The sustainable development goals (SDGs) are a new chapter in human development.
They include just one health goal, SDG3, aiming to: “Ensure healthy lives and promote well-being for all at all ages”. SDG3 acknowledges that health is a universal human right and that women’s empowerment is critical. This important change makes addressing the inequities of poor maternal health even more urgent.
It also requires more research on maternal and child health from around the world, so we can gather evidence to inform change and assess progress.
The SDGs have set the ambition to reduce the global average of maternal deaths to less than 70 per 100,000 live births by 2030. To help achieve this, The Lancet Maternal Health Series has drawn up a five point plan for all stakeholders to achieve good maternal health.
Quality: We need good quality, evidence-based maternal health services that respond to local needs and meet new challenges.
Equity: Every woman, everywhere should be reached with good quality, affordable, respectful care.
Health systems: Countries’ entire health systems must be strengthened, so they can respond to the changing contexts of women’s lives, and stand up to shocks and environmental threats.
Financing: Sustainable financing for maternal health is needed to maintain maternal health gains and accelerating progress.
Better evidence: Better local evidence will improve local quality of care.
Economic growth and “health convergence”
Most maternal deaths happen in low-income countries; but over the next 20 years, these countries should see economic growth that will allow them to spend more. If they spend even a small portion of that new money on health, through public financing of health insurance and investment in health systems and infrastructure, it could make a big difference to maternal health outcomes.
Getting to a “grand convergence in health,” where avoidable infectious, maternal, and child deaths are at low levels in all countries by 2035, would mean spending an extra $23 per person on health around the world. That would be approximately twice what was spent in 2015. In the 34 poorest countries, this would prevent 190,000 maternal deaths in 2035. Most countries could fund this increase in health spending themselves.
The data revolution and mHealth
The “data revolution” means increased, better use of data to make decisions and keep decision makers responsible.
“mHealth” means using mobile phone technology to improve public health, research, and services. Mobile phones are now available almost everywhere, even in the poorest and most remote areas. There are more phones in the world than people. mHealth could help countries gather and interpret information so they can provide better services. For individuals, it can help families and patients engage more directly in their healthcare experience—for example, South Africa’s “MomConnect” programme sends text messages with important health information to pregnant women and new mothers.
Mobile phones can also help keep service providers honest: for example, Uganda and India have systems that let citizens with phones report corruption, poor services and other problems.
The success of mHealth and the data revolution needs technology, but it also needs “data literacy”—that is, it needs people to know how to use the data that are available. This is a skill, but it is also a process for empowerment and social inclusion. Building it up requires policy makers and decision makers to create a culture where decisions are informed by data. Communities must insist on the right to engage with, and control, their own data.
People can make poor decisions about their health. Even when barriers to access are removed, they will often fail to access life-saving care. “Behavioural economics” looks at why people make decisions that hurt them, and what needs to change. Three promising approaches are: (1) changing how choices are ordered; (2) changing how information is presented; and (3) paying people to resist social and cultural pressures that might cause them to make poor decisions.
Universal health care
Universal health care means making sure that all people, everywhere get essential health services without experiencing financial hardship. It is an important global goal and part of the SDG on health. Universal health care helps maternal health in several ways, by removing catastrophic health expenditure, and increasing use of services. It has comprehensive, respectful maternal health services at its core, and is a major opportunity to improve maternal health, decrease child and adult mortality, and reduce poverty around the world.
Universal health care could also expand access to care for illness during pregnancy and childbirth and afterwards, and to care for mental health concerns. Monitoring of UHC after the SDGs must include examination of maternal health coverage, quality, and impact.
Better health metrics, better evidence
In the new era of the SDGs, we need better understanding, better data, and better planning. This means new, better ways of measuring maternal illness and death, to generate the information that will allow us to improve quality of care, especially for the most vulnerable.
Better measurement will mean standardised definitions and ways of recording causes of death, as well as types and levels of illness. Many low- and middle-income countries also need better systems to record pregnancy outcomes (births, stillbirths, neonatal deaths, and maternal deaths). UN agencies, donors, national governments, and others can work together to agree on new measurements, better ways of gathering and analysing data, and standards for regular surveys of households and health care facilities—all with the goal of ensuring that every woman can give birth without risk to her life, or to that of her baby.
Research is also needed to improve our understanding of risk factors, and to figure out the best ways to track pregnancies and their outcomes. New systems will be needed to capture information about women who do not access formal healthcare systems.
Midwifery-led units alongside larger obstetric care facilities have improved outcomes for women and their newborn babies in some contexts. Along with other benefits, alongside midwifery-led units eliminate the need for transfers between facilities in emergencies.
Midwifery-led care is predominant in high-income countries with the least unnecessary interventions, the best outcomes and the lowest costs. This care is provided in different ways, including: through care teams in maternity hospitals; through midwife-led units alongside maternity hospitals; and by midwives within communities and homes.
The experiences of these countries are important in those other countries where maternal deaths are decreasing, and where transitions between care models are occurring.
Health systems strengthening
Healthcare providers and health systems must ensure that all women receive good quality, evidence-based, equitable, respectful care. The right level of care needs to be offered at the right time, in a way that respects, protects, and promotes human rights. But good health for women and newborns during and after pregnancy—as well as the prevention of unintended pregnancies—has enormous implications for health systems.
While ending avoidable maternal death must remain a priority, death is the tip of the iceberg. Beneath it are many different causes and consequences of poor maternal health. We must look at this honestly and openly, reviewing and improving evidence, and refining health systems’ priorities and the way we judge progress.
It will not be enough just to improve coverage of current services; instead, health systems will need to understand and improve pathways for care, and health services along the continuum of care.
Sustainable health financing
Increasing health investment in countries can have a great economic benefit. Almost 25% of the growth of national income in low-income countries between 2000 and 2011 came from increased life expectancy. With countries’ national incomes expected to grow over the next 20 years, this could increase funding for health systems. Growing national incomes can also be supported by new ideas for raising tax income. These new ideas include raising more money by taxing tobacco, alcohol and tourism; and reducing subsidies for fossil fuels.