Exclusion, Inequity and Health System Development: The Critical Emphases for Maternal, Neonatal and Child Health
Green, Andrew, Gerein, Nancy, Bulletin of the World Health Organization
The World health report 2005 provides a powerful analysis of the global scandal of mothers' and children's ill-health (1). Every year, over half a million women die from pregnancy-related causes and over 10 million children die under five years of age. These deaths are largely preventable. The report correctly identifies the causes as lying primarily in failures within health systems to provide appropriate frameworks and resources to deliver the technical interventions, and in broader social and cultural factors.
Evidence on technical interventions is well covered. Midwifery-led care at the first level of services, with accessible back-up in hospitals, is essential for reducing maternal and neonatal mortality. The report is crystal clear on this, acknowledging past failures of training traditional birth attendants and problems of over-medicalization of childbirth. Universal access, both financial and geographical, to care by skilled attendants is emphasized, although a description of the requirements of referral systems to ensure timely access to obstetric care would have been helpful. Issues too often ignored are included: violence, discrimination and marginalization during pregnancy, sex selection, and the need for evidence to develop policy on postpartum care.
Making pregnancy safer requires high-quality antenatal care, improving society's care of pregnant women, and dealing with unwanted pregnancies. Building on WHO-sponsored research (2), the report describes how antenatal care could deal more opportunely with issues such as malnutrition, malaria, tuberculosis, family planning, and sexually transmitted infections and HIV/ AIDS. The health burden from unsafe abortion is graphically described, but the report misses the opportunity to note the responsibility of health ministries to advocate on this issue, and to consider the underexploited technology of emergency contraception (3). Neonatal mortality receives a welcome analysis, but kangaroo care (strapping the newborn baby next to the mother's skin for warmth and breastfeeding) is unfortunately omitted, though it echoes the statement that progress in neonatal health does not require sophisticated technology. Child health is well summarized, building on experiences with developing a continuum of care from community to referral level throughout the health system.
The report focuses on health system aspects critical for maternal, neonatal and child health (MNCH) but which also provide a wider foundation to strengthen health systems. Firstly, it endorses the district health system as the appropriate structure to deliver the integrated care essential in MNCH, but recognizes earlier failings to support this. It also suggests that emphasis on primary care may have had the unintended consequence of neglecting hospitals, a critical part of the referral chain. Such an integrated approach challenges the vertical approaches of donors and public--private partnerships. …