We used urban and rural crude birth rate data from the with decentralisation and has shaped models of primary UN Demographic Yearbooks from 1970–2013, population data from the UN World Urbanisation Prospects 2014 , 18–21 and total crude birth rate data from UN World Population Prospects 2012 to estimate the percentage of births care and universal health coverage. This rise in occurring in urban areas from 1970–2050 by region. We used average values of available urban and rural crude demand for high-value health care will accelerate with birth rates per country within the region as a proxy for the entire region. the growth of a global, urban middle class. This com- munity demand could also be channelled to lobby for greater health spending. 100 100 91·1 Urbanisation

80 80 The world’s urban population nowadays exceeds the rural, 75·05 with migration to cities proceeding quickest in LICs. By 71·6 2050, the UN projects that 66% of the population will live 22 60 60 59·2 in urban areas, leading to an increase in the proportion of urban births. Our analyses show that by 2030, 52% of births will be in urban areas, rising to 60% by 2050. This 40 40 change is a rise from 39% in 2000 (figure 1). The changing demographics of delivery should transform our approaches to improve the access and quality of obstetric care. 20 20

Antenatal coverage–at least four visits (%) Living in cities brings important benefits for pregnant Births attended by skilled health personnel (%) women and newborn babies, including reduced travel time to clinics, greater choice of services, and greater con- 0 0 23–27 Rural Urban Rural Urban centration of well trained providers. These benefits result in lower maternal mortality in many more urban areas than in rural areas.28 Families moving to cities could also rapidly Figure : Coverage of maternal health interventions by urban or rural residence in low-income and middle-income countries adopt urban norms, such as the use of modern health care Each circle represents a country. Black horizontal lines represent median value for each subgroup. Available data, 2005–13: (figure 2).29,30 Despite these advantages, the rich–poor gap in 85 countries had data available for the births attended by skilled health personnel and 72 countries had data available for the access to health services in urban areas is sizeable; this the antenatal coverage indicator. Data taken from WHO. gap is sometimes larger than the gap in rural areas.31,32 Rural families migrating to urban centres often move to slums or For the UN Demographic MICs, which shifts the balance of decision making from informal settlements, where they face new barriers to the Yearbooks see http://unstats. the federal level to the states, making uniform policy use of quality childbirth services, such as reliable transport, un.org/unsd/demographic/ products/dyb/dyb2.htm adoption a challenge. Decentralisation could have an high cost of delivery in private clinics, security concerns, 33–35 For the UN World Urbanisation effect on the achievement of the SDGs, for example, as and poor treatment by health workers. Prospects 2014 see https://esa. provincial governments might feel less accountable to Poor women in cities can too often deliver at facilities un.org/unpd/wup/ the SDG targets that the national government has that are unregulated, employ poorly trained providers, For the UN World Population committed to. and are unequipped to handle obstetric emergencies.33,35 Prospects 2012 see https://esa. Decentralisation carries a potential trade-off between For example, a study in the slums of Nairobi found that un.org/unpd/wpp/Publications/ Files/WPP2012_Volume-I_ increased efficiency of services due to well grounded although 70% of the women interviewed delivered in a Comprehensive-Tables.pdf local planning and the danger of feeble performance, due health facility, only 48% of them delivered at a health 36 For the WHO data see to inadequate resources or poor governance. This facility with minimum standards for obstetric care. http://apps.who.int/iris/ challenge is now surfacing in India, where the federal Similarly, in the Dhaka slums of Bangladesh, only 37% of bitstream/10665/164590/ government has decided to transfer a higher share of the private-sector health staff had received formal training.37 1/9789241564908_eng.pdf

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New urban models of care are emerging. In South Rangpur Africa, onsite maternity units were introduced at (0·10 million) hospitals to handle the increasing volume at secondary Mymensingh Sylhet and tertiary urban facilities. These units are designed to (0·17 million) (0·17 million) provide appropriate care to low-risk pregnant women within hospitals and access to emergency services if needed.38 The Manoshi programme in Bangladesh, managed by BRAC, a non-governmental organisation (NGO), was designed to address the barriers that urban 39–41 pregnant women are facing (figure 3, panel 1). Gazipur Although NGOs and other partners are essential, primary (0·54 million) accountability for the health of urban dwellers resides Dhaka with local and regional government. One crucial role of (3·17 million) government is regulating a minimum quality of infra- Rajshahi (0·35 million) Narayanganj structure and clinical care. For example, by recognising (0·50 million) the need for policies specific to the urban poor, India created the National Urban Health Mission to improve Comilla Barisal 42 (0·11 million) access and quality. (0·28 million) Research in urban maternal health has not kept pace with the urbanisation of births. In the absence of vital Chittagong Khulna (1·14 million) registration and strong health-information systems, (0·52 million) demographic surveillance systems can be used to track Bandarban and understand the changing demographics and needs of people living in informal settlements. For example, Cox’sBazar the Nairobi Urban Health and Demographic Surveillance System was designed to capture information on the health and health care available to people living in Nairobi’s slums.36 Figure : Cities in Bangladesh where Manoshi operates Health crises The health systems of LICs and MICs are often hampered by insufficient resources, high prevalence of disease, maternal and reproductive health services through high scarcity of providers, and weak governance at the best of levels of insecurity and collapse of basic health times. When unexpected shocks, such as disease outbreaks, infrastructure.50 Conflict and the post-conflict recovery armed conflict, and natural disasters, lead to surging period are marked by increased fertility and MMRs.51 In demand for care, these fragile systems can collapse. Such one analysis, sub-Saharan African nations experiencing emergencies simultaneously increase the number of recent armed conflict had MMRs that were 45% higher patients and decrease the capacity of the system to care for than did those countries without recent conflict.52 them because of deaths and injuries of providers, Natural disasters, such as the 2010 earthquake in Haiti, destruction of facilities, and disruption of electricity, water Typhoon Hagupit in the Philippines in 2014, and the and sanitation, and supply chains.43–45 Pregnant women and 2015 earthquake in Nepal, rendered large sections of the children are often disproportionately affected.46,47 national health system virtually inoperable.53 Global Disease outbreaks are among the most visible health climate change might make extreme weather more crises. The 2014–15 Ebola virus outbreak in west Africa is common in the coming decades.54,55 an example of the profound effect that an outbreak can Previous crises have spurred migration on an epic have on health systems and the health of mothers and scale. The UN estimates that 59·5 million people were newborn babies in fragile health systems.48 Following the forcibly displaced in 2014; the largest single annual Ebola virus outbreak, which killed many health workers increase in history, attributed largely to the war in Syria.56 and closed delivery clinics, the MMR is projected to Pregnant women and women of reproductive age often double to more than 1000 per 100 000 livebirths in Guinea face adverse maternal health outcomes both during the and Liberia and to more than 2000 in Sierra Leone, migration process and even after resettling in returning to wartime levels.44,48 Infectious diseases also higher-income countries. Migrant women from LICs and have a direct effect on maternal health; for example, conflict settings can face communication barriers and Ebola appears almost universally fatal in pregnant suboptimal care from providers, or might not trust the women and newborn babies.48 health system resulting in higher maternal morbidity Armed conflict, which affected about 1·2 billion people and mortality than for native-born women in most, in 2015,49 harms civilians directly and limits access to although not all, populations and contexts.57,58 www.thelancet.com 69 Series

The WHO defines UHC as a means to ensure that Panel : Manoshi case study: maternal and newborn care innovations in the urban people obtain essential health services without slums of Bangladesh experiencing financial hardship.63 This definition Rapid urbanisation poses unprecedented health challenges in Bangladesh. Health-care advances on past notions of expanded access to care access and utilisation is especially low among the urban slum population. Barriers to care (eg, Declaration of Alma Ata, Health Care for All) by include physical and financial challenges, fear of the hospital environment, and including financial protection. This development disrespectful and abusive behaviour from health-care providers. In 2007, 86% of slum responds to a growing concern about the large women gave birth at home with an unskilled attendant.39 out-of-pocket health-care payments that can lead to impoverishment.64,65 In response to the changing needs of urban residents, BRAC started Manoshi in 2007, a UHC advances maternal health in several ways and has programme offering culturally appropriate, medically proven maternal and child health an important role as part of an integrated RMNCAH services for slum dwellers.40 These services include antenatal check-ups, health and agenda.12 Pregnant women, particularly those with nutrition education, post-partum visits, and childhood immunisations. In response to obstetric complications that require surgery and hospital women’s desires to give birth at or near the home, BRAC established delivery centres admission, experience high health-care costs in countries within the slums, which provide safe and dignified delivery services and facilitate timely without strong insurance systems, and will directly referral to higher-level facilities if complications arise.41 benefit from UHC.1,66–68 Countries that have adopted Manoshi has expanded to all major cities in Bangladesh, reaching 7 million slum dwellers national health insurance programmes, such as Mexico by 2014 (figure 3). As a result of Manoshi, from 2007–11, the proportion of women in the and Rwanda, have reduced catastrophic health targeted slums having four or more antenatal care visits increased from 27% to 52% and expenditures.69,70 A study in Ethiopia found that the there has been an increase in facility based deliveries from 15% to 65% (Afsana K, inclusion of free caesarean sections in an essential health unpublished).39 Manoshi delivery centres are being upgraded to provide basic emergency intervention package averted 98 cases of poverty per obstetric care, to minimise unnecessary referrals to hospitals. Manoshi reaffirms that $100 000 spent.71 culturally appropriate and safe provision of delivery services, referral support, and the To the extent that UHC promotes removal of point-of-care building of trust between the community and health system are paramount for the fees for essential services, it will probably help increase health of mothers and newborn babies, even among the slum populations. coverage of maternal health services. In sub-Saharan Africa, countries that removed user fees for delivery increased facility births and decreased neonatal mortality.72–74 There is a growing consensus that health systems must Introduction of UHC does not guarantee pro-poor become more resilient—ie, ready to effectively respond outcomes, however. To improve the health of poor women, to crises, maintain core functions, and change course if health insurance has to cover conditions predominantly the situation requires it.59 A resilient health-care system suffered by the poor and to ensure that the poor are is able to provide care both for victims of the crisis and exempted from premiums and copayments, as in Rwanda for routine health needs—such as maternal and newborn and Mexico—sometimes called progressive universalism.1 care. Vertical or disease-specific funding and UHC can also benefit pregnant women to the extent programming does not appear to build resilience. For that it expands access to care for chronic and acute illness example, Liberia, which received substantial donor during pregnancy, childbirth, and post partum. As the funding, focused on a few vertical health goals and was burden of non-communicable diseases increases in LICs able to achieve the child-health MDG but could not and MICs, indirect causes of maternal mortality will rise.75 sustain provision of basic services under stress.48 Pregnant women will increasingly present to clinics with Resilience also requires that health systems be chronic diseases; in Ghana in 2011, 46% of all obstetric responsive to community needs and expectations in complications recorded by health facilities were due to normal times to build the public trust that will be crucial indirect causes.76 Panel 2 highlights the challenges faced during emergencies.59 For example, the Zika virus by one pregnant woman in Ghana with pre-existing epidemic in Brazil and other South American countries cardiac disease as she navigated the health-care system. has highlighted the importance of implementing policies Mental health concerns such as depression that are that promote women’s rights and are responsive to their prevalent among pregnant and post-partum women are health needs ahead of a crisis. The calls for women to largely neglected in maternal health programmes.77,78 avoid becoming pregnant highlighted the inadequate Introduction of UHC can also promote a life-course policies and services for family planning and safe approach to address the non-obstetric health needs of abortion, and the lack of women’s autonomy in women and their families. Antenatal care, labour, and reproductive decision making.60 delivery, and post-partum services can be a platform for diagnosis and addressing other health conditions. For Health-system innovations example, when Mexico implemented its national health Universal health coverage insurance, Seguro Popular, it saw an increase in cervical UHC has emerged as a key global aspiration, endorsed cancer screening, mammography, and the treatment of by a range of actors (individuals and organisations) hypertension for the patients who were insured.79 Early and countries, and is included in the SDG on health. 1,61,62 diagnosis and treatment of these conditions might

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improve pregnancy outcomes as well. UHC and maternal health agendas should thus be viewed as complementary Panel : A case study of a pregnant woman with heart disease navigating the health rather than competing. system in Ghana UHC is a path rather than a destination and insurance A 21-year-old married primigravida living near the Buduburam refugee camp in Accra, reform is only one of many reforms required to improve Ghana, visits Government Hospital A when she is 4 months pregnant with complaints of health system performance. With increases in use, extensive swelling in her legs. The woman has worked as a dishwasher at a local restaurant governments will need to invest in expanding health after completing 9 years of education. She is given a diuretic, instructed to avoid salt, and system capacity to avoid compromising quality. told that the swelling would subside after pregnancy. After moving to her brother’s house Expanding the pool of competent health workers on the other side of Accra, she delivers her child at term at a private hospital. The swelling through training midwives has been successful in this does not subside and she develops shortness of breath, dizziness, a rapid heartbeat, and 80 regard in several LICs. However, access alone will not fatigue. She is referred by a doctor at the private hospital to a prayer camp, where she is improve outcomes—high-quality health care is essential prayed for, prescribed traditional medicine, and told her symptoms are due to a curse. She and has frequently been overlooked in the rush to get returns home after spending a few hours at the prayer camp. The following day (1 day after 81,82 women into health facilities. The UHC’s monitoring discharge from delivery), her symptoms unabated, she goes to Government Hospital B, frameworks after the 2015 development agenda must where she is referred to Korle-Bu Teaching Hospital, the main teaching hospital in Accra, include key maternal health indicators of coverage, affiliated with the University of Ghana. At Korle-Bu, she is diagnosed with biventricular 82,83 quality, and health impact. heart failure secondary to dilated cardiomyopathy and severe pulmonary oedema. Her condition deteriorates and she is placed on a ventilator for 5 days with invasive cardiac Behavioural economics to improve choices monitoring. After 3 weeks, she is declared ready for discharge from hospital, but is detained Good maternal and neonatal health outcomes require for an additional 10 days in the hospital because she lacks insurance and cannot pay her high quality and accessible health-care systems, but also hospital bills. At this point, she registers for health insurance, which will assist with future rely on decisions and actions taken by the mother and financing for her chronic heart condition. She is referred to a hospital closer to her current her partner, such as the frequency of antenatal care home for continued management of her condition. visits, the choice of delivery location, the timing of departure for the delivery facility, and whether and when to initiate post-partum contraception. Traditionally, health—eg, in improving medication adherence.88 maternal health programmes have focused on cost and Another common bias is time inconsistency: the tendency information barriers seeking appropriate health care. to overvalue the present and undervalue the future.91,92 Efforts to stimulate demand have therefore emphasised Behavioural economics has great potential to expand the use of mass media campaigns, community health the policy toolkit for maternal health, particularly in worker outreach, text messages, and fee exemptions or situations in which coverage and outcomes remain vouchers.84,85 suboptimal despite the elimination of access barriers. However, growing evidence from the field of Three promising approaches are: (1) changing how behavioural economics suggests that behavioural and choices are ordered (eg, desired choice made the default), psychological factors, from social norms to mis- (2) shifting how information is framed (eg, gain versus information to procrastination, play a central role in loss), and (3) providing economic incentives to help decision making—individuals are not always fully women resist social and cultural pressure (eg, cash for informed rational actors. Systematic biases in decision facility delivery) and offset present bias. We illustrate making might help explain why, even when primary how common behavioural biases might affect the barriers to access are removed, the uptake of life-saving decisions of pregnant women and new mothers, and interventions is surprisingly low. Drawing on eco- suggest behavioural economics approaches that could nomics and psycho logy, behavioural economics overcome these in the table. examines why individuals make decisions that are Although behavioural economics has already been inconsistent with their own stated goals and wellbeing, widely applied in tax, energy, and consumer finance and how changes in the decision architecture and policy, its role in health policy is still nascent.93 framing of choices can positively influence behaviour Additionally, behavioural economics is not a panacea: in and outcomes.86,87 the context of deeply rooted poverty, women’s economic Behavioural economists have found that people, and dependency, inadequate health systems, and constrained particularly those living with the daily stresses of poverty, care options, even good choices can result in bad might minimise their cognitive burden by choosing outcomes. But interventions to correct biases might default options or using decision heuristics (eg, principles make maternal health strategies more effective and based on practice) to simplify complex choices, which efficient—a hypothesis that needs testing in real-world could result in suboptimal choices.88,89 This might further conditions. exacerbate the lack of control experienced by those affected by poverty.90 This insight has led to the integration of tools, Mobile health (mHealth) and the data revolution such as defaults and reminders, into traditional policies Over the past decade, a global telecommunications and programmes. Reminders have shown promise for revolution has resulted in near-ubiquitous access to www.thelancet.com 71 Series

Definition Examples of bias in maternal health Potential behaviour economics applications to maternal health Present bias or time Underweigh the value of benefits received in the future Insufficient savings for delivery or transport; delay of Delivery savings accounts with SMS reminders; inconsistency relative to today; decisions that would be made today initiation of contraception in the post-partum precommitment during ANC to initiate contraception and would be made tomorrow are inconsistent; period resulting in unsafe birth spacing post partum; vouchers for free contraception that expire behaviour economics tools: defaults, commitment devices, incentives, deadlines, reminders Social norms and Make decisions on the basis of preferences, values, and Influence of family and social pressure about delivery Create social commitments (eg, ANC group meetings) to pressure, persuasion interests of other rather than one’s self; behaviour decisions, breastfeeding, and use of contraception direct social pressure; create incentives for targeted economics tools: commitment devices, incentives behaviour that offer a reason to ignore social pressure Limited attention Inability to attend to all competing priorities for time Limited ability to process facility choices; limited Provide simplified information about facility choices; and cognition; difficulty sorting through all the relevant attention or cognitive capacity in early postnatal precommitment during ANC to initiate contraception costs and benefits of various options: behaviour period influences use of contraception, postnatal, post partum; vouchers for free contraception that expire; economics tools: defaults, reminders, simplification, or and neonatal care SMS reminders about postnatal and neonatal framing of information, labelling, incentives appointments Incorrect beliefs Decision making on the basis of false beliefs about facts Underestimate the likelihood of complications from Equip community health workers and ANC nurses with and probabilities; behaviour economics tools: framing, home delivery; incorrect beliefs about side-effects of appropriately framed and simplified information; provide timing, or salience of information contraception; incorrect beliefs about facility quality objective information on quality of facility options

Based partly on the conceptual framework developed by the Behavioral Economics and Reproductive Health Initiative (www.beri-research.org).86 SMS=short message service. ANC=antenatal care.

Table: Common biases in decision making and behavioural economics tools applicable to maternal health

mobile phones, even in the most remote, resource- proliferation of social accountability mechanisms for limited areas; the number of mobile phones exceeds the users to demand quality services. Uganda and India have world’s population.94 Mobile phone networks cover large systems for mobile-enabled citizen reporting—from areas of territory that were previously inaccessible—at corruption to facility dysfunction to experiences of more than 95% signal accessibility worldwide. The field disrespectful care.100,101 of mHealth leverages this cellular technology with the Despite the enthusiasm for mHealth, considerations of aim of improving public health, clinical research, and equity, privacy, and the sparse evidence of effectiveness at services. Device and connectivity costs have substantially regional and national scales must be kept in mind. reduced in the past decade, making it more feasible to Mobile technology might not be readily available in the use mobile phones for both routine communication and most economically disadvantaged populations or those more complex data collection and information sharing.95 living in remote areas. Gender inequities could make it Many countries are integrating mHealth strategies into difficult for women to access mobile phones and for national health information systems. For example, front- information to reach them.102 line workers equipped with simple devices are able to Beyond mHealth, greater availability of data has led to efficiently gather census population denominators (eg, a data revolution, a term that has increasingly entered women of reproductive age, pregnant women) and the mainstream of policy and development discourse and systematically plan surveillance and follow-up.96 The refers to strengthening the use of data for decision DHIS2 system,97 a web-based open-source health-infor- making and accountability.103 Additionally, growing mation system that runs on mobile phones and interest in measuring results, particularly among global computers, offers automated visualisation of data for funders such as the World Bank’s Health Results health managers in 47 countries. Furthermore, civil Innovation Trust Fund, has translated into many experi- registration and vital statistics systems (CRVS) in ments in performance-based payments. These experi- lower-MICs can benefit from innovative technological ments have had mixed results, with more consistently approaches. User-initiated short message service-based positive results for increasing use than for improving notifications of life events and digitisation of CRVS have productivity and quality.104,105 Nevertheless, there is some created the opportunity for improved tracking systems.98 evidence that providing performance data back to However, CRVS remains fragmented from other health- providers can enhance performance and the quality of information systems and pilot projects lack plans and reporting.106 funding for scaling.98,99 Success of mHealth and, more broadly, the data At the individual level, mHealth has the potential to revolution requires technology but also, crucially, data engage families and patients more directly in their literacy. Advocates argue that data literacy is less a health-care experience. With the growth of technology, technical skill than a process for empowerment and patients will have more self-care and diagnostic tools that social inclusion.103 Building this process will demand a can be used at home, saving time and money. For culture of data-informed decision making among policy example, in South Africa, the MomConnect programme makers and development partners alike. Critically, sends informational text messages to pregnant and post- communities need to be empowered to actively engage partum women.39 Technology has also enabled the with and control their own data.

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Discussion revolution will strengthen measurement of health and The maternal health landscape is rapidly changing. health-system performance, but big data does not equal Major shifts in power, focus, and geography over the next big insight. For this, policy makers and advocates need to 15 years will transform the possibilities to save lives and meaningfully engage with data. Behavioural economics reduce maternal illness and disability. One of these shifts is another innovation that helps shed light on how biases is projected robust economic growth in LICs and MICs and limited information prevent women from seeking or that will generate more domestic resources that can be staying in care even when it is free and accessible. spent on health. As poor countries graduate to middle- Insights from this field can help to close the gap between income and high-income status, they will come to rely users’ health aspirations and their actions. less on external health aid. National governments and, How will the shocks and innovations discussed in this increasingly, state and local governments will be deciding Review affect the experiences of pregnant women? In the maternal health policy. Decentralisation holds both 15 years, the typical pregnant woman in an LIC or MIC the promise of greater accountability and responsiveness could be living in a large urban slum, which might be to local needs, and also the likelihood of widening subject to heat waves, droughts, and disease outbreaks. subnational inequities as provinces follow divergent She will have fewer births than her mother. Her health policy paths and might struggle to effectively regulate the system will receive little or no donor funding, and she private sector. This devolution of power from global to will see fewer foreign NGO vehicles in her neigh- local will be magnified by the 17 SDGs, whose 169 targets bourhood. She will certainly have a mobile phone and could be seen by governments of LICs and MICs as a list might have health insurance. Her pregnancy might be from which to select domestic priorities, rather than a recorded in a database available to her health workers commitment to a unified global compact.107 The large and health officials, and perhaps to the woman herself. number of health targets inevitably means more This scenario has substantial benefits and risks, with competition for limited resources and policy attention several implications for policy. for maternal health. Additionally, future health crises, First, strategic framework: the three delays model (ie, such as severe weather events, disease outbreaks, and delays in seeking, reaching, and receiving care), which conflicts, will further challenge health systems and has been tremendously useful in the guiding of past probably distract from maternal health priorities. maternal health strategy, will need to be updated to However, there are opportunities for maternal health recognise the new geography of birth. The framework among these changes. At the global level, the large will need to address women living in urban and rural number of existing maternal health initiatives and remote areas and emphasise high-quality routine commitments will propel the momentum on maternal childbirth services as a core health-system obligation. health, particularly if they can focus rather than divide The first and second delay for urban women, and to policy-maker attention. Furthermore, UHC could help some extent rural women, is likely to be reduced by 2030, to reintegrate maternal health into the broader women’s through education, improved roads, increased health health agenda by providing access to care throughout awareness, exposure to urban social mores, health the life course, such as for chronic conditions. However, insurance, and behavioural nudges. The third delay, achieving UHC is fundamentally a political process and receiving high-quality care, has been relatively neglected its success will require sustained political will, public in the global discourse and needs urgent attention. support, and civil society advocacy. Greater engagement Research on quality and testing of improvement with communities is a crucial prerequisite for UHC strategies must be central in global and domestic and local governments in charge of health might be maternal health agendas. more motivated to seek it than distant bureaucrats. If Second, health-system financing: national and regional so, the coming decades will see a more meaningful role governments in even the poorest countries will face for communities in health-system governance. Finally, growing pressure to provide UHC. UHC initiatives must urbanisation presents new opportunities to concentrate include the people living in poverty from day one or risk on quality health care and reduce geographic barriers to perpetuating inequities in maternal health. Efforts must access. However, this promise will be undermined if be made to include women in the informal sector, recent new migrants live primarily in slums and informal urban migrants, and those in remote rural and urban settlements where clinics are unregulated or slum settings. Inclusion of maternal health services and unaffordable. women’s health across the life course should be at the These changes also require the maternal health com- core of all benefit packages. munity to embrace policy and technological innovation Third, community action: communities will need to to improve the preconditions for maternal health and build pressure for greater domestic health spending and health-system performance. As an increasing number of accountability for health-system performance. New women have a mobile phone and access to social media technologies will help to provide civil society with they will share their experiences, good and bad, driving information about facility quality, including respectful higher expectations of health systems. The data care. Communities and women’s organisations will play www.thelancet.com 73 Series

an important role in demanding effective coverage with Diseases of the National Institutes of Health under award number high-quality services and not coverage in name only. T32AI114398. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Fourth, global-health governance: the role of donors Health. The funders did not have any role in data collection, analysis, in many countries will diminish, but global pressure for interpretation of findings, or writing of the paper. MEK had full access to all effective maternal health policy will continue to be data in the study and had final responsibility for the decision to submit for important. In countries where donors still contribute publication. substantial funds to health-care provision, the donors References 1 Jamison DT, Summers LH, Alleyne G, et al. 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71 Verguet S, Olson ZD, Babigumira JB, et al. Health gains and 89 Thaler RH, Sunstein C. Nudge: improving decisions about health, financial risk protection afforded by public financing of selected wealth and happiness. New Haven, CT: Yale University Press, 2008. interventions in Ethiopia: an extended cost-effectiveness analysis. 90 The World Bank. Making services work for poor people. Lancet Glob Health 2015; 3: e288–96. Washington, DC: The World Bank Group, 2003. 72 Dzakpasu S, Powell-Jackson T, Campbell OMR. Impact of user fees 91 Ashraf N, Karlan D, Yin W. Tying Odysseus to the mast: evidence on maternal health service utilization and related health outcomes: from a commitment savings product in the Philippines. a systematic review. Health Policy Plan 2014; 29: 137–50. Q J Econ 2006; 121: 635–72. 73 Dzakpasu S, Soremekun S, Manu A, et al. Impact of free delivery 92 DellaVigna S. Psychology and economics: evidence from the field. care on health facility delivery and insurance coverage in Ghana’s J Econ Lit 2009; 47: 315–72. Brong Ahafo region. PLoS One 2012; 7: e49430. 93 Volpp KG, Asch DA, Galvin R, Loewenstein G. Redesigning employee 74 McKinnon B, Harper S, Kaufman JS, Bergevin Y. Removing user health incentives–lessons from behavioral economics. N Engl J Med fees for facility-based delivery services: a difference-in-differences 2011; 365: 388–90. evaluation from ten sub-Saharan African countries. 94 ICT Data and Statistics Division. ICT facts and figures. http://www. Health Policy Plan 2015; 30: 432–41. itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2015. 75 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of pdf (accessed July 9, 2015). burden of disease and injury attributable to 67 risk factors and risk 95 Mehl G, Labrique A. Prioritizing integrated mHealth strategies for factor clusters in 21 regions, 1990–2010: a systematic analysis for universal health coverage. Science 2014; 345: 1284–87. the Global Burden of Disease Study 2010. Lancet 2012; 380: 2224–60. 96 WHO. Assisting community health workers in Rwanda: MOH’s 76 Ministry of Health and Ghana Health Service. National assessment for RapidSMS and mUbuzima. Geneva: World Health Organization, emergency obstetric and newborn care. Accra: Ministry of Health, 2011. 2013. 77 Mahenge B, Stockl H, Likindikoki S, Kaaya S, Mbwambo J. 97 DHIS2. DHIS2 overview. 2015. https://www.dhis2.org (accessed The prevalence of mental health morbidity and its associated factors Dec 22, 2015). among women attending a prenatal clinic in Tanzania. 98 WHO, University of Oslo, HISP India, Health Metrics Network. Int J Gynaecol Obstet 2015; 130: 261–65. Systematic review of eCRVS and mCRVS interventions in low and 78 Ramchandani PG, Richter LM, Stein A, Norris SA. Predictors of middle income countries. Geneva: World Health Organization, 2013. postnatal depression in an urban South African cohort. 99 AbouZahr C, de Savigny D, Mikkelsen L, Setel PW, Lozano R, J Affect Disord 2009; 113: 279–84. Lopez AD. Towards universal civil registration and vital statistics 79 Gakidou E, Lozano R, González-Pier E, et al. Assessing the effect of systems: the time is now. Lancet 2015; 386: 1407–18. the 2001–06 Mexican health reform: an interim report card. 100 Ureport. Uganda voice matters. http://www.ureport.ug/ Lancet 2006; 368: 1920–35. (accessed July 9, 2015). 80 Van Lerberghe W, Matthews Z, Achadi E, et al. Country experience 101 Dasgupta J, Sandhya Y, Lobis S, Verma P, Schaaf M. with strengthening of health systems and deployment of midwives in Using technology to claim rights to free maternal health care: countries with high maternal mortality. Lancet 2014; 384: 1215–25. lessons about impact from the My Health, My Voice Pilot Project in 81 Souza JP, Gulmezoglu AM, Vogel J, et al. Moving beyond essential India. Health Hum Rights 2015; 17: 135–47. interventions for reduction of maternal mortality 102 Leo B, Morello R, Mellon J, Peixoto T, Davenport S. Do mobile (the WHO Multicountry Survey on Maternal and Newborn Health): phone surveys work in poor countries? Working Paper 398. a cross-sectional study. Lancet 2013; 381: 1747–55. Washington, DC: Center for Global Development; 2015. 82 Quick J, Jay J, Langer A. Improving women’s health through 103 Data Pop Alliance White Paper Series. Beyond data literacy: universal health coverage. PLoS Med 2014; 11: e1001580. reinventing community engagement and empowerment in the age 83 Boerma T, Eozenou P, Evans D, Evans T, Kieny MP, Wagstaff A. of data. New York, NY: Data Pop Alliance,2015. Monitoring progress towards universal health coverage at country 104 Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to and global levels: framework, measures and targets. PLoS Med 2014; improve the delivery of health interventions in low-and middle-income 11: e1001731. countries. Cochrane Database Syst Rev 2012; 2: CD007899. 84 Obare F, Warren C, Njuki R, et al. Community-level impact of the 105 Cashin C, Chi YL, Smith P, Borowitz M, Thomson S. reproductive health vouchers programme on service utilization in Performance in health care: implications for health system Kenya. Health Policy Plan 2013; 28: 165–75. performance and accountability. Berkshire: Open University Press, 85 Soubeiga D, Gauvin L, Hatem MA, Johri M. Birth preparedness and 2014. complication readiness (BPCR) interventions to reduce maternal 106 Renaud A, Semasaka JP. Verification of performance in results-based and neonatal mortality in developing countries: systematic review financing (RBF): the case of community and demand-side RBF in and meta-analysis. BMC Pregnancy Childbirth 2014; 14: 129. Rwanda. Geneva: The World Bank Group, 2014. 86 Ashton L, Giridhar N, Holcombe SJ, Madon T, Turner E. A review 107 Aizenman N. How to eliminate extreme poverty in 169 not-so-easy of behavioral economics in reproductive health. Berkeley, CA: steps. All Things Considered. Washington, DC: NPR, 2015. Behavioral Economics in Reproductive Health Initiative, 2015. 108 Sweeney R, Mortimer D. Has the swap influenced aid flows in the 87 The World Bank. World development report 2015: mind, society, health sector? Health Econ 2016; 25: 559–77. and behavior. Washington, DC: The World Bank Group, 2015. 88 Datta S, Mullainathan S. Behavioral design: a new approach to development policy. Rev Income Wealth 2014; 60: 7–35.

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Maternal Health 6 Quality maternity care for every woman, everywhere: a call to action

Marjorie Koblinsky, Cheryl A Moyer, Clara Calvert, James Campbell, Oona M R Campbell, Andrea B Feigl, Wendy J Graham, Laurel Hatt, Steve Hodgins, Zoe Matthews, Lori McDougall, Allisyn C Moran, Allyala K Nandakumar, Ana Langer

To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to Published Online guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in September 15, 2016 maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable http://dx.doi.org/10.1016/ S0140-6736(16)31333-2 Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding This is the sixth in a Series of 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl six papers about maternal health everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. See Online/Comment National and local governments must be supported by development partners, civil society, and the private sector in http://dx.doi.org/10.1016/ leading efforts to improve maternal–perinatal health. This effort means dedicating needed policies and resources, and S0140-6736(16)31534-3, sustaining implementation to address the many factors influencing maternal health-care provision and use. Five http://dx.doi.org/10.1016/ S0140-6736(16)31525-2, and priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities http://dx.doi.org/10.1016/ of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, S0140-6736(16)31530-6 including for the most vulnerable women; increase the resilience and strength of health systems by optimising the See Online/Series health workforce, and improve facility capability; guarantee sustainable finances for maternal–perinatal health; and http://dx.doi.org/10.1016/ accelerate progress through evidence, advocacy, and accountability. S0140-6736(16)31533-1, http://dx.doi.org/10.1016/ S0140-6736(16)31472-6, Introduction women, mirrored by a doubling of the gap in levels of http://dx.doi.org/10.1016/ Globally, the maternal mortality ratio nearly halved maternal mortality between the best and worst S0140-6736(16)31528-8, between 1990 and 2015. However, progress was patchy, performing countries in the past 20 years.10 http://dx.doi.org/10.1016/ S0140-6736(16)31527-6, and with only nine countries with an initial maternal mortality The dual streams of poor-quality or inaccessible care http://dx.doi.org/10.1016/ ratio greater than 100 achieving the Millennium coexist everywhere—a universality that spans countries of S0140-6736(16)31395-2 1 Development Goal (MDG) 5 target of 75% reduction. low, middle and high income, including fragile and Maternal and Child Health, 26 countries made no progress, and in 12 countries— conflict-affected nations; and those considered econo - HIDN (M Koblinsky PhD, including the USA— maternal mortality ratios increased.1 mically and politically stable. Every woman, everywhere, A C Moran PhD) and Office of Health Systems A woman’s lifetime risk of dying as a result of pregnancy has a right to access quality maternity services, and the (A K Nandakumar PhD), USAID, and childbirth remains more than 100 times higher in benefits of such access extend to the fetus, newborn babies, Washington, DC, USA; sub-Saharan Africa than in high-income countries.1 children, and adolescents. Effectively addressing maternal Department of Learning Health Deaths of newborn babies have also declined at a slower health requires integrated programming that takes into Sciences and Department of Obstetrics and Gynecology, rate than those of older infants and children, and account these inextricable linkages, and requires Global REACH, University of 2–4 stillbirths remain high. connections with the broader social and political context in Michigan Medical School, Ann Yet maternity service use has increased substantially in which women live (appendix). The breadth and complexity Arbor, MI (C A Moyer PhD); the past 10 years since the 2006 Lancet maternal health of such linkages are reflected across the Lancet Series and Department of Infectious Disease Epidemiology, London Series: three-quarters of women now deliver with a skilled other publications on stillbirths, newborn babies, mid- School of Hygiene & Tropical birth attendant and two-thirds receive at least four wifery, and adolescent health. Medicine, London, UK antenatal care visits worldwide.5,6 This mismatch between In this paper, we highlight the most pressing issues in (C Calvert PhD, burden and coverage exposes a crucial gap in quality of maternal health and ask two questions: what actions can Prof O M R Campbell PhD, Prof W J Graham DPhil); Health care. Millions of women receive services that are delayed, be taken in the next 5 years to achieve the Sustainable Workforce, WHO, Geneva, inadequate, unnecessary, or harmful,7–9 minimising the Development Goal (SDG) target of a global maternal Switzerland (J Campbell MPH); opportunity for health gains for both mothers and babies. mortality ratio less than 70 maternal deaths per Abt Associates, Bethesda, MD, In parallel to the women accessing services but 100 000 livebirths by 2030, with no single country having a USA (A B Feigl PhD, L Hatt PhD); Saving Newborn Lives, Save receiving poor-quality care, millions of women and maternal mortality ratio greater than 140 maternal deaths the Children, Washington, DC, adolescents who undertake their journey through per 100 000 livebirths? What steps can be taken to ensure USA (S Hodgins DrPH); pregnancy and childbirth outside the health system are that high-quality maternal health care is prioritised for Department of Social Statistics left behind from the progress in coverage. They every woman (including adolescents) and baby everywhere, and Demography, University of Southampton, Southampton, represent a vulnerable population facing multiple chal- supporting the vision of the Global Strategy for Women’s, UK (Prof Z Matthews PhD); lenges that arise from their individual circum stances. Children’s, and Adolescent Health? Partnership for Maternal Statistics show a growing divergence within and We consulted experts, reviewed the literature, and Newborn and Child Health, between countries in coverage of maternity services for carefully analysed the five papers of this Series; our overall Geneva, Switzerland www.thelancet.com 77 Series

ratio >70), gaps in access to maternity services remain; and Key messages direct causes of maternal death predominate although • The MDG5 target to reduce maternal mortality by 75% was not achieved. The gap between indirect causes, particularly infections, can be present. In countries with highest and lowest mortality has increased despite increased use of stages IV and V with maternal mortality ratios less than 70, maternity care. nearly all women access services, and indirect causes of • This mismatch exposes an important gap in quality of care—delayed, inadequate, death are substantial. In all stages, effective quality unnecessary, or even harmful services—minimising the opportunity for health gains for coverage is the goal: the right care, tailored to the local mothers and babies. burden of illness, received by the right women at the right • In parallel, millions of pregnant women and adolescents are left behind from the progress time, in a respectful manner.8,10 in coverage. Where women reach maternity care services, timeliness, • Poor-quality and inaccessible care coexist everywhere—in countries of low, middle, and quality, and excessive intervention need to be addressed.7,9 high income; in fragile nations; and in those considered economically and politically stable. High effective coverage of known interventions parti- • Five priorities require immediate attention to catalyse action and support the vision of cularly for vulnerable populations (figure 1)—eg, use of global initiatives to achieve the SDG3 global target of a maternal mortality ratio of less appropriate uterotonic drugs for prevention of post-partum than 70: (1) prioritise quality maternal health services that respond to local specificities of haemorrhage,17 antibiotics for sepsis, and preventive inter- need and meet emerging challenges; (2) promote equity through universal coverage of ventions for anaemia18—could greatly decrease maternal quality maternal health services, including for the most vulnerable women; (3) increase deaths19–21 and improve perinatal outcomes. 22 In later stages resilience and strength of health systems by optimising the health workforce and of the obstetric transition, routine labour augmentation23 improving facility capability; (4) guarantee sustainable financing for maternal–perinatal and excessive caesarean delivery24–27 emerge as negative health; and (5) accelerate progress through evidence, advocacy, and accountability. unintended consequences of increased access to facility • Crucial to achieving equity will be the growing pressure on national and regional delivery.7,9 An effective national strategy should also attend governments in even the poorest countries to provide universal health coverage. to iatrogenic outcomes arising from poor-quality care and • As conditions evolve, and women’s preferences change and diversify, these priorities will excessive intervention.7,9 require strong partnerships between the maternal health community and those There are sound recommendations on the content of addressing reproductive, newborn, child, and adolescent health care more broadly; those care and guidelines for implementation throughout the focused on the increasing burden of non-communicable diseases, malnutrition, infectious continuum of pregnancy to post-partum care.7–9,28,29 diseases, and mental ill-health; and those focused on other SDG targets, from ending Adherence to high-quality clinical practice guidelines, poverty to building resilient infrastructure. when combined with simulation-based training, can • To achieve and accelerate these actions will result in benefits for women, newborn babies, improve providers’ knowledge, clinical skills, attitudes,30 and stillbirths, that will extend to children, families, and the community, in this generation and women-centred approaches.31,32 and the next. Although global recommendations for the content of care are valuable, to make standardised global prescrip - tions for implementation strategies is inappropriate.8 Both (L McDougall MSc); and themes are to improve maternal health, ensure the quality health systems and maternity-care models vary within and Maternal Health Task Force, of maternal health care for all women and adolescents, and between countries, so there is no simple universal solution. Women and Health Initiative, Harvard TH Chan School of guarantee access to care for those left behind who are most Providing maternity care in a given setting is, in part, a Public Health, Boston, MA, USA vulnerable. These themes underlie the priority areas for function of available resources and existing infra- (Prof A Langer MD) action summarised in panel 1. structure—including the private sector, human resources, Correspondence to: financing, and factors such as geography, population Dr Marjorie Koblinsky, Maternal Priority 1: Prioritise quality maternal health density, facility density and capability, and distance and Child Health, HIDN, USAID, services between peripheral and referral centres.8 Even so, countries Washington, DC 20004, USA [email protected] Context-appropriate implementation strategies with the best outcomes, lowest clinical interven tion rates, Prevention of unwanted or poorly timed pregnancy is the and lowest costs have integrated midwifery-led care

See Online for appendix first step. By ensuring access to modern contraceptives for through different models that include team-based care in all women and adolescents, everywhere, this step could maternity wards, alongside midwifery-led units (low-risk reduce maternal deaths by an estimated 29%.11 In 2015, units alongside full scope maternity hospitals), free- 12% of women had unmet need for contraceptives,12 and standing midwifery-led units, and home-based midwifery.9 approximately 7·9% of maternal deaths were attributed to Despite the diversity in models of providing care, the unsafe abortion.13 Thus, safe abortion services are also starting point is the same for all countries: to ensure that important. every woman, everywhere, delivers in a safe environment. For pregnant women continuing to term, Souza’s Each country needs a clear national statement of what care obstetric transition14 extends the concept of demographic needs to be provided to pregnant women, what constitutes and epidemiological transitions to maternal health, and routine care for uncomplicated deliveries, and what helps stage appropriate intervention priorities. Panel 2 mechanisms are required to respond on a timely basis to presents settings in five stages from high fertility and complicated deliveries, including referral linkages. maternal mortality to low fertility and mortality. Across Countries then need to carefully compare this national settings corresponding to stages I–III (maternal mortality statement with their present situation using tools such as

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facility and population-based surveys, or routine infor- Panel : Priorities and priority actions for accelerated progress toward improved mation systems. The appendix summarises these priority maternal health actions to improve facility capabilities. • Priority 1: Prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges Build linkages within and between maternal–perinatal • Priority action 1.1: Ensure timely, equitable, respectful, evidence-based, and safe and other health-care services maternal–perinatal health care, delivered through context-appropriate implementation Effective clinical interventions for direct causes of maternal strategies death are well-known (figure 1), but to achieve better • Priority action 1.2: Build linkages within and between maternal–perinatal and other outcomes globally also requires that the increasing burden health-care services to address the increasing diversity of the burden of poor maternal of indirect causes of maternal morbidity and mortality is health addressed.10 This priority action involves clarity on • Priority 2: Promote equity through universal coverage of quality maternal health services, interventions, and integration with other facets of the including for the most vulnerable women health system, from prevention, to primary care, to tertiary- • Priority 3: Increase the resilience and strength of health systems by optimising the health facility networks. workforce and improving facility capability In sub-Saharan Africa, infectious diseases, such as • Priority 4: Guarantee sustainable financing for maternal–perinatal health malaria and HIV, take their toll on maternal health and • Priority 5: Accelerate progress through evidence, advocacy, and accountability contribute to the burden of perinatal deaths.20,33–35 In • Priority action 5.1: Develop improved metrics, and support implementation research to settings with fewer of these infectious diseases or fewer promote accountable, evidence-based maternal health care deaths due to traditional direct causes, non-communicable • Priority action 5.2: Translate evidence into action through effective advocacy and diseases and mental health become more prominent, accountability for maternal health often in relation to older motherhood and obesity.9,10,36 In such contexts, if prevention is unsuccessful, effective- ness of maternity services will increasingly require Panel : Stages in the obstetric transition and corresponding priority actions integration across health-care services and linkages between levels of care. This approach will vary by context. Stages I and II (maternal mortality ratio >420) In low-income, high-burden settings, some of these Prioritise the following: services are unavailable, and funding and programming • Develop and support front-line infrastructure and human resources silos fragment others: HIV/AIDS, tuberculosis, and • Provide access to simple preventive interventions, including family planning, malaria resources should be required to effectively link bednets, iron supplementation, and safe abortion with maternity services.37 • Provide routine maternal health-care components (eg, antenatal care and A substantial patient-safety literature identifies move- uterotonics post-delivery) and emergency response for urgent problems (eg, ment between services as an important point when care haemorrhage and newborn resuscitation) to reduce major direct causes of mortality breaks down. For example, antiretroviral therapy protocols • Improve service quality with provider training, including respectful treatment of for HIV-positive women identified via antenatal care women, ready access to basic equipment and supplies, supportive supervision, and screening were adapted to require fewer visits to ensure other key supports high coverage of prevention of mother-to-child trans- • Focus on equitable demand creation (UHC) 38 mission in the narrow time-window before delivery. Stage III (maternal mortality ratio 70–420) Reduc tion of maternal and perinatal deaths attributable to Assume actions for stages I and II are met, and prioritise the following: eclampsia or pre-eclampsia requires functional linkages • Improve management of routine delivery and of complications, including a timely 39 between antenatal care and hospital-based services. The referral process call-to-action for the Lancet stillbirth Series, echoes the • Improve service quality through appropriate integration, especially for infections, importance of coherent integrated action across services to malnutrition, and mental health, as well as triage and referral 4 improve maternal, newborn, and stillbirth outcomes. • Employ quality of care improvement methods (including clinical practice guidelines), Innovative interventions (eg, new screening tests, high- timely data collection, and use for decision making and programme improvements tech medicine, and telemedicine) can provide solutions • Increase demand for services, with specific focus on the vulnerable, through but also pose challenges for maintaining equity, particularly respectful satisfactory care provision based on women’s needs and perspectives, when costly. address transport or location needs, and effective use of financial initiatives (UHC) Local empirical studies are needed to collect basic descriptive data on approaches for integrating maternal Stages IV and V (maternal mortality ratio <70) health care and services for non-communicable diseases, Assume actions for stages I to III are met, and prioritise the following: infectious diseases, malnutrition, and mental health. • Improve integration or linkages with health care for infections, malnutrition, NCDs, Implications for staff workload, skill mix, and service and mental health quality of midwives, but also of laboratory technicians, • Address between and within facility delays anaesthetists, community health workers, and supply • Improve quality of care and decrease excessive medicalisation chain managers, among others, need to be assessed to • Increase satisfaction with care and sense of wellbeing clarify the implications for woman-centred care. Pre-service UHC=universal health coverage. NCDs=non-communicable diseases. training curricula need to be strengthened to ensure health www.thelancet.com 79 Series

health.50 Gender inequality can also affect health-care Sepsis and other maternal infections 52 • Tetanus toxoid providers, many of whom are women. • Clean delivery Solutions to gender inequality include access to basic • Antibiotics Complications of unsafe • WASH abortion information about maternal, perinatal, and reproductive • Family planning health; and care seeking targeted at women, families, • Safe abortion services Other maternal disorders 9% • Post-abortion care communities, and providers; as well as a commitment to 18% 53 • Caesarean section humanised services. The roles of men and influential • Other emergency family members, such as mothers-in-law, are key and need obstetric care 22% Haemorrhage to be addressed to enable women to make informed care • Uterotonics 18% • Blood transfusion choices. On a small scale, appropriate messages shared • Balloon tamponade through mass media, interpersonal counselling, and 8% • Surgery Obstructed labour • NASG women’s groups have improved use of facilities for birth, • Caesarean section 12% 13% referral for complications, and reduced maternal morbi- Indirect causes Hypertensive disorders dities, stillbirths, and perinatal mortality.15,54–57 Messages are • Iron folate supplements • Early identification and 58,59 • Malaria intermittent more effective when they involve problem solving and timely delivery treatment 58,60,61 • Magnesium sulphate parti ci patory community engagement. Some pro- • Insecticide-treated nets • Calcium • Antiretrovirals grammes focused on education, employment, and auto- • Aspirin • Antihypertensive nomy for women and girls have also shown effectiveness • Caesarean section in improving use of maternal health services.47 Women living in remote areas or in areas of humanitarian 40 Underlying causes crises face other challenges. Rural residence brings the • obvious barrier of increased distance to hospitals. Solutions • Malnutrition • Infections to improve access can include linking women to delivery • Non-communicable diseases services during antenatal care, providing maternity waiting homes to bring women closer to services before labour begins, and improving and subsidising transport, including for emergencies.3 • Infection screening and treatment • Family planning • Ongoing management of chronic • Diet supplementation and Women in areas of humanitarian crises are among illness fortification the super-vulnerable populations of fragile states. 16 countries49 are in the high-alert category of the Fragile Figure : Main causes of maternal death and key interventions (2013)10,15,16 States Index, and in nine, more than a third of women WASH=water, sanitation, and hygiene. NASG=non-pneumatic anti-shock garment. reside in conflict areas. Many have high maternal mortality ratios: 60% were either seriously or moderately off target workers’ skills in managing women with comorbidities, for MDG 5.62 High fertility and unwanted pregnancies are and that clinical practice guidelines are available and typically common, particularly among adolescents, and followed.2 Essential drug lists will need to be expanded to are often caused by sexual violence inflicted as a weapon include those for indirect morbidities. of war.63 Despite increased need, maternal and reproductive Priority 2: Promote equity through universal health resources for even basic services such as family coverage planning, obstetric emergencies, and comprehensive Women everywhere fail to seek care for numerous reasons, abortion care are insufficient or non-existent during including sociocultural factors such as gender inequality, humanitarian crises, especially in countries with pre- location because of remoteness or conflict, and financial existing weak health systems.64 For example, in the Ebola constraints.40–46 These three major access barriers require virus epidemic, maternal and infant mortality, which were immediate attention. already high before the outbreak, increased substantially Gender inequality reflects power imbalances between during the crisis.65 Ensuring access and availability of these men and women both within the household and in the basic services is necessary everywhere, including in areas wider societal context,47 and is both defined and perpetuated with humanitarian crises. by sociocultural norms. Documented to varying degrees in Financial constraints underlie much of the poor access to every country worldwide,48 gender disparities affect women maternal health services in all settings.44–46 Poor sub- and maternal health through pathways directly49 (eg, early populations in low-income and middle-income countries marriage and childbearing, decision making about care still face catastrophic expenditures due to emergency seeking, costs of care, and types of care sought) and obstetric care. In parts of Mali, for example, more than 50% indirectly50,51 (eg, education and availability of food). of households needing emergency obstetric care incurred Gender-based violence, one of the most extreme forms of catastrophic expenditures.66 Establishment of large pre-pay- dis crimi nation against women, increases during ment and risk-pooling mechanisms, which reduce reliance pregnancy and directly affects maternal and perinatal on out-of-pocket spending, could curb catastrophic health

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expenditures in the near-term and long-term. A systematic concentrated in the low-income and middle-income review found that health insurance was positively correlated countries.78 Even in countries with improving provider-to- with the use of maternal health services, although the population ratios, the geographical distribution of effects on quality-of-care and health outcomes remained providers remains a challenge, with several countries incon clusive.67 Other financing instruments can also be reporting densities in the most underserved areas that are deployed to promote access such as cash transfers, a small fraction of those in urban areas.79 microcredit, vouchers, and user fee removal.68–70 To support Figure 2 compares the ratios of practising midwives, free health-care policies additional investment in pay and auxiliary midwives, nurse midwives, and obstetricians and recruitment, commodities, and infrastructure might be gynaecologists to the number of pregnancies in African needed, including staff pay increases for more demanding countries.80 It shows that countries with the largest workloads.71–73 numbers of births (eg, Democratic Republic of the Congo, “Leaving no one behind” is a key slogan in the well- Tanzania, Kenya, and Ethiopia) have some of the emphasised SDGs of greater equity, but will such promise lowest densities of midwives and obstetricians (<2 per reach these populations left behind with a disproportionate 1000 pregnancies). burden of poor maternal health? Universal health coverage To address complex and multifaceted health workforce is the core mechanism for achieving SDG 3, with linked challenges that hinder the provision of maternal–perinatal objectives around quality and availability of care, matching care requires an integrated approach to better balance uptake with need, and improving cost-effectiveness and health workforce needs, demand, and supply, as well as to financial protection.74 Every universal health coverage provide health workers with an enabling work environ- initiative should include a strong maternal health service ment. Some of the required interventions might be specific core and ensure that it reaches every woman, everywhere to the staff most directly involved in providing maternity with quality care, and without causing financial hardship care. For instance, the policy and regulatory environment and pushing families into poverty. Progressive uni- for midwifery care should be realigned with midwives’ pre- versalism is presented as the pathway to achieving service education and accreditation requirements. Despite universal health coverage, defined as a determination to having the potential to address most maternal and include people who are poor from the beginning, as newborn health needs, in many countries, midwives are elaborated by Kruk and colleagues.75 not authorised to perform within the full scope of their profession, and they lack the authorisation to deliver the Priority 3: Increase the resilience and strength of signal functions of basic emergency obstetric and neonatal health systems care. There is also evidence that, beyond skilled health In view of the existence of unserved populations, and workers, task shifting to other roles, such as community- changing and diverging maternal health needs, an increase based health workers, can play a substantial part—in of the strength and resilience of national health systems to certain contexts and during certain circumstances—in respond at scale with quality care, and in a sustainable expanding access to select health services, particularly manner, is urgently needed. Resilience demands mecha- family planning and medication abortion services.81,82 nisms to ensure essential health services are delivered, Effectively addressing health workforce bottlenecks regardless of the stress on the system; and must include requires an integrated and comprehensive approach. the capacity to address the special needs of women, Countries—and, where relevant, development partners— adolescents, and newborn babies,68,76 even as those needs need to invest in training, deploying, and retaining health change with outbreaks (such as Ebola virus disease or Zika workers; by expanding the fiscal space and allocating virus infection) or with conflicts. This resilience is a resources more equitably and efficiently across levels of the challenge for countries with over-stretched staff and weak health systems; by strengthening pre-service education to governance. At a minimum, the building of resilient and ensure a quantitative scale-up, a rural pipeline for health strong health systems requires an emphasis on increasing workforce production and deployment, and improvement and optimising the health workforce and improving facility in the quality of their competencies; by ensuring a gender- capability. balanced approach to health workforce education, deploy- Human resources are a glaring challenge to health ment, and management; by adopting a range of financial systems in all countries, especially low-income and and non-financial incentives to improve management middle-income countries. The numbers of skilled health systems and the work environment in which they operate, professionals (ie, midwives and physicians, and others so as to maximise worker motivation and performance,78 such as anaesthetists); and their composition, deployment, and minimise risks of attrition and emigration. retention, and productivity are dynamic yet crucial The necessary expansion of the health workforce should variables in ensuring universal access to sexual, re- lead to cost-effective resource allocation, prioritising a productive, maternal, and newborn health.77 skills mix that harnesses inter-professional primary care Modelled estimates point to the need for more than teams of health workers, and avoiding the pitfalls and cost 18 million additional health workers by 2030 to meet the escalation of over-reliance on specialist and tertiary care. SDGs and universal health coverage targets, with gaps A WHO framework (appendix) illustrates the supply, www.thelancet.com 81 Series

Pregnancies OB/GYN ratio (in thousands) per 1000 pregnancies <200 <0·15 201–400 0·16–0·25 401–1000 0·26–0·50 1001–2000 0·51–1·25 2001–10 000 1·26–2·00 No data No data

Midwifery ratio* Total HRH ratio per 1000 pregnancies per 1000 pregnancies <2 <2 3–5 3–5 6–10 6–10 11–15 11–15 16–25 16–25 No data No data

Figure : Human resource ratios per 1000 pregnancies in Africa 2012 OB/GYN=obstetricians and gynaecologists. HRH=human resources for health. *Midwifery workforce including midwives, auxiliary midwives, and nurse midwives.

demand, and contextual factors for human resources, capacity, stock outs and supply chains, and maintenance which has been adapted for the specific needs of maternity and infrastructure. Planning means such as the One services in a UNFPA Handbook.83 Health tool can also help to assess needs. Subsequently, An inadequate workforce is not the only challenge. budgeted plans with target dates need to be put in place to Campbell and colleagues8 elaborate on the extent to which address the aspiration gap. countries have inadequate numbers of functional facilities. The starting point needs to be a clear national statement of Priority 4: Guarantee sustainable financing for what should constitute primary care for uncomplicated maternal–perinatal health deliveries, and what mechanisms, including referral, need Capture expanded domestic fiscal space for to be in place for complicated deliveries. As we have maternal health suggested, facility capability can be carefully compared The investment case for health financing, particularly with the present situation measured using facility surveys for investing in the health and education of women, has (ie, quantifying the aspiration gap); and reviews of bed been clearly made by a Lancet Commission, WHO, and

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others.84–86 Additional investments in high maternal and which is reassuring in the face of the decline in overall child mortality countries would yield high rates of development assistance. return, producing up to nine-times the economic and As Kruk and colleagues72 noted, new initiatives are being social benefit by 2035.86 Yet a real resource gap remains.87 developed to maintain momentum for reproductive, During the 2013–35 timeframe, Stenberg and maternal, newborn, child, and adolescent health in the colleagues86 project that an additional investment of SDG era. For example, the Global Financing Facility was US$72·1 billion is needed to achieve high coverage of an launched in July, 2015, to increase, coordinate, and better essential package of maternal and newborn health target donor and domestic funding for women’s, services. These services can be expected to yield a triple children’s, and adolescents’ health in support of the 2030 benefit of reduced maternal deaths, stillbirths and SDGs.87 Still, some development players remain sceptical, newborn deaths, and gains for child health and citing concerns that the Global Financing Facility will development. How then can the global community further fragment the global system and undermine the translate potential long-term investment returns into position of UN agencies.93 Moreover, whether and how concrete next steps that will improve maternal health such mechanisms will reach the super-vulnerable within during the next 5 years? their countries is unclear. The next 5 years will be In this Series, Kruk and colleagues75 highlighted that the important for the Global Financing Facility to demonstrate economic transition in low-income and middle-income its capacity to raise national health resources and effectively countries can increase the domestic fiscal space for health. improve health. However, 10 years after a Lancet Series paper on financing for maternal health,88 concern remains as to whether the Effectively employ strategic purchasing and maternal health financing gaps can be filled with domestic performance-based incentives resources. Nandakumar and colleagues89 showed that Equally important to mobilising adequate financial between 1995 and 2011 as countries transitioned from low resources for maternal-newborn health care is the optimal to lower-middle-income status and donor spending allocation and efficient use of those resources. As domestic declined, governments did not step in to fill the gap. resources increasingly fund such programming, the Indeed, the authors identified an increase in the share of importance of supporting governments and private out-of-pocket spending and other private sources of financiers to implement strategic purchasing will also financing for health. Another analysis71 found that while grow. Strategic purchasing can be defined as proactively government spending on health in high-income countries identifying which models of care and interventions to rises commensurately with gross domestic product invest in (taking into account cost-effectiveness, burden of growth, each percentage point increase in economic disease, and population preferences); determining how growth in low-income countries is associated with only they should be purchased (including contractual mecha- half a percentage point growth in government spending nisms, pricing, and payment systems); for whom they on health.71 A recent analysis echoed these concerns, should be purchased (which groups might benefit from projecting that between 2013 and 2040, only 3% of low- subsidies); and selecting which health-care providers to income countries and 37% of middle-income countries are purchase services from—ideally those who can provide the likely to reach the goal of 5% of gross domestic product highest quality of care most efficiently, whether public or spent by the government on health.90 private sector.94,95 Not only can this active purchasing For these reasons, greater coordination and investment approach ensure that scarce resources are allocated in national advocacy is needed to support governments to appropriately, but also—if designed well—the mechanisms build and sustain health investments. Advocates should for paying providers can incentivise improvements in leverage the consensus statement on domestic resource performance and quality of care. mobilisation that emerged from the 2015 Conference on Reviews of the effects of financial incentive programmes, Financing for Development in Addis Ababa to campaign including financing based on performance or results and for improving countries’ tax policy and tax administration. vouchers, on improving the quality and quantity of Options to explore include sales’ taxes on alcohol and maternal health service provision suggest these pro- tobacco, tourist taxes, and redirecting fossil fuel subsidies grammes can be successful, especially when users have to health. choice among providers.96,97 However, result-based financing schemes that reward providers for better out- Deploy coordinated and targeted donor assistance for comes must be thoughtfully designed to avoid unintended vulnerable populations consequences, such as only serving the lowest-risk women. Continued donor support for maternal health interventions Additionally, rigorously monitoring for accountability in is most important where need cannot be met by domestic result-based financing programmes is key to its effects; resources, such as in super-vulnerable populations in and as yet, such measurement remains challenging in which location and individuals’ characteristics stack many settings of low-income and middle-income against subgroups of women.10 Development aid for countries, particularly regarding equity. Nonetheless, in maternal health has increased annually since 2003,90–92 the next 5 years, particular attention should be paid to www.thelancet.com 83 Series

intelligently incorporating performance elements to registration systems that accurately and comprehensively provider payment systems to improve the efficiency and document pregnancy outcomes—births, stillbirths, effectiveness of resource use for maternal health services. neonatal deaths, and maternal deaths106—are needed in Private-sector providers form a substantial part of health many low-income and middle-income countries. The systems in many countries. They are responsible for one of Maternal Death Surveillance and Response, a global every five deliveries across 57 low-income and strategy that aims to identify and respond to maternal middle-income countries,98 and a majority of care in some deaths, is a useful start.107 settings. Leveraging the power of the private health sector Additionally, research that aims to better understand the to deliver maternal health services efficiently and effectively changing patterns of sociodemographic, obstetric, and is not easy,99 but through approaches such as contracting medical risk factors is needed. What are the best and social franchising it can be another important mechanisms for real-time tracking of pregnancies and component of strategic purchasing. Contracts set clear their outcomes? How can such mechanisms capture those expectations for providers, and tie payments to women who either do not obtain care or seek care outside achievement of predefined objectives.72 If use of private the formal health-care system? Addressing such issues will providers for maternal health services grows,100 contracts be pivotal in effectively and equitably improving maternal between government payment agencies (such as national health and the quality of care in the coming years of leaving health insurance schemes) and private providers will be an no one behind. important component for promoting quality and access.101 To measure the burden and the ability of health systems Franchising also has the potential to improve quality and to provide quality maternal health care for all, the table maternal health outcomes in the private sector, but the provides examples of indicators that cover a number of evidence base is weak.100,102 domains. Some indicators are already widely used (eg, caesarean section rate by wealth quintile); others require Priority 5: Accelerate progress through evidence, development (eg, percentage of women delivering without advocacy, and accountability obstetric intervention), standardisation (eg, percentage Develop improved metrics and support implementation with a length of stay of 12 or 24 h after a singleton vaginal research delivery in a facility), and validation. This list is not Research is an essential component of the post-2015 exhaustive, and has yet to include indicators related to maternal health agenda. Yet research funding is not important issues such as delays in treatment, timely commensurate with need: only 35% of published research referrals, use of financial incentives, women’s satisfaction, in 2011–14 addressed these problems in high-burden and specific provider skills. However, a subset of these countries. Nonetheless, the number of research papers on indicators could be used depending on context. For maternal health in high-burden countries doubled in example, in areas with very low coverage of facility delivery 2011–14 compared with the previous 5 years.103 (panel 2; stages I and II with maternal mortality ratio On the basis of recent literature reviews,104,105 the five >420), managers could focus on barriers to service use (eg, papers in this Series,7–10,75 and discussions with the Series’ social, geographical, and financial) along with the content authors, we identified two types of research specifically of the care delivered; whereas in areas with low maternal needed to scale up and accelerate progress in maternal mortality (stages IV and V with maternal mortality ratio health. The first is on measurement of the causes and <70) and high coverage of contacts with antenatal care and levels of morbidity and mortality, vulnerable groups, and facility delivery, morbidity-related metrics, content of care on indicators to measure progress of policies and promote (insufficient and excessive intervention), and women’s accountability, health system capability, content of intra- satisfaction take precedence. partum care, and women’s satisfaction. Secondly, research into models for implementing care at all stages of the Implementation research: maternal health priorities obstetric transition (panel 2) and into methods for scaling Implementation research aims to understand what, why, up pre-service training of skilled birth attendants is and how interventions work (and can be improved) in real- urgently needed. world settings; and requires working with populations affected by the interventions, and with those involved in Measurement: redefining maternal health metrics directing, managing, and providing the services.124 The Improvement of measurement and coding of maternal appendix illustrates our assessment of high-priority mortality and morbidity, including direct and indirect research areas, categorised by the priority areas. causes and risk factors, is essential to guide intervention Bridging the gap between priority identification and the research, set implementation priorities, and improve implementation of research projects to address persisting quality of care, particularly for women and babies most at or new maternal health needs requires sustained com- risk. Better measurement will require standardising mitment on the part of national governments, donors, definitions and methods of determining and recording and researchers. National governments—especially in direct, indirect, and contributing causes of death, as well as low-income and middle-income countries—need to categories of illness and illness severity.10 Better civil vital allocate resources to support locally-driven research, and

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Widespread existing Issues experience (example of existing data source) Proposed indicator of effect Pregnancy-related mortality ratio, preferably cause Yes (vital registration, USA, Captures deaths; need timely and empirically based estimates; use of pregnancy-related definition specific and Mexico108,109) avoids erratic approach to coincidental deaths Risk of severe maternal morbidity Yes (facility-based, UK,110 or Captures morbidity, broadens focus from mortality survey, multiple countries111) Percentage of women delivering without obstetric No (DHS, Brazil and Denmark Captures desire to avoid excessive intervention; multiple versions of indicator exist; needs global intervention (eg, caesarean section or induction) medical records73,112) consensus on definition Proposed indicator of coverage SBA at birth by place of birth (level and sector), and type Yes (Ghana DHS113) Captures contact with person theoretically providing routine care, identification of complications, of provider (midwife, doctor, or obstetrician) and at least some basic emergency obstetric care; need to ascertain what types of provider are trained to do regarding routine childbirth care and emergency obstetric and newborn care Uterotonics immediately after birth for prevention of No (facility-based, Ecuador114) Captures care at individual level; measures content of routine care of an effective intervention, which post-partum haemorrhage (among facility births) has a benchmark of 100%; challenging to measure in absence of good medical records (women’s self-report via survey is unreliable) Percentage with ANC with all essential elements of care Yes (Ghana DHS, Ethiopia, Captures care at individual level; moves beyond number or timing of ANC contacts to assess receipt India, and Nigeria113,115) of effective care; data to calculate indicator are widely available; essential elements need to be agreed and possibly expanded Caesarean section rate, by wealth quintile or setting Yes (DHS, multiple countries116) Captures life-saving intervention for mothers and newborn babies, but since not all women require (urban or rural), or both caesarean, also reflects “too little, too late” and “too much, too soon”, and highlights inequitable access Met need for family planning Yes (DHS117,118) Important preventive measure, reflects importance of links with other reproductive health services Postnatal care visit within 24 h of delivery (home births) Yes (Countdown, multiple Captures contact in immediate post-partum period; for facility delivery, assesses if length of stay is or length of stay for 24 h with check (facility births) countries117) sufficient for postnatal checks; for home births without SBA, assesses coverage of postnatal home visit; need to standardise the adequate period (12 or 24 h postnatally); data could be used to calculate total length of stay after vaginal singleton delivery after facility birth Percentage of HIV-positive pregnant and post-partum Yes (Countdown, multiple Captures integration of maternal health services with general health services; most existing indicators women receiving ART countries117) focus on PMTCT, whereas this indicator emphasises women’s own need for access to general health services that continue care beyond pregnancy; to operationalise this indicator, a decision would be needed as to whether to measure any ART or long-term treatment for a certain length of time Proposed indicator of systems output Readiness of facility with respect to infrastructure (water, Yes (service provision Captures facility capability to provide routine childbirth care and emergency care, and is required for electricity, continuous opening), routine childbirth care assessment data8,119,120) the two indicators: availability of emergency obstetric and newborn care, and availability of routine (infection prevention, AMSTL, and partograph), basic childbirth facilities; operationalisation requires standardisation across range of instruments,

emergency care (antibiotics, uterotonics, MgSO4, manual including consensus on whether a signal function was performed within a 3-month interval extraction of placenta, removal of retained products, assisted vaginal delivery), comprehensive care (caesarean section and blood transfusion), staffing Availability of emergency obstetric and newborn care No (Ethiopia and Zambia121,122) Captures geographical access to functional emergency care, bolsters desirability of geolocated facility facilities within 2 h data, assessment of facility capability; experience is growing; best measured with facility censuses, including private sector Availability of routine childbirth facilities within 2 h No (Zambia121) Captures routine provision and complements previous indicator at little marginal cost; has advantage of emphasising access to decent care for all deliveries, not just complicated ones Full-time equivalence of midwives (SBAs) per 100 births No (Sri Lanka123) Captures human resources available; provides clear understanding of numbers with skills to do effective delivery in relation to numbers of births; need to develop appropriate benchmarks and expected tasks of SBA

DHS=Demographic and Health Survey. ANC=antenatal care. SBA=skilled birth attendant. ART=antiretroviral therapy. PMTCT=prevention of mother-to-child transmission. AMSTL=active management of the third stage of labour.

Table: Examples of indicators for measuring burden and ability of health systems to provide quality maternal health care to build capacity among in-country researchers, including Translate evidence into action through effective advocacy health system experts, epidemiologists, and social and accountability for maternal health scientists. Only when in-country researchers have the Stakeholders (governments, donors, multilateral partners, training to compete for funding successfully, and civil society, and private sector) investing in effective and countries allocate resources to support such efforts, will joint platforms for action can mobilise resources, strengthen research truly reflect the needs of programmes in these laws and policies, and promote mutual accountability. countries. At the same time, donors must see the value The Global Strategy’s Every Woman Every Child in—and provide funding for—evidence generation and advocacy platform supports the delivery of the SDGs, by long-term, data-driven programming that targets encouraging partners to act together to leverage financial, vulnerable populations. policy, and service delivery commitments for maternal www.thelancet.com 85 Series

health and related issues.125 Since its launch in 2015, the and newborn outcomes, as reflected in the Lancet Global Strategy has attracted more than 150 commitments newborn health Series.22 from governments and other partners towards its In the transition to the new SDG era, robust national, implementation.126 Partners are further guided by evidence regional, and global advocacy, as well as accountability presented in this and other related Lancet Series (stillbirth, efforts, are needed to ensure women’s and children’s health adolescent health, newborn health, and midwifery), and not only retain their prominence, but that they are seen as through related action plans such as the 2015 Ending cornerstones for achieving other goals, including several Preventable Maternal Mortality (EPMM) plan127 and the that reach beyond health. In the MDG era, the Global Every Newborn Action Plan (ENAP),128 which have Strategy’s independent Expert Review Group131 and the converging priorities.3 All these documents highlight the Countdown to 2015132 initiative provided periodic, need for effective maternal and newborn advocacy within scientifically credible feedback on what needed to improve the continuum of reproductive, maternal, newborn, child, and where.132 To support the SDGs, successor groups, the and adolescent health care. Independent Accountability Panel, and the Countdown to Regional advocacy can also play a vital role in reducing 2030 will provide evidence on needs and gaps that can be inequities and improving quality of care for women and converted into actionable messages by advocacy actors such newborn babies. An example is the Campaign for the as the Partnership for Maternal, Newborn, and Child Accelerated Reduction of Maternal Mortality in Africa, Health; Women Deliver; White Ribbon Alliance; and others. which assists partners to use data and evidence for advocacy through its African Health Stats platform. Moving forward Country scorecards and other data products can also help Building on the priorities identified in this Series (panel), parlia mentarians, media, and civil society track national interventions known to reduce maternal death (figure 1), per for mance on regional commitments such as the 2001 and potential implementation priorities by stage of Abuja Declaration, which committed countries to maternal mortality ratio reduction (panel 2), figure 3 spending 15% of government budgets on health.129 The schematically represents an action plan for local, national, Global Health Observatory estimates that on average in regional, and global stakeholders to accelerate progress 2013, these countries allocated 11·4% to health, a toward improving maternal health. It emphasises that substantial improvement compared with an average of sustained efforts must be defined and initiated at local and 3·1% in 1995.130 Whether this increase has translated into national levels, as well as complemented and supported by improved maternal health-specific funding remains efforts at the regional and global levels. This plan unclear. The voice of parents and families is another key complements existing action plans, such as the Global influence to be tapped to bring about improved maternal Strategy for Women and Children,125 EPMM,97 and ENAP128

1 Identify key elements of national and local context 1 Advocate for: • Burden of illness and vulnerable populations • Increased attention to maternal health • Dominant models of care, including responsive linkages and referral systems • Building linkages within maternal health-care services, between levels of care • Capabilities of facilities (public and private) and with other aspects of health care • Provider numbers, cadres, skills, and distribution • Increased government spending on health care • Cultural, financial, geographical factors affecting illness, care seeking, and • Women’s rights and agency access; women’s perspective and satisfaction • Woman-centred care • Implementation research needed to improve access, efficiency, effectiveness, and responsiveness of maternal health services

2 Develop national and local 2 Provide global evidence-based action plans to address gaps clinical practice guidelines and • Human resources quality improvement methods • Facility and referral capabilities National Improved Global and • Content, quality, and integration and local level maternal regional level of care provision action health action • Health system strenthening, 3 Provide evidence-based case responsiveness, and resilience studies to guide country-level • Ensure financial sustainability implementation • Data and health information systems • Address access barriers

4 Provide funding for country 3 Set clear timelines for action 4 Tie action plans to local and 5 Ensure funding for targeted gap analyses, improvement in plan implementation national budgets international assistance for measurement, and countries in need implementation research

Figure : Maternal action plan to accelerate progress towards improving maternal health

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by emphasising the need to contextualise local and guarantee access to care for those left behind or those who national-level action, including a careful assessment of the are most vulnerable. In addition, this Series describes, local context, locally-driven action plans, and imple- organises, and analyses a large body of information that, if mentation plans that are tied to local and national budgets. applied, could improve the health and pregnancy experience It also emphasises the important interplay between local of millions of women and save thousands of lives worldwide. and global stakeholders, and the relative strengths of each. On the basis of hard-fought experience working for National and local stakeholders are best positioned to improvements in maternal health during the MDG era, this identify and address key elements needed to ensure Series provides a crucial knowledge base to inform actions effective maternal health-care provision for all women, during the new SDGs for the next 5 years. The priority including adolescents. These elements include assessing actions provide a timely update of the evidence similar to the local burden of disease; current models of care; the themes such as the EPMM or ENAP strategic directions,3 private sector’s role; provider numbers, skills, and working and are a supportive and more elaborated evidence base to conditions; financial initiatives available and their effect on inform the development of plans and priority actions. maternal and newborn care; and the cultural, financial, Maternal health strategies need to respond to the specific and geographical factors affecting illness, care-seeking, and often rapidly changing population needs as demo- access, and women’s perspectives and satisfaction. It also graphics, epidemiology, and economies evolve; and as involves setting measurable, costed, time-anchored goals preferences shift and diversify. This response will require for human resources and their support; facility capabilities; unprecedented collaboration with a wide array of partners content, quality, and integration of care provision; and to improve equitable access to efficient, high-quality, and health information systems and data needed. National and respectful maternal health care with functioning referral local stakeholders will be instrumental in ensuring that systems. It will require a fundamental shift towards care such goals are supported by corresponding national and centred on the woman and family, with better linkages local budgetary allocations, and through collaboration across reproductive, maternal, newborn, child, and between various levels and sections of government, civil adolescent health, and more, as non-communicable society, private sector, and with other relevant ministries. diseases and other maternal illnesses become apparent. At a global and regional level, stakeholders will need to Crucial to achieving equity in maternal health will be the advocate for increased attention to maternal–perinatal growing pressure on national and regional governments health, and ensure women’s rights and agency are in even the poorest countries to provide universal health acknowledged, which includes involving women in their coverage—ie, high-quality services available for every own health care. Global stakeholders should encourage a woman, everywhere, with financial protection. Maternal fundamental shift towards more woman-centred and health improvements will influence, and be influenced by, family-centred care, including more functional linkages achievements within the wider continuum of care; those between maternal health-care services and other aspects of working on non-communicable diseases, infectious health care, such as combining family planning and diseases, nutrition, and mental health; and in relation to newborn care provision during post-partum care visits or other SDG targets, from those aimed at ending poverty to integrating HIV and nutrition services.133 Although such those building resilient infrastructure. Finally, as these linkages are not easy to implement and sustain, and efforts yield independent and rigorous data, such results although funding silos are often difficult to bridge, this can guide national and local governments and global shift is precisely what is needed to realise the maximum partners in working together to focus on what is needed to possible gains for maternal–perinatal health globally. reach the SDG target for a maternal mortality ratio less Global stakeholders can also help by supporting than 70 by 2030, and to attain equitable and accelerated continued efforts to provide evidence-based clinical improvement in maternal health. practice guidelines, and case studies of programme imple- Contributors mentation. Finally, global partners can fund research on MK conceptualised the paper and worked closely with CAM, SH, AL, ABF, measuring maternal and newborn outcomes, imple- LH, AKN, ACM, CC, and OMRC on the first draft. CAM provided valuable editorial and technical inputs. LM helped with conceptualisation of the mentation facilitators for known interventions, and test priorities and editorial support, and OMRC and CC provided continuous integration and linkages with others services, all the while editorial and technical support. All authors contributed draft sections of being aware that different contexts are likely to require the paper, provided input to its overall direction and content, and reviewed different implementation strategies. each draft of the paper. Declaration of interests Conclusions We declare no competing interests. This Series, following up on the 2006 Lancet maternal Acknowledgments survival Series and building on recent related publications This paper was funded by the MacArthur Foundation, the Bill & Melinda Gates Foundation, USAID, and MCSP. The funders did not (including those on midwifery, newborns, stillbirths, and have any role in the development or writing of this paper. We thank adolescents), suggests two fundamental issues that need to Frank Anderson, Linda Bartlett, Neal Brandes, Asha George, be addressed to improve maternal health: to ensure the Amanda Glassman, April Harding, Alain LaBrique, Margaret Kruk, quality of maternal health care for all women, and to David Milestone, Judith Moore, Lisa Nichols, Saiqa Panjsheri, www.thelancet.com 87 Series

Tom Pullum, Jim Ricca, Pamela Riley, Jeff Smith, Mary Ellen Stanton, 20 Brabin B, Verhoeff F. The contribution of malaria. In: Maclean AB, and Ann Starrs for their insights that initiated the drafting of this ed. Maternal morbidity and mortality. London: Royal College of paper. We thank Giorgio Cometto, Giorgia Gon, Rima Jolivet, Obstetricians and Gynaecologists, 2002: 65–78. Emily Hillman, Corrine W Ruktanonchai, Malay Mridha, and 21 Kyei NN, Chansa C, Gabrysch S. Quality of antenatal care in Zambia: Samiksha Singh who assisted with specific inquiries or figures. We are a national assessment. BMC Pregnancy Childbirth 2012; 12: 151. grateful for the grounding for the paper contributed by the Series’ lead 22 Mason E, McDougall L, Lawn JE, et al. From evidence to action to authors. Finally, we thank the anonymous reviewers for their useful deliver a healthy start for the next generation. Lancet 2014; comments. 384: 455–67. 23 Clark SL, Simpson KR, Knox GE, Garite TJ. 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