We will now take a closer look at the results from the Van Lerberghe et al paper in The Lancet Series on Country Experiences. This paper documented the experiences of low and middle income countries that implemented midwifery and midwives as one of the main strategies to improve maternal and child health. 21 countries were included, and they found four that achieve sustained and substantial reductions in maternal and newborn mortality. These four countries were Burkina Faso, Cambodia, Indonesia, and Morocco. By the end of this lesson, you will be able to describe the key policies and systems that were implemented early to have the most impact on maternal and neonatal health. Understand how the sustained effort led to improvement overtime. Describe the three main areas of effort. Discuss the areas for continued improvement. Each of the four countries made a rapid scale up of midwifery at the heart of their policy changes. However, there is much more than simply scaling up midwifery that made these countries successful. Their changes also included increased investment in the overall service delivery network. Deployment of midwives to meet and generate increased demand. Lifting financial barriers and prioritizing universal access to care. Attention to quality of care, and respectful person-centered care. Let's look at how one of the countries actually did this to better understand the process. Let's go to Cambodia in Southeast Asia. Cambodia, over the past 25 years, has implemented an aggressive and plan to meet the MDGS, and now, SDGs. Let's take a look at the data. Here we see the metric of number of births attended by a skilled birth attendant. It is gone from less than 40% in 2000 to nearly 98% in 2017. Here we see the number of nurses and midwives per 1,000 people has nearly doubled in the past 20 years. And they are in progress to increasing that number from less than 1 per 1,000 in the 90s to more than 5 per 1,000 people by 2030. The maternal mortality ratio has gone from more than 300 per 100,000 to just over 100 per 100,000. A remarkable achievement, with the intent to further lower the ratio to 70 per 100,000. This figure shows the neonatal mortality rate. Remember, this is the rate of a newborn dying in the first 28 days of life and is an important marker of health in a country. They have reduced the rate for more than 40 per thousand live births to around 15 per thousand. Another remarkable improvement. I think this figure is important, as the QMNC framework states at the scaling up of midwifery with family planning will lead to improved outcomes in over 50 metrics. We haven't spent a lot of time talking about family planning, but this is a big part of what midwives and other health professionals do. Helping families space or avoid pregnancies in order to complete education, work or raise healthy children with adequate nutrition and access for their children to education. Cambodia has increased the number of women of reproductive age who have their family planning needs met from about 20% to over 60%, which is a great improvement. There is room for continued growth here, though, as all women of reproductive age should have those needs met. This figure, I believe, shows that with the increase in access to family planning and health education, we can see a concomitant decrease in the adolescent birth rate. An important metric when we want to look at the rights of girls to education and a delay in childbearing until they are fully grown, ensuring a safer and healthier pregnancy and birth. This final figure is a key to all areas of improvement. Cambodia made a commitment to universal health coverage, making essential services accessible and affordable, and providing access to preventative medicines such as vaccines and primary health care. So now that we have seen some of the gains that Cambodia has made, let's look a little deeper into how they did that. As we go through some of their steps, it is important to keep in mind that while we can learn some lessons from Cambodia, success in your own setting may look very different, as each setting has its own set of resources, challenges and community priorities. But there are some basic political and policy structures that are universal to success. So what did Cambodia do? According to a paper jointly published by the Cambodian Ministry of Health in collaboration with multiple stakeholders in Cambodia, including the Partnership for Maternal, Newborn and Child Health, and the World Health Organization, as well as others. They credit three pillars that drove their successes. First, they improved and developed laws and standards and guidelines. These focused on supporting universal coverage with a package of strategic plans designed for high impact. They developed technical standards and guidelines in reproductive, maternal, newborn and child health. Additionally, the develop mechanisms for improved coordination led by different task forces and working groups. Second, they strengthened health systems in three areas, health care financing, the health workforce, and tracking progress with data. The health care financing efforts include an increasing government allocations to health, and the development of an expansion of three health care financing schemes, performance-based financing, health equity funds, and vouchers. The health workforce efforts included a comprehensive health workforce development plan with increasing the number of midwives and improving the quality of midwifery care and improving all staff standards through in service trainings. The use of data for tracking progress. These efforts included annual performance reviews, strengthening of health information systems, tracking SDGs with regular population-based surveys, and maternal death reporting and case reviews. The third pillar was delivery strategies. Key delivery strategies have included development of improved health infrastructure, including more health facilities of all categories, and improve structural capacity of these facilities to provide quality of care. Implementation of an integrated routine primary health care delivery system through provinces and districts that includes village health workers, community groups, and linking with NGOs. Vertical programs for immunization and malaria, and finally, health promotion and behavior change campaigns for exclusive breastfeeding and antenatal care seeking practices. Altogether, these have reduced and equity and improved access to essential care, which have in turn improved many outcomes. So what is it that they did that worked so well? They had a high-level political commitment. They had impressive expansion of health care network. A commitment to universal access. An investment in midwives scaled up services. All of these brought a rapid increase in up taken coverage. Let's see how these changes were made overtime to have impact. This graphic shows the different program inputs implemented from 1995 to 2013. We see from the start a strong birth spacing policy, safe motherhood, work towards health coverage, and the legalization of abortion. An important and often overlooked component to improved maternal and child health. Abortion care is healthcare. And in countries where abortion is illegal or inaccessible, we see a rise in maternal death from black market abortions. The next big push we see is the focus on midwifery in midwives. A multipronged approach that included raising the perception of midwifery as a respectable profession and a campaign to increase pay and reimbursement schemes in order to attract and retain midwives. This figure from Lerberghe et al takes the inputs from previous from the previous slide along with the other policy, financing and data changes, so we can see how they all come together for maximum impact. From the foundation of political commitment and leveraging donor funds to reflect this commitment. We see the drive to get the funds into the programs and priorities start to work. With the funds and policies in place, the workforce and health centers are developed and barriers such as cost and payments are removed. Finally, focusing on transfers and integration of health systems as well as strengthening the skills and respectful care all lead to improved outcomes. Priority areas for future action include, supporting the quality of respectful person centered-care at the policy level. Monitoring over medicalization, the caesarean rate in Cambodia in urban areas is on the rise and in some places more than 60%. Reducing socioeconomic inequities, continuing investments in education, water and sanitation, and poverty reduction. It is clear though that Cambodia has made dramatic gains with a strong commitment and investment in their maternal, newborn, and child health. While your country's picture may be quite different in the solutions that are created to solve these challenges will be unique to your setting, there are universal needs. Regardless of the specific pathway, care organization must be organized to one, address the needs of vulnerable populations such as displaced people, minority populations, and those living in poverty. It needs to respond to healthcare systems, threats, and disruptions that may be caused by such things as extreme weather, conflict, and disease outbreak. It needs to utilize new innovative strategies such as new technologies that extend the reach and capacity of caregivers and the health care system. And address widening disparities related to population changes arising from such things as increasing chronic diseases and the unmet need for adequate and available contraception Cambodia is a great example of top down changes to care organization at the country level. There are also bottom up approaches to improve care organization at the local level. Up next you will hear from my colleague and friend doctor Rachel's Zaslow on how care is organized in a village in northern Uganda.
