strategies-toward-ending-preventable-maternal-mortality-(epmm).pdf

Strategies toward ending

preventable maternal

mortality (EPMM)

Strategies toward ending

preventable maternal

mortality (EPMM)

PHOTO CREDITS (top to bottom)

• Karen Kasmauski/MCSP

• UNICEF/Dormino

• Shaqul Alam Kiron/MCHIP

WHO Library Cataloguing-in-Publication Data

Strategies toward ending preventable maternal mortality (EPMM).

1.Maternal Death – prevention and control. 2.Maternal Mortality – prevention and control. 3.Obstetric Labor

Complications – prevention and control. 4.Maternal Health Services – standards. 5.Health Services Accessibility.

6.Universal Coverage. I.World Health Organization.

ISBN 978 92 4 150848 3 (NLM classication: WQ 270)

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iii

Strategies toward ending preventable maternal mortality (EPMM)

Contents

Abbreviations 1

Introduction 2

Background 3

Lessons learned: successes and challenges 3

Way forward 4

Targets for maternal mortality reduction post-2015 6

Global targets to increase equity in global MMR reduction 6

Country targets to increase equity in global MMR reduction 6

Establishment of an interim milestone to track progress toward the ultimate MMR target 7

Strategic framework for policy and programme planning to achieve MMR targets 8

Laying the foundation for the strategic framework 8

Guiding principles, cross-cutting actions and strategic objectives for policy and

programme planning 9

Guiding principles for EPMM 10

Empower women, girls, families and communities 10

Integrate maternal and newborn care, protect and support the mother–baby relationship 10

Prioritize country ownership, leadership and supportive legal, regulatory and nancial

mechanisms 11

Apply a human rights framework to ensure that high-quality sexual, reproductive,

maternal and newborn health care is available, accessible and acceptable to all

who need it 12

Cross-cutting actions for EPMM 14

Improve metrics, measurement systems and data quality 14

Prioritize adequate resources and eective health care nancing 15

Strategies toward ending preventable maternal mortality (EPMM)

Elaboration of the ve strategic objectives to guide programme planning

towards EPMM 18

1. Address inequities in access to and quality of sexual, reproductive, maternal and newborn

health care 18

2. Ensure universal health coverage for comprehensive sexual, reproductive, maternal

and newborn health care 19

3. Address all causes of maternal mortality, reproductive and maternal morbidities

and related disabilities 20

4. Strengthen health systems to respond to the needs and priorities of women and girls 25

5. Ensure accountability to improve quality of care and equity 26

Conclusion 28

Acknowledgements 29

Annex 1. Goal-setting for EPMM: process and timeline 30

Annex 2. Accelerating reduction of maternal mortality strategies and targets

beyond 2015: 8–9 April 2013, Geneva, Switzerland 31

Annex 3. Targets and strategies for ending maternal mortality:

16–17 January 2014, Geneva, Switzerland 33

Annex 4. Country consultation on targets and strategies for EPMM.

14–16 April, 2014, Bangkok, Thailand 35

References 41

Figure 1:

Maternal mortality ratio (MMR, per 100 000 live births stratied by MMR level)

Figure 2:

MMR reduction at country level 7

Figure 3:

Global estimates for causes of maternal mortality 2003–2009 20

Box 1:

Population dynamics 5

Box 2:

Ultimate goal of EPMM 9

Box 3:

Rationale and scope of strategic objectives for EPMM 16

Box 4:

Evidence-based resources for planning key interventions 22

Strategies toward ending preventable maternal mortality (EPMM)

Abbreviations

AAAQ availability, accessibility, acceptability and quality of services

AMDD Averting Maternal Death and Disability program

ARR annual rate of reduction

CEDAW Committee on the Elimination of Discrimination against Woman

ENAP Every Newborn Action Plan

EPMM eliminating ending preventable maternal mortality

GFF Global Financing Facility

HIV human immunodeciency virus

HRC United Nations Human Rights Council

HRP Human Resource Planning

IHI Institute for Healthcare Improvement

MCHIP Maternal and Child Health Integrated Program

MDG Millennium Development Goal

MDSR maternal death surveillance and response

MHTF Maternal Health Task Force

MMR maternal mortality ratio

OHCHR Oce of the High Commissioner for Human Rights

PMNCH Partnership for Maternal, Newborn and Child Health

RHR Reproductive Health and Research

SRMNCAH sexual, reproductive, maternal, newborn, child, and adolescent health

UHC universal health coverage

UN United Nations

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

USAID US Agency for International Development

WASH water, sanitation and hygiene

WHO World Health Organization

Strategies toward ending preventable maternal mortality (EPMM)

Introduction

As the 2015 target date for the Millennium Development Goals (MDGs) nears, ending preventa-

ble maternal mortality (EPMM) remains an unnished agenda and one of the world’s most critical

challenges despite signicant progress over the past decade. Although maternal deaths world-

wide have decreased by 45% since 1990, 800 women still die each day from largely preventable

causes before, during, and after the time of giving birth. Ninety-nine per cent of preventable

maternal deaths occur in low- and middle-income countries

(1)

. Within countries, the risk of death

is disproportionately high among the most vulnerable segments of society. Maternal health,

wellbeing and survival must remain a central goal and an investment priority in the post-2015

framework for sustainable development to ensure that progress continues and accelerates, with

a focus on reducing inequities and discrimination. Attention to maternal mortality and morbidity

must be accompanied by improvements along the continuum of care for women and children,

including commitments to sexual and reproductive health and newborn and child survival.

The time is now to mobilize global, regional, national and community-level commitment for

EPMM. Analysis suggests that “a grand convergence” is within our reach, when through con-

certed eorts we can eliminate wide disparities in current maternal mortality and reduce the

highest levels of maternal deaths worldwide (both within and between countries) to the rates

now observed in the best-performing middle-income countries

(2)

. To do so would be a great

achievement for global equity and reect a shared commitment to a human rights framework

for health.

High-functioning maternal health programmes require awareness of a changing epidemiolog-

ical landscape in which the primary causes of maternal death shift as maternal mortality ratios

(MMRs) decline, described as “obstetric transition”

(3)

. Strategies to reduce maternal mortality

must take into account changing patterns of fertility and causes of death. The ability to count

every maternal and newborn death is essential for understanding immediate and underlying

causes of these deaths and developing evidence-informed, context-specic programme inter-

ventions to avert future deaths.

The EPMM targets and strategies are grounded in a human rights approach to maternal and

newborn health, and focus on eliminating signicant inequities that lead to disparities in access,

quality and outcomes of care within and between countries. Concrete political commitments

and nancial investments by country governments and development partners are necessary to

meet the targets and carry out the strategies for EPMM.

Strategies toward ending preventable maternal mortality (EPMM)

Background

Lessons learned: successes and challenges

MDG 5a calls for a 75% decrease in MMR from 1990 to 2015. By 2013, a 45% reduction was

achieved (from 380 deaths/100 000 live births in 1990 to 210 deaths/100 000 live births), show-

ing signicant progress but still falling far short of the global goal.

To achieve the MDG target, each country was required to maintain an average annual rate of

reduction (ARR) in MMR of 5.5%. Instead, the average ARR among countries between 1990 and

2013 was only 2.6%. However, countries showed that with commitment and eort, they could

accelerate the pace of progress: the average ARR increased to 4.1% during 2000–2010 from just

1.1% during 1990–2000. Moreover, 19 countries sustained an average ARR of over 5.5% for every

year from 1990 to 2013; the highest average ARR ranged from 8.1% to 13.2%

(4)

MDG 5b calls for universal access to reproductive health for all women by 2015, as measured

by antenatal care coverage, contraceptive prevalence, unmet family planning need and ado-

lescent birth rates. As of 2014, although gains were made in each category, insucient and

greatly uneven progress was measured by each of these indicators

(5)

. Far more work is needed

to ensure that all women receive basic preventive and primary reproductive health care services,

including preconception and interconception care, comprehensive sexuality education, family

planning and contraception, as well as adequate skilled care during pregnancy, childbirth and

0 1,750 3,500875 Kilometers

Maternal mortality ratio (per 100 000 live births), 2013

Data Source: World Health Organization

Map Production: Health Statistics and

Information Systems (HSI)

World Health Organization

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever

on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities,

or concerning th

e d

elimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines

for which there may not yet be full agreement.

<20

20–99

100–299

300–499

500–999

≥1000

Population <100 000 not included in the assessment

Data not available

Not applicable

FIGURE 1: Maternal mortality ratio (MMR, per 100 000 live births stratied by MMR level)

(4)

Strategies toward ending preventable maternal mortality (EPMM)

the postpartum period. Further attention is needed to develop valid metrics and improve data

quality to measure access to reproductive health for women and girls.

The MDGs mobilized resources as well as political will in countries, and made global commitments

to improve sexual and reproductive health, and maternal and child survival to an unprecedented

degree. They demonstrated that shared global goals, targets and strategies could galvanize

the concerted eort needed to achieve measurable progress. Low- and middle-income coun-

tries that have made rapid progress toward achieving MDG 5 used unique strategies tailored to

local needs and contexts. They all used multisector approaches and catalytic strategies to trans-

late evidence into strong programming based on clearly articulated guiding principles

(6)

. The

progress made has brought the “grand convergence” of health outcomes into view, making it

possible to envision a world in which low-, middle- and high-income countries have compara-

ble rates of maternal mortality

(2)

At the same time, there are signicant lessons to be learned. The MDG framework has been crit-

icized for giving rise to a fragmented approach to health planning that has not encouraged

intersectoral collaboration or programme integration to improve coordination, innovation and

eciency. Furthermore, the MDGs paid insucient attention to development principles, such as

human rights, equity, poverty reduction, empowerment of women and girls and gender equality.

The focus on national averages may have resulted in prioritization of conditions and populations

that were most easy to address rather than elimination of health disparities among vulnerable

subgroups

(7)

Way forward

The changing trends in population demographics and the global disease burden will impact

maternal risk and inuence the strategies that countries implement to end preventable mater-

nal deaths.

The “obstetric transition” concept was adapted from classic models of epidemiologic transitions

experienced as countries progress along a trajectory towards development. Applied to mater-

nal and newborn health care, countries pass through a series of stages that reect health system

status and the shift in primary causes of death as reductions in the rate of maternal mortal-

ity are achieved. In theory, as development progresses, bringing declines in fertility and overall

maternal mortality, the causes of death shift from direct causes and communicable diseases to

a greater proportion of deaths from indirect causes and chronic diseases

(3)

. In practice, this

shift is observable in recent estimates of global maternal causes of death

(8)

. Dierent primary

causes of death require dierent strategies and interventions. The stages described in the obstet-

ric transition model can provide guidance on the most urgent health priorities and focal areas

for improvement at various levels of MMR. Improved understanding of the causes of death in

each context through maternal death surveillance and response (MDSR), condential enquires,

and other methods for counting every death will provide more information to plan targeted

interventions.

An important corollary to this model is the need for dynamic planning that both accounts for

immediate priorities and projects future needs as countries move toward EPMM. Countries

with very high MMR would need to focus strategies on family planning, tackling direct causes

Strategies toward ending preventable maternal mortality (EPMM)

of maternal mortality, and improving basic social and health system infrastructure and mini-

mum quality of care. Countries with lower MMR face a dierent set of primary risks and health

system challenges; their strategies must shift to address noncommunicable diseases and other

indirect causes, social determinants of poor health, humanization of care, and the over-use of

interventions. Countries in the middle MMR ranges face simultaneous challenges of infectious

and noncommunicable conditions that have an impact on maternal health and survival. While

equity is an important concern at all levels, as average mortality rates fall, special attention must

be laid on eliminating disparities among vulnerable subgroups.

Therefore, EPMM must have a framework that is specic to oer real guidance for strategic plan-

ning by policy makers and programme planners, yet exible to be meaningfully interpreted and

adapted for maximal eectiveness in the various country contexts in which it must be imple-

mented. An intensive consultative process has informed the development of EPMM targets and

strategies to fulll this objective (see Annex 1).

Box 1: Population dynamics

Changing demographics will have signicant implications for programme planning and ser-

vice delivery in the decades to come. The population inux into cities and increased number

of people living in urban slums may well change how people demand and access health

services. Increase in people around the world moving to cities resulted in 55 million new

slum dwellers globally since 2000. These are shifting needs that pose a challenge for coun-

try planners and health systems. According to UN Habitat statistics, sub-Saharan Africa has

a slum population of 199.5 million, South Asia 190.7 million, East Asia 189.6 million, Latin

America and the Caribbean 110.7 million, Southeast Asia 88.9 million, West Asia 35 million

and North Africa 11.8 million

(9)

Factors such as rapid urbanization, political unrest in conict areas, changes in fertility rates,

or growing numbers of institutional births change the panorama of maternal risk and call for

reappraisal of a country’s maternal health strategy and programme priorities. Privatization

and decentralization of health care delivery systems are responses to changing population

dynamics whose eects must be studied

(10)

. Countries need tools to identify current pro-

gramme priorities based on the most frequent direct causes and determinants of maternal

death in their context. Immediate, medium term and long range planning are needed to

project health system infrastructure, commodities and maternity care workforce that can

meet these evolving needs, along with a rational framework for their allocation. A single

maternal health strategy will not be adequate for every country, or within each country over

time and for all subpopulations.

Strategies toward ending preventable maternal mortality (EPMM)

Targets for maternal mortality

reduction post-2015

Maternal health stakeholders strongly support the continued need for a specic target for mater-

nal mortality reduction in the post-2015 development framework, with the ultimate goal of

ending all preventable maternal deaths. To achieve this goal, progress needs to be accelerated

as well as concerted national/global eorts and global targets are needed to reduce disparities

in maternal mortality between countries. Within countries, national targets and plans must also

address disparities among subgroups to help achieve both national and global equity, and a

“grand convergence” in maternal survival.

Global targets to increase equity in global MMR reduction

By 2030,

all

countries should reduce MMR by at least two thirds of their 2010 baseline level. The

average global target is an MMR of less than 70/100 000 live births by 2030. The supplemen-

tary national target is that

country should have an MMR greater than 140/100 000 live births

(a number twice the global target) by 2030.

Achieving the above post-2015 global target will require an average global ARR in MMR of 5.5%,

similar to the current MDG 5a target. To achieve the global target all countries must contrib-

ute to the global average by reducing their own MMR from the estimated 2010 levels (based on

forthcoming maternal mortality estimates 1990–2015 developed by the Maternal Mortality Esti-

mation Inter-Agency Group (MMEIG)).

Intensied action is called for in countries with the highest MMRs who will need to reduce their

MMR at an ARR that is steeper than 5.5%. However, the secondary target is an important mech-

anism for reducing extremes of between-country inequity in global maternal survival. Countries

with the lowest MMRs nd it dicult to achieve a two third reduction from the baseline. It is rec-

ognized that when the absolute number of maternal deaths is very small, dierences become

statistically meaningless, hampering comparisons. However, even in these countries, there are

likely to be subpopulations with high risk of maternal death, and thus achieving within-country

equity in maternal survival would be an important goal.

These targets while ambitious are feasible given the evidence of progress achieved over the past

20 years. They will focus attention on maternal mortality reduction and maternal and newborn

health as critical components of the post-2015 development agenda. The process for setting

these targets and the choice of indicators are articulated elsewhere

(11,12)

Country targets to increase equity in global MMR reduction

To prioritize equity at the country level, expanded and improved equity measures should be

developed to accurately track eorts to eliminate disparities in MMR between subpopulations

within all countries.

Strategies toward ending preventable maternal mortality (EPMM)

Country targets: The MMR target of less than 70 by 2030 applies at the global level but not neces-

sarily for individual countries. The following sets of national targets are recommended (Figure 2).

•

For countries with MMR less than 420 in 2010 (the majority of countries worldwide): reduce

the MMR by at least two thirds from the 2010 baseline by 2030.

• For all countries with baseline MMR greater than 420 in 2010: the rate of decline should

be steeper so that in 2030, no country has an MMR greater than 140.

•

For all countries with low baseline MMR in 2010: achieve equity in MMR for vulnerable pop-

ulations at the subnational level.

Target-setting is accompanied by the need for improved measurement approaches and data

quality to allow more accurate tracking of country progress as well as causes of death. To

contextualize the targets and allow collaborative strategic planning and best practice sharing

at the regional level, it may be appropriate, in some regions, to dene more ambitious targets.

Establishment of an interim milestone to track progress toward

the ultimate MMR target

To help countries monitor progress toward individual national targets for 2030 and evaluate the

eectiveness of their chosen mortality reduction strategies, a major interim milestone is pro-

posed for 2020. This will be set based on the nal 2015 MMR estimates, which will determine the

2010 baseline MMR for the post-2015 targets at both the global and national levels.

Country 3

Country 2

Country 1

Global

reduction > 2 ⁄ 3

(ARR ~5.5%)

103

600

500

400

300

200

100

1990 2000 20202010 2030

MMR per 100,000 live births

Countries with baseline

MMR <420

ARR: annual rate of reduction.

Source: WHO, 2014b

Country C

Country B

Country A

Global

1000

800

600

400

200

1990 2000 20202010 2030

MMR per 100,000 live births

Countries with baseline MMR >420

140

FIGURE 2: MMR reduction at country level

Strategies toward ending preventable maternal mortality (EPMM)

Strategic framework for policy

and programme planning to

achieve MMR targets

Laying the foundation for the strategic framework

The contribution of maternal, newborn and child health for sustainable development

EPMM is a pillar of sustainable development, considering the critical role of women in families,

economies, societies, and in the development of future generations and communities. Investing

in maternal and child health will secure substantial social and economic returns. A recent analy-

sis suggests that increasing health expenditure by just US$ 5 per person per year through 2035

in the 74 countries that account for the bulk of maternal and child mortality could yield up to

nine times that value in social and economic benets

(13)

Focusing on implementation eectiveness as the foundation for a paradigm shift

A paradigm shift for the next maternal health agenda rests on a strong foundation of imple-

mentation eectiveness, which marries a well-considered strategic policy framework with a

ground-up focus on implementation performance that accounts for contextual factors, health

system dynamics and social determinants of health.

Eective care for women and girls, as well as mothers and newborn must draw upon intersec-

toral collaboration and cooperation at every stage, given the vital linkages between MMR and

a country’s water, sanitation and hygiene (WASH) systems, transportation and communication

infrastructure, and educational, legal and nance systems. It must be responsive to local condi-

tions, strengths and barriers, and address implementation needs and challenges from the ground

up. Programme planning must be people-centric, i.e. driven by people’s aspirations, experiences,

choice and perceptions of quality

(14)

. Care services must be based on respect for women’s and

girls’ agency, autonomy, and choice.

Eective programme planning must be wellness-focused and population-based, providing sup-

portive primary and preventive care to the majority of women who are essentially healthy so

that they can experience planned, uncomplicated pregnancies and births, while ensuring that

high risk pregnancies and complications are recognized early, and interventions when indi-

cated are undertaken in an appropriate and timely manner. Care must therefore emphasize the

framework of availability, accessibility, acceptability and quality of services (AAAQ), as well as

other human rights standards, such as participation, information and accountability, which are

ensured through cultivation of a robust enabling environment.

Eective service delivery integrates the delivery of key interventions across the sexual, reproduc-

tive, maternal, newborn, child and adolescent health (SRMNCAH) spectrum whenever possible,

to lower costs while increasing eciencies and reducing duplication of services

(15).

At the same

Strategies toward ending preventable maternal mortality (EPMM)

time it will meet the health and social needs of women and communities, and support the goal

of people-centric health care. Reproductive and maternal health policy makers and planners

must prioritize adequate resources and eective health care nancing, while ensuring that ser-

vice delivery is cost-ecient.

To be eective for

every

woman, mother and newborn, SRMNCAH care must adopt a rights-based

approach to planning and implementation, situating health care within a broader framework of

equity, transparency and accountability, including mechanisms for participation, monitoring and

redress. Furthermore, improved metrics, measurement systems and data quality are needed to

ensure that all maternal and newborn deaths and stillbirths are counted, and that other impor-

tant processes, structures and outcome indicators of AAAQ are tracked.

Guiding principles, cross-cutting actions and strategic

objectives for policy and programme planning

The following strategic framework reects the contributions and support of a wide stakeholder

base, under which key interventions and measures of success must be developed.

Box 2: Ultimate goal of EPMM

Guiding principles for EPMM

• Empower women, girls and communities.

• Protect and support the mother–baby dyad.

•

Ensure country ownership, leadership and supportive legal, regulatory and nancial frameworks.

• Apply a human rights framework to ensure that high-quality reproductive, maternal and new-

born health care is available, accessible and acceptable to all who need it.

Cross-cutting actions for EPMM

• Improve metrics, measurement systems and data quality to ensure that all maternal and new-

born deaths are counted.

• Allocate adequate resources and eective health care nancing.

Five strategic objectives for EPMM

• Address inequities in access to and quality of sexual, reproductive, maternal and newborn

health care.

• Ensure universal health coverage for comprehensive sexual, reproductive, maternal and new-

born health care.

• Address all causes of maternal mortality, reproductive and maternal morbidities, and related

disabilities.

• Strengthen health systems to respond to the needs and priorities of women and girls.

• Ensure accountability to improve quality of care and equity.

Strategies toward ending preventable maternal mortality (EPMM)

Guiding principles for EPMM

Empower women, girls, families and communities

Prioritizing the survival and health of women and girls requires recognition of their high value

within society through attention to gender equality and empowerment. This includes strategies

to ensure equal access to resources, education (including comprehensive sexuality education),

and information, and focused eorts to eliminate gender-based violence and discrimination,

including disrespect and abuse of women using health care services. Gender-based violence is

widespread around the world and aects the reproductive health of women and girls throughout

their lives. Its adverse consequences include unwanted pregnancies, pregnancy complications

including low birth weight and miscarriage, injury and maternal death, and sexually transmitted

infections, such as human immunodeciency virus infection (HIV)

(16)

Strategies for empowering women in the context of their reproductive and maternal health

care must ensure that they not only have the power of decision making but also the availabil-

ity of options that allows them to exercise their choices. Achieving substantive equality calls

for governments to address structural, historical and social determinants of health and gen-

der discrimination, including economic inequality and workplace discrimination, and to ensure

equal outcomes for women and girls

(17,18)

. Evidence shows that when girls exercise their rights

to delay marriage and childbearing and choose to advance in school, maternal mortality goes

down for each additional year of study they complete

(19,20)

. These and other interventions that

develop women’s capacity to care for and choose for themselves contribute to empowerment,

which includes autonomy over their own reproductive lives and health care decisions, access to

health care services and options, and the ability to inuence the quality of services through par-

ticipatory mechanisms and social accountability. Supporting women’s ability and entitlement to

make active decisions also positively inuences the health of their children and families.

People are empowered to participate in and inuence how the health system works when they

are included as true partners in accountability mechanisms, and when participatory processes

are instituted for identifying factors that aect women and girls seeking care. Numerous stud-

ies have also shown that engaging men and boys as supporters and change-agents can improve

the health of families and entire communities

(21)

. In addition to education, information and tra-

ditional or social media campaigns, these critical dimensions of a framework for empowerment,

can help change social norms in families and communities.

Integrate maternal and newborn care, protect and support the

mother–baby relationship

The health outcomes for mothers and their newborn and children are inextricably linked; mater-

nal deaths and morbidities impact newborn and child survival, growth and development

(22)

Therefore, an integral part of the framework is to protect and support the mother–baby rela-

tionship and to encourage the integration of strategies and service delivery for both, including

linkage of vital registration data collected for mothers and their newborn and prevention of

mother-to-child transmission of HIV. In eect, any policy or programme that focuses on either

Strategies toward ending preventable maternal mortality (EPMM)

maternal or newborn health should include consideration of the other. This is the principle of

“survival convergence”

(23)

It is important to recognize the special signicance of the mother–baby relationship. Newborn

health outcomes are enhanced when necessary care is provided without separation of the baby

from its mother. Such integration of care is also more acceptable to women and families, and e-

cient for the health system. Maternal and newborn health services should be delivered together

whenever this can be done without compromising quality of care for either.

Prioritize country ownership, leadership and supportive legal,

regulatory and nancial mechanisms

The strategic framework for maternal and newborn health prioritizes country ownership, lead-

ership, and supportive legal, regulatory and nancial frameworks to ensure that strategies for

EPMM transcend policy and translate into action within countries. A key focus of this principle

is good governance and eective stewardship of the full array of political tools, social capital

and nancial resources available to support and enable a high-performing health system. Trans-

parent, publicly available information on maternal health budgets and policies is needed to

promote accountability and deter corruption.

Country ownership applies to leaders and policy makers, and also extends to civil society through

community input and participation. Community engagement and mobilization are enhanced

through social accountability mechanisms that encourage women and communities to partici-

pate in the system and play their part to ensure that maternal and newborn health care is AAAQ,

and is organized to respond to their health needs as well as their values and preferences

(24)

Strong leadership encourages an enabling environment to facilitates policies and nancial com-

mitments by country leaders, and also development partners and funders. Strong leadership is

also critical to champion global and country MMR targets, enable all countries to make contin-

uous progress through the stages of the obstetric transition, and develop and maintain health

care systems that can reliably and equitably deliver the necessary care to end preventable mater-

nal deaths.

Supportive legal mechanisms include laws and policies that uphold human rights in the con-

text of maternal health care, laws that guarantee access to comprehensive maternal health care

and provide for universal health coverage (UHC), mechanisms for legal redress for those harmed,

abused or abandoned in the course of seeking care, as well as supportive employment laws and

frameworks for legal licensure of the maternity care workforce within the jurisdictions where

they are needed

(25–28)

. Supportive legal mechanisms also extend beyond the arena of health

care service organization and delivery to include laws that address gender discrimination and

empower women and girls, for example, by prohibiting early marriage.

Supportive regulatory mechanisms enable eective human resources management of the nec-

essary workforce, such as regulation of midwives, nurses and doctors, and guide task sharing

with the goal of increasing timely access to quality care including interventions for prevention

and management of complications. The collection of vital statistics and improved data on causes

of maternal and newborn deaths and stillbirths through MDSR can also be supported through

facilitative regulatory mechanisms.

Strategies toward ending preventable maternal mortality (EPMM)

Supportive nancial mechanisms aimed at achieving UHC include conditional cash transfers,

voucher programmes, various forms of insurance and performance-based incentives. Support-

ive nancial mechanisms can also refer to donor harmonization and eorts by donors to ensure

that funding does not impose structural barriers to the achievement of important outcomes not

readily measured within short funding cycles or along vertical technical and programme lines.

Apply a human rights framework to ensure that high-quality

sexual, reproductive, maternal and newborn health care is

available, accessible and acceptable to all who need it

The Oce of the High Commissioner for Human Rights (OHCHR) supports the various human

rights monitoring mechanisms within the UN system. These treaty-monitoring bodies have con-

sistently viewed maternal mortality as a human rights issue. The Committee on the Elimination

of Discrimination against Woman (CEDAW), the Human Rights Committee and the Committee on

the Rights of the Child have each explicitly interpreted the right to life to include an obligation

to prevent and address maternal mortality

(29–31)

. CEDAW has armed that an important indi-

cator of states’ realization of women’s rights is whether they ensure equality of health results for

women – including lowering of maternal mortality rate

(32)

. Treaty monitoring bodies have also

highlighted the prevention of maternal mortality and the provision of maternal health services

within state obligations to fulll the right to health

(33,34)

. The Committee on Economic, Social

and Cultural Rights has explicitly indicated that states’ obligations to ensure maternal health care

for women – which includes pre-natal and post-natal care – is a core obligation under the right

to health

(35)

. Treaty monitoring bodies have also linked elevated rates of maternal mortality to

lack of comprehensive reproductive health services

(36)

, restrictive abortion laws

(37)

, unsafe or

illegal abortion

(38,39)

, adolescent childbearing

(40)

, child and forced marriage

(41)

and inade-

quate access to contraceptives

(42)

The United Nations Human Rights Council (HRC) has also recognized high rates of maternal mor-

tality and morbidity as unacceptable and a violation of human rights. Its resolution emphasizes

that maternal mortality is not solely a health and development issue, but also a manifestation of

various forms of discrimination against women

(26)

. International human rights standards require

governments to take steps to “improve child and maternal health, sexual and reproductive health

services, including access to family planning, pre- and post-natal care, emergency obstetric ser-

vices and access to information, as well as to resources necessary to act on that information”.

Where resources are limited, states are expected to prioritize certain key interventions, including

those that will help guarantee maternal health and in particular emergency obstetric care

(43)

However, a human rights approach to maternal and newborn health extends beyond the provi-

sion of services to embrace a broader application of rights-based principles aimed at protecting

and supporting the health of populations. The OHCHR in its guidance for addressing maternal

mortality and morbidity using a rights-based approach includes empowerment, participation,

non-discrimination, transparency, sustainability, accountability and international assistance as

fundamental principles. Furthermore, this OHCHR guidance specically highlights enhancing the

status of women, ensuring sexual and reproductive health rights including addressing unsafe

abortion, strengthening health systems and improving monitoring and evaluation as necessary

elements of a rights-based strategic framework for reducing maternal mortality and morbidity

(44)

Strategies toward ending preventable maternal mortality (EPMM)

As it becomes possible to envision an end to preventable maternal and newborn deaths, the

scope of strategic planning must move beyond focusing solely on prevention of worst out-

comes for ‘women at highest risk’ towards supporting and encouraging optimal outcomes

for ‘all women’. Thus, the topmost priorities of a health agenda for a sustainable future must

include educating and empowering women and girls, gender equality, poverty reduction, uni-

versal coverage and access, and equity within the overall context of a rights-based approach to

health and health care. This re-orientation towards optimal health for all requires a fundamen-

tal paradigm shift.

Strategies toward ending preventable maternal mortality (EPMM)

Cross-cutting actions for EPMM

Improve metrics, measurement systems and data quality

A key aim of improving measurement systems is to ensure that all maternal and newborn deaths

are counted. Only an estimated one third of countries have the capacity to count or register

maternal deaths

(45)

. Less than two fths of all countries have a complete civil registration system

with accurate attribution of the cause of death, which is necessary for the accurate measurement

of maternal mortality

(4)

. In 2011, only two of the 49 UN least developed countries had over 50%

coverage of death registration

(46)

Today, estimation is necessary to infer MMRs in many countries where little or no data are avail-

able; unfortunately, these countries are the very ones where mortality and severe morbidity are

often highest due to weak health infrastructure. Because countries around the world do not use

standardized instruments and indicators to track maternal mortality, estimation must presently

be used to make international comparisons and measure progress towards global targets. Esti-

mates that are adjusted using models that allow comparability and make up for missing data

yield dierent point estimates than countries’ own data sources, which causes confusion and

consternation.

A cross-cutting priority for the post-2015 strategy is to move towards counting every maternal

and perinatal death through the establishment of eective national registration and vital sta-

tistics systems in every country, as articulated within the recommendations of the Commission

for Information and Accountability

(28)

. This will require implementation of a revised stand-

ard international death certicate that clearly identies deaths in women of reproductive age

and their relationship to pregnancy, and standard birth and perinatal death certicates (still-

births and newborn deaths up to 28 days of age). Ideally, these registries should link the data of

mothers and their newborns. Standard denitions (with standardized numerators and denom-

inators) for coding and reporting maternal deaths and indirect obstetric deaths must be used

both within and across countries for an accurate understanding of the causes of death and to

allow valid comparisons; thus all countries should adopt denitions that are consistent with the

current International Classication of Diseases manual. The World Health Organization (WHO)

has claried the application of these denitions to deaths during pregnancy, childbirth and the

puerperium

(47)

. MDSR and similar perinatal death surveillance, including condential inquiries

and collection of quality of care data on near misses and severe morbidities are also important

mechanisms for ensuring that every death is counted.

There are other equally important uses for improved metrics and measurement systems, includ-

ing for the purpose of accountability to track equity and to ensure programme eectiveness.

Indicators for equity that need to be developed should not overburden data collection sys-

tems, specically at facility level. Agreement on programme coverage indicators is needed to

measure quality and eectiveness of care

(48)

; these data could be used also for accountabil-

ity, e.g. through auditing and feedback. In addition to standardized data sources, indicators and

intervals for data collection to allow for better global comparisons, and the local use of data for

ensuring quality of care and health system accountability in clinical programmes are important

Strategies toward ending preventable maternal mortality (EPMM)

components of programme eectiveness. New technologies for data collection (e.g. mapping,

mobile phones) with shown eectiveness could also speed up data collection to allow eective,

real-time use.

Prioritize adequate resources and eective health care nancing

The imperative to prioritize adequate and sustainable resources for maternal and newborn health

refers both to development partners and donors in the global community, and to political lead-

ers and nancial decision makers in countries. It encompasses adequate budgetary allocation

through specic, transparent budget lines for maternal and newborn health. It includes health

care nancing for UHC as well as innovative nancing mechanisms and incentives to ensure

equity, increase coverage and improve quality. Intersectoral collaboration beyond the health

sector is a critical success factor for EPMM. Close partnership with the nancial sector is a vital

component of intersectoral collaboration, and must include both public and private national

health care players, ministries of nance, and private as well as bilateral global development

partners and donors.

A multistakeholder nancing group led by The World Bank has issued a concept note for a Global

Financing Facility (GFF) for SRMNCAH from 2015 to 2030. Elaborating on analyses published

in two recent reports

(13,49)

, the GFF lays out a framework for achieving the aforementioned

“grand convergence” between low- and high-income countries for these health outcomes by

2030. The framework projects domestic contributions and estimates the gap nancing needed

by donors to achieve high coverage for SRMNCAH by 2030 in the 75 countries in which 98% of

maternal and newborn deaths occur

(50)

. According to this framework, low- and middle-income

countries should allocate at least 3% of their gross domestic product to general government

health expenditures of which at least 25% (and up to 50%) should be allocated to SRMNCAH.

Global funders should make up the funding gap, which is estimated to range from US$ 5.24 per

person in 2015 to US$ 1.23 per person in 2030

(51)

Budget transparency, assured through budget monitoring, analysis and advocacy, is an impor-

tant way for civil society beneciaries to verify that policy commitments made are in fact fullled.

A human rights approach to monitoring maternal health budgets ensures that policy deci-

sions, including allocation of nancial resources, are carried out on the basis of transparency,

accountability, non-discrimination and participation

(52)

. The Commission on Information and

Accountability for Women’s and Children’s Health recommends that countries track and report

at least two indicators:

(i) total health expenditure by nancing source, per capita; and

(ii) total reproductive, maternal, newborn and child health expenditure by nancing source, per

capita

(28)

Eective health care nancing includes exploration of nancial incentives and other economic

measures for improving AAAQ to women, families and communities. While some nancial incen-

tives have been shown to increase the utilization of maternal and newborn health services and

oer promise in their ability to improve quality and equity, some have had unintended adverse

eects and more studies are needed to ascertain the full impact of nancial incentives on mater-

nal health outcomes

(53)

Strategies toward ending preventable maternal mortality (EPMM)

Box 3: Rationale and scope of strategic objectives for EPMM

Progress toward EPMM necessitates a comprehensive approach along the continuum of

care for each pregnancy and throughout each woman’s reproductive years. The approach

should address not only the causes of maternal death, but also the social and economic

determinants of health and survival.

It calls for a system-level shift from maternal and newborn care that is primarily focused on

identication and treatment of pathology for the minority, to skilled and wellness-focused

care for all. This includes preventive and supportive care to: strengthen women’s own capa-

bilities in the context of respectful relationships, be responsive to their needs, focus on

promotion of normal reproductive processes, provide rst-line management of complica-

tions and accessible emergency treatment when needed. This approach requires eective

interdisciplinary teamwork and integration across facility and community settings. Findings

of a new Lancet special series suggest that midwifery is central to this approach

(54)

The comprehensive maternal health strategic framework presented here for inclusion in

the post-2015 sustainable development agenda applies across the full continuum of health

care that is relevant to the goal of ending preventable maternal and newborn mortality, and

maximizing the potential of every woman and newborn to enjoy the highest achievable

level of health. This includes sexual, reproductive, maternal and newborn health care, and

comprises adolescent health, family planning and attention to the infectious and chronic

noncommunicable diseases that contribute directly and indirectly to maternal mortality.

Furthermore, the human rights approach that is a fundamental guiding principle of this

strategic framework extends beyond solely the organization and provision of clinical ser-

vices to include focused attention to broader human rights issues that contribute to the

social determinants of health, such as the status of women and gender equality, poverty

reduction, universal coverage and access, as well as non-discrimination and equity.

This strategic framework is intended to provide meaningful and useful guidance to inform

programme planning for EPMM and optimal maternal and newborn health. Given the reality

of nite resources and limited capacities, not every desired intervention can be undertaken

immediately, and some interventions will be more eective than others. Thus, decision

makers have to make rational choices about priorities and phasing, bearing in mind the

human rights principle of progressive realization – the obligation to do everything that is

immediately possible given the constraints of limited resources. The principle of progressive

realization also outlines obligations that are immediate regardless of resources, for example,

the immediate obligation to take action to eliminate discrimination.

The key interventions for EPMM are known; thus the post-2015 maternal health strategy is

not a list of prescribed technical interventions. Countries must now go beyond doing the

right things to do things right. Alongside eective clinical interventions, it is important to

pay attention to the non-clinical aspects of respectful maternity care. The development of

health systems that can deliver the correct interventions both eectively and equitably,

with reliable high quality under conditions that are dynamic is a priority. Moreover, a rm

grounding in implementation eectiveness is important, since programme priorities are

Strategies toward ending preventable maternal mortality (EPMM)

subject to change as countries move through stages in their transition to lower levels of

maternal mortality.

The strategic framework for EPMM is intentionally non-prescriptive. It oers broad strategic

objectives rather than a detailed list of clinical interventions; interventions and measures

of success must be tailored to the country and selected based upon local context including

epidemiology, geography, health systems capacity and available resources. Each strategic

objective includes illustrative examples of global best practices that need to be adapted,

adopted and monitored to ensure that they are eective in context. Thus, the strategy

emphasizes the importance of short term, medium term and long range programme plan-

ning to achieve and maintain high-performing systems that can deliver improved outcomes.

Strategies toward ending preventable maternal mortality (EPMM)

Elaboration of the ve

strategic objectives to guide

programme planning towards

EPMM

1. Address inequities in access to and quality of sexual,

reproductive, maternal and newborn health care

All countries should increase eorts to reach vulnerable populations with high-quality primary

and emergency SRMNCAH services. Disparities in access to and quality of health care exist wher-

ever there is a factor (such as wealth, geography, gender, ethnicity, class, caste, race, religion) that

places some people at a social disadvantage relative to others and puts them at risk for stigma,

discrimination and unequal treatment. In the context of reproductive, maternal and newborn

health it includes disrespect and abuse of women who seek maternity care in facilities or from

skilled providers. Vulnerable populations include: the urban and rural poor; adolescents; com-

mercial sex workers; people who are marginalized; the socially excluded; lesbian, gay, bisexual,

and transgender population; those living with disabilities or HIV; immigrants; refugees; those

in conict/post-conict areas; as well groups who experience disparities regularly. These dis-

parities must rst be recognized and analysed at a basic level to determine how health system

operations, planning and programming for maternal health, and service distribution result in

inequitable health outcomes so they can be addressed and eliminated.

Governments and technical experts should improve the availability and eective use of data on

inequities and their eect on reproductive and maternal health. Valid equity indicators must be

developed. Disaggregated data on them should be routinely collected and used to understand

the determinants of inequities and to design, implement and monitor interventions to elimi-

nate them.

Programme planners should promote equitable coverage and equal access to sexual, reproduc-

tive, maternal and newborn health care services through better eorts to understand the unique

challenges and needs of subpopulations within societies to achieve substantive equality. This

includes identifying and addressing barriers to access – nancial, legal, gender, age, cultural,

geographic or based on fear of disrespectful care – and understanding the factors, including

values and preferences, that make care acceptable to all who need it and encourage sustained

demand at scale. It also means ensuring that an adequate workforce is available to provide the

full range of SRMNCAH care to all subpopulations. This may include workforce analysis and long

range planning, subsidies to representatives of vulnerable populations for health professional

education, human resources incentives to encourage placement and retention in underserved

communities, and task sharing to extend the reach of essential services.

Strategies toward ending preventable maternal mortality (EPMM)

Health care quality reects the degree to which care systems, services and supplies increase

the likelihood of a positive health outcome

(55)

. Recognizing that inequity in maternal health

includes systematically uneven quality and not just access, eorts must also ensure that the care

that is oered to all populations is of comparably high quality. To this end, governments should

plan, implement and evaluate contextualized policies, programmes and strategies that take into

account inequities and ensure that representatives from disadvantaged groups have a voice in

these processes. This must be part of the eort to understand how to make a global best prac-

tice yield eective, high-quality results in the context in which it is to be implemented and for

all populations.

2. Ensure universal health coverage for comprehensive sexual,

reproductive, maternal and newborn health care

UHC is dened as “all people receiving quality health services that meet their needs without

being exposed to nancial hardship in paying for the services”. This denition encompasses two

equally important dimensions of coverage: reaching all people in the population with essential

health care services, and protecting them from nancial hardship due to the cost of health care

services

(56)

. Particular emphasis must be placed on ensuring access without discrimination,

especially for the poor, vulnerable and marginalized segments of the population

(57)

UHC comprises access without discrimination to essential safe, aordable, eective, quality

medicines as well as to essential health services

(57)

. Governments should determine the set

of essential SRMNCAH covered services and commodities, using evidence of cost-eective-

ness to identify the priority package. Strategic planning must include resource mobilization and

eective service delivery to guarantee that the worst-o in the population are reached with the

essential service package, based on an understanding of population demographics and plan-

ning for the appropriate number of human resources.

A priority for expanding coverage to more people is to identify and remove barriers to utiliza-

tion, and to promote the AAAQ. Countries should develop national strategies to improve care

coverage during labour and childbirth, and expand high-quality, evidence-based service cov-

erage to include preconception and interconception care, family planning, antenatal care and

postpartum care. Standards are needed for the indications and safe use of medical and surgical

interventions, including caesarean section. Development of functioning referral systems is cru-

cial. To achieve these goals, governments and development partners should explore innovative

nancing mechanisms to drive improvements in both coverage and quality. Specic provisions

to protect families accessing emergency obstetric care and emergency newborn care from nan-

cial catastrophe are especially important.

Applying a human rights approach to UHC suggests a pathway to progressive universalism.

Reports from WHO and a Lancet Commission have described a pathway to UHC that could be

achieved within one generation. Governments are called upon to rst institute publicly funded

insurance making essential services available to all without out-of-pocket expenditures, and

later to expand services through progressive mandatory prepayment and pooling of funds with

exemptions for the poor, bolstered by a variety of nancing mechanisms, to cover a larger bene-

ts package

(49,56)

. Transparency and participatory mechanisms to include civil society in both

Strategies toward ending preventable maternal mortality (EPMM)

the decision making process and the monitoring and evaluation of UHC programmes are neces-

sary to maximize ownership and promote accountability.

3. Address all causes of maternal mortality, reproductive and

maternal morbidities and related disabilities

The post-2015 global maternal health strategy cannot prescribe a list of interventions that will

maximize progress towards EPMM in every country. Each country must rst understand the

most important causes of maternal deaths in its population. Programme planning must then

involve prioritization based on analysis of context-specic determinants of risk and health sys-

tems capacity. The stages of a progressive obstetric transition described by Souza and coworkers

provide a framework and suggest programme priorities that may take precedence at each stage

(3)

. This framework cannot be applied indiscriminately but provides a foundation for country-

specic analysis and adaptation based on local ndings. Thus, a clear planning priority is that

countries should improve the quality of certication, registration, notication and review of

causes of maternal death.

While the distribution of major causes of maternal death diers between countries and for sub-

populations within countries, these are well known

(8)

At the same time, recent reports support the notion of a transition from deaths attributable to

direct causes where MMR is very high towards a greater proportion of deaths due to indirect

causes as MMR decreases, necessitating an accompanying shift in country strategies for mater-

nal mortality reduction

(8,58)

. Maternal causes of death that carry stigma, including abortion

and HIV infection, are likely to be underreported or misclassied. Nevertheless, recent analyses

suggest that the number of deaths following unsafe abortion has increased signicantly in sub-

Saharan Africa, even as the global number of maternal deaths attributable to complications of

abortion has fallen due to major decreases in developed countries since 1990. Although HIV-

related deaths in pregnancy accounted for 2.6% of global maternal deaths in 2013, they were

associated with nearly 4% of all maternal deaths in sub-Saharan Africa

(4)

Unmet need for family planning also contributes substantially to maternal mortality. A recent

analysis using maternal mortality estimates from the WHO and data on contraceptive prevalence

from the 2010 UN World Contraceptive Use database suggested that maternal mortality would

have been almost two times higher in 172 countries without contraceptive use at current levels,

indirect (27%)

haemorrhage (27%)

hypertensive disorders (14%)

sepsis (11%)

abortion complications (8%)

embolism (3%)

other direct (10%)

FIGURE 3: Global estimates for causes of maternal mortality 2003–2009

Strategies toward ending preventable maternal mortality (EPMM)

and projected that an additional 104 000 deaths per year could be averted by fullling unmet

need for family planning (a 29% annual reduction globally)

(59)

Structural and social barriers that contribute to maternal death include delays in seeking, access-

ing and receiving appropriate treatment, as well as health system deciencies that compromise

the availability, accessibility or quality of care.

It is estimated that for every maternal death, 20–30 more women experience acute or chronic

pregnancy-related morbidities, such as obstetric stula or depression, which impair their func-

tioning and quality of life, sometimes permanently

(60)

. The true scope of the problem is unknown

due to lack of accurate systems for measurement. A WHO-led Maternal Morbidity Working Group

has agreed on a consensus denition for maternal morbidity (“any health condition attributed to

or complicating pregnancy, childbirth or following pregnancy that has a negative impact on the

woman’s well-being or functioning”) and is working on the development of a measurement tool

(61)

. Countries must develop plans for tracking and treating maternal morbidities, and should

use standard denitions and metrics whenever possible.

Having identied the most important causes of maternal death, as well as the prevalence of key

diseases and malnutrition along with maternal morbidity, the unmet need for family planning,

the capacity and reach of the health system, and the human and nancial resources available,

each country should plan a context-specic strategy for implementing eective interventions

to address them.

Intersectoral coordination is a critical element of country planning to address all causes of mater-

nal mortality at each stage of the obstetric transition. Where MMR is very high, improvement in

basic infrastructure including WASH systems, roads and health care facilities, workforce planning

and education for girls are key areas for intersectoral linkages with maternal health programme

planning. As countries reduce MMR, there is a need to strengthen the recognition and manage-

ment of indirect causes of maternal death, and coordinate with other relevant sectors and health

providers to address care for noncommunicable diseases, develop innovative education, screen-

ing and management approaches for these conditions, as well as appropriate clinical guidelines

and protocols. Quality and appropriateness of care remain important issues, however with a par-

ticular focus on avoiding over-medicalization and harms related to overuse of interventions

(3)

Each strategy should include a systematic approach to implementing evidence-based standards,

guidelines and protocols, and to monitoring and evaluating their outcomes. Countries and devel-

opment partners must agree to collect data on indicators that allow implementers to evaluate

the quality and eectiveness of their care processes. To date, few maternal and neonatal health

programmes in high burden countries have adopted a large-scale process improvement initia-

tive. However, various systematic process improvement methods have shown positive increases

in use of eective interventions

(62)

Although eective interventions exist for the major causes of maternal death, in many contexts

the best available, low-cost, high-impact interventions are not implemented well enough or

widely enough. Governments and development partners should make eective interventions

that address the most prevalent causes of death in the population available at scale by building

on existing successful reproductive and maternal health services, taking into account cost- and

programme-eectiveness.

Strategies toward ending preventable maternal mortality (EPMM)

High-impact evidence-based clinical interventions

Partnership for Maternal, Newborn and Child Health

(PMNCH)

Essential interventions, commodities and guidelines

for reproductive, maternal, newborn and child health

http://www.who.int/pmnch/knowledge/

publications/201112_essential_interventions/en/

PMNCH publications http://www.who.int/pmnch/knowledge/publications/en/

http://www.who.int/pmnch/knowledge/search/en/

http://www.who.int/pmnch/knowledge/tools/en/

http://www.who.int/pmnch/knowledge/databases/en/

WHO

Guidelines on maternal, reproductive and women’s

health

http://www.who.int/publications/guidelines/

reproductive_health/en/

WHO

Guidelines on preconception care

http://www.who.int/maternal_child_adolescent/

documents/concensus_preconception_care/en/

WHO

Reproductive Health Library

http://apps.who.int/rhl/en/

WHO Human Resource Planning (HRP)/Reproductive

Health and Research (RHR)

Clinical and health systems guidance on all aspects of

reproductive health)

www.who.int/hrp/en/

WHO, United Nations Population Fund (UNFPA), United

Nations Children’s Fund (UNICEF), Averting Maternal

Death and Disability (AMDD) program

Monitoring emergency obstetric care: A handbook

http://www.who.int/reproductivehealth/publications/

monitoring/9789241547734/en/

Maternal Health Task Force: PLOS collection on

maternal health

http://www.ploscollections.org/static/maternalhealth

Box 4: Evidence-based resources for planning key interventions

Trustworthy and regularly updated sources for identifying evidence-based, high-impact

clinical interventions, and best available guidance on topics that are critical for eective

health system strengthening are discussed here.

To be eective in the specic context where it is to be implemented, each country’s plan

must be customized to t its own population health needs, health system capacity and

available resources. Moreover, it is likely that the priority interventions for each country will

change over time as the variables in the planning equation shift and as best available evi-

dence on eective clinical interventions evolves.

Therefore, country planners must analyse their context-specic needs, research the best

currently available evidence on eective interventions to meet those needs, and apply a

rational framework for prioritizing essential services and scaling up. Each country’s frame-

work will need to be revisited at regular intervals to track progress, reassess the underlying

assumptions and adjust the plan as needed.

Strategies toward ending preventable maternal mortality (EPMM)

Geneva Foundation for Medical Education and

Research

Obstetrics, gynecology and reproductive medicine:

Guidelines, reviews, position statements,

recommendations, standards

http://www.gfmer.ch/Guidelines/Obstetrics_

gynecology_guidelines.php

Nutrition

WHO

e-Library of Evidence for Nutrition Actions

http://www.who.int/elena/en/

http://www.who.int/nutrition/publications/en/

http://www.who.int/nutrition/topics/en/

http://www.who.int/nutrition/gina/en/

http://www.who.int/nutrition/nlis/en/

Water, sanitation and hygiene (WASH)

WHO

Water, sanitation, hygiene

http://www.who.int/water_sanitation_health/

publications/en/

http://www.who.int/water_sanitation_health/hygiene/en/

http://www.who.int/water_sanitation_health/hygiene/

settings/ehs_hc/en/

OHCHR

On the right track: good practices in realizing the rights

to water and sanitation

http://www.ohchr.org/EN/Issues/WaterAndSanitation/

SRWater/Pages/GoodPractices.aspx

Commodities

UN Commission on Life-Saving Commodities for

Women and Children Commissioners’ Report

http://www.unfpa.org/public/home/publications/

pid/12042

Maternity care workforce

WHO

Optimizing health worker roles to improve access

to key maternal and newborn health interventions

through task shifting

http://www.who.int/reproductivehealth/publications/

maternal_perinatal_health/978924504843/en/

WHO

Increasing access to health workers in remote and rural

areas through improved retention

http://www.who.int/hrh/retention/guidelines/en/

UNFPA

State of the World’s Midwifery Report 2014

http://unfpa.org/public/home/publications/pid/17601

Global Health Workforce Alliance

Knowledge Centre (multiple publications)

http://www.who.int/workforcealliance/knowledge/en/

Facility readiness and basic infrastructure

WHO

Service availability and readiness assessment

http://www.who.int/healthinfo/systems/

sara_introduction/en/

http://www.who.int/healthinfo/systems/

sara_reference_manual/en/

http://www.who.int/healthinfo/systems/

sara_implementation_guide/en/

Strategies toward ending preventable maternal mortality (EPMM)

WHO

Global Health Observatory

Health infrastructure

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devices/health care_infrastructure/en/

WHO

Public health and infrastructure

http://www.who.int/trade/distance_learning/gpgh/

gpgh6/en/

WHO

Operations manual for delivery of HIV prevention,

care and treatment at primary health centres in high-

prevalence, resource-constrained settings

http://www.who.int/hiv/pub/imai/operations_manual/en/

Scaling up eective interventions

WHO, Global Health Workforce Alliance

Scaling up, saving lives (report)

http://www.who.int/workforcealliance/knowledge/

resources/scalingup/en/

WHO-ExpandNet

Beginning with the end in mind: planning pilot

projects and other programmatic research for

successful scaling up

http://www.who.int/reproductivehealth/publications/

strategic_approach/9789241502320/en/

K4Health

Guide to fostering change to scale up eﬀective health

services

https://www.k4health.org/toolkits/fostering-change

Institute for Health care Improvement (IHI)

The breakthrough series: IHI’s collaborative model for

achieving breakthrough improvement

http://www.ihi.org/resources/Pages/IHIWhitePapers/

TheBreakthroughSeriesIHIsCollaborativeModelfor

AchievingBreakthroughImprovement.aspx

WHO, UNAIDS, UNICEF

Towards universal access: scaling up priority HIV/AIDS

interventions in the health sector. Progress report 2010

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en/

WHO

Strategic approach to strengthening sexual and

reproductive health

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strategic_approach/RHR_07.7/en/

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innovations

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innovations to policies and programmes

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Health system strengthening

PMNCH

Success factors for women’s and children’s health:

multisector pathways to progress

http://www.who.int/pmnch/successfactors/en/

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Health systems topics: about health systems

HSS publications

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Strategies toward ending preventable maternal mortality (EPMM)

Alliance for Health Policy and Systems Research

Publications

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A compilation of institutions producing synthesis

documents

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alliancehpsr_hpsrsynthesis.pdf?ua=1

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Implementation research platform

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implementationresearch/en/

4. Strengthen health systems to respond to the needs and

priorities of women and girls

For health systems to respond to the priorities and the needs of women and girls, they must

be seen as social institutions in addition to delivery systems for clinical care interventions, with

the capacity to either marginalize people or enable them to exercise their rights. This complex-

ity reects the conceptualization of health systems as being made up of both “hardware and

software”

(63)

. The “hardware” of a health system represents the basic health system building

blocks that include service delivery, health workforce, information, medical products and tech-

nologies, health care nancing, and nally, leadership and governance or stewardship

(64)

. The

“software” describes the human relationships, desires and values, roles and norms, power struc-

ture and meanings, both explicit and implicit, that actors and users assign to the health system.

Health system strengthening must include both the hardware (such as ensuring the availabil-

ity of essential health infrastructure, amenities and commodities), and the software (including

attention to organizational development and management, improving transparency and coun-

tering corruption, ensuring mechanisms for participation and community engagement and

prioritizing respectful care norms and values).

Systems thinking can help countries understand the constraints and areas of weakness within

the health system, and to apply this understanding to design and evaluate interventions that

improve health and health equity. Engaging all stakeholders is critical because in a complex

adaptive system, “every intervention, from the simplest to the most complex, has an eect on

the overall system, and the overall system has an eect on every intervention”

(65).

Priorities

in the area of service delivery include, expanding health promotion and preventative services,

and improving integration of all forms of care for women, newborns and adolescents. Of par-

ticular importance is the integration of prevention, screening, and treatment for infectious and

noncommunicable diseases (e.g. HIV, malaria, cardiovascular disease, depression) into routine

SRMNCAH care. Ensuring basic service availability and readiness at the facility level entails reg-

ular assessment and verication that essential health infrastructure and amenities are in place

and functioning to the level of need. Basic amenities include an adequate number of beds and

skilled providers for the population to be served, as well as reliable power and WASH, rooms or

dividers that ensure privacy, communication and computer equipment with good connectivity

and access to emergency transportation

(66)

. While much attention has been focused on increas-

ing facility-based care, for a high-performing health system it is equally important to focus on

community-based primary care and eective referral systems, ensuring seamless coordination

across time, settings and disciplines, and between facilities. In the area of medical products and

Strategies toward ending preventable maternal mortality (EPMM)

technologies, governments must ensure the availability of essential commodities and appropri-

ate technologies, based on considerations of equity and cost-eectiveness.

In the area of health information, countries must develop a functioning and user-friendly health

information system to assist in data collection, as well as communication and coordination

between levels of care, and between providers and patients. The health information component

is one of the most critical components of the health system because when it is strengthened,

the “software” component of the health system is activated which contributes to improvement.

For example, there is evidence that putting information from condential inquiries into action

at local levels by engaging local opinion leaders and strengthening the capacity of health pro-

fessionals is associated with reduced MMR in health facilities

(67)

To strengthen the health care workforce, governments must provide appropriate regulatory sup-

port, pre-service and in-service training, and sucient resources to deploy health care providers

(midwives, doctors, and other skilled maternity care providers, including specialists) in adequate

numbers to meet population needs. The health care workforce must be prepared to not only pro-

vide the essential sexual, reproductive, maternal and newborn care but also to recognize and

manage any co-existing medical conditions, e.g. noncommunicable diseases (such as diabetes

and heart disease). Country-level workforce management is necessary to ensure optimal recruit-

ment, distribution and retention of health workers, enact supportive supervision, and explore

task shifting as needed to improve access to high-quality care. Evidence suggests that 87% of

essential maternal and newborn health care services can be provided by midwives, subject to

them being educated and regulated to international standards and working in well-equipped

enabling environments

(68)

. Furthermore, it is projected that universal coverage of essential

maternal, newborn and family planning interventions that fall within the scope of midwifery

practice could avert 83% of all maternal and neonatal deaths and stillbirths

(69)

. Professional

associations, both at the national and global level, play an important role in establishing norms

for the regulation of health care workers and setting professional standards with regard to their

education and core competencies.

In the areas of leadership and governance, increased cooperation with other sectors (such as

nance, education, energy, water and sanitation, nutrition, social services, mobile telecommu-

nications technology and private health care services) is needed to promote good reproductive

and maternal health outcomes, and to realize the potential impact of health care nancing mech-

anisms to strengthen the system. Transparent and accountable governance entails informed and

constructive involvement of all relevant stakeholders in policy and programme development.

5. Ensure accountability to improve quality of care and equity

Planning for accountability in the post-2015 maternal health strategy emphasizes two equally

important dimensions:

(i) the improved ability to track and measure progress towards EPMM and routinely report on

it; and

(ii) social accountability, which refers to the range of actions that citizens and civil society

actors take to hold government and health system leaders to account (70) for their commit-

ments in the area of maternal and newborn health care delivery. These two dimensions of

Strategies toward ending preventable maternal mortality (EPMM)

accountability complement and enhance one another and help ensure that health systems

are directly accountable to the women and communities for whom they exist.

To track progress and ensure accountability for maternal health outcomes, governments must

improve data availability and quality, with specic attention to strengthening civil registration

systems that can provide reliable information on cause of death. Countries should build and

strengthen national and subnational data collection through routine periodic data collection,

increased measurement capacity, and informative monitoring and reporting. National data

registries should collect data on the causes and conditions of every maternal death through

condential enquiries or MDSR, and cases of severe maternal morbidity through a near-miss

reporting approach, to facilitate moving from estimating maternal mortality to counting deaths.

Facility-level accountability also contributes signicantly to improved maternal and newborn

health outcomes, through the establishment of quality standards and performance measures

that are evaluated at the point of service through ongoing quality assurance and continuous

quality improvement activities.

For eective social accountability, it is necessary to create participatory mechanisms at every

level of the health system, across public and private sectors. Health systems together with civil

society representatives should dene and communicate clear roles, responsibilities and stand-

ards for civil society participation in accountability mechanisms, supported by transparent and

equitable legal frameworks to ensure not only citizens’ rights to participation but also their right

to remedy where appropriate. This helps ensure that services are responsive to community needs

and demands, and that accountability mechanisms are transparent and inclusive.

Strategies toward ending preventable maternal mortality (EPMM)

Conclusion

The ultimate goal of the post-2015 maternal health strategy is to end all preventable mater-

nal mortality. The strategy to achieve this goal is grounded in a holistic, human rights-based

approach to sexual, reproductive, maternal and newborn health and rests on the foundation of

implementation eectiveness, which is context-specic, systems-oriented and people-centric.

It prioritizes equity, both in the selection of targets and the strategic framework to achieve them.

Its guiding principles are: empowering women and girls as well as communities; integrating

maternal and newborn care; protecting and supporting the mother–baby relationship; prioritiz-

ing country ownership, leadership and supportive legal, regulatory and nancial frameworks and

an intersectoral approach to improvement; and applying a human rights framework to ensure

that high-quality sexual, reproductive, maternal and newborn health care is available, accessi-

ble and acceptable to all who need it. Cross-cutting actions to reach the goal include improving

metrics, measurement systems and data quality, and prioritizing adequate resources and eec-

tive healthcare nancing.

There are ve broad strategic objectives laid out as a framework for countries to develop and

implement interventions for EPMM:

(i) to address inequities in access to and quality of sexual reproductive, maternal and newborn

health care services;

(ii) to ensure UHC for comprehensive sexual, reproductive, maternal and newborn health care;

(iii) to address all causes of maternal mortality, reproductive and maternal morbidities and

related disabilities;

(iv) to strengthen health systems to respond to the needs and priorities of women and girls; and

(v) to ensure accountability to improve quality of care and equity.

The Safe Motherhood Action Agenda (1997) called for ten priority actions for the next decade. A

review of these priority actions revealed the majority being woven through the maternal health

strategy we propose for the post-2015 development agenda. Measurable progress has been

made as a result of the global commitment to maternal and newborn survival embodied in

the MDGs; at the same time, the number of deaths, the inequity in MMR both between and

within countries, and the fact that 800 women continue to die each day from preventable causes,

often going uncounted (so that their lives simply don’t count) is unacceptable and remains a

global outrage that must be amended. It’s everyone’s responsibility to make sure that maternal

and newborn survival and health gure prominently in the sustainable development agenda,

considering the critical role of women and the babies they bear in the development of future

generations and communities. In 2030, let’s be able to stand and say that EPMM occurred on our

watch and as a result of our collective commitment and actions.

Strategies toward ending preventable maternal mortality (EPMM)

Acknowledgements

The paper was written by Rima Jolivet (Maternal Health Task Force), in collaboration with “end-

ing preventable maternal mortality“ (EPMM) working group core planning team including: Carla

Abou Zahr (Consultant), Agbessi Amouzou (UNICEF), Doris Chou (WHO), Isabel Danel (Center

for Disease Control), Luc de Bernis (UNPFA), Mengistu Hailemariam Damtew (Federal Ministry of

Health Addis Ababa, Ethiopia), Lynn Freedman (Colombia University, United States of America),

Metin Gülmezoglu (WHO), Marge Koblinsky (USAID), Gita Maya Koemarasakti (Ministry of Health

of Indonesia), Rajat Khosla (WHO), Matthews Mathai (WHO), Aette McCaw-Binns (University of

the West Indies, Kingston, Jamaica), Ann-Beth Moller (WHO), Joao Paolo Souza (University of São

Paulo, Brazil), Annie Portela (WHO), Lale Say (WHO), Jerey Smith (JHPIEGO/Johns Hopkins Uni-

versity) , Mary Ellen Stanton (USAID), Petra Ten Hoope-Bender (International Confederation of

Midwives), Joshua Vogel (WHO) and Mary Nell Wegner (Maternal Health Task Force).

The document reects thirty-one public comments and forty-ve comments from 42 WHO

Member States.

Strategies toward ending preventable maternal mortality (EPMM)

Annex 1. Goal-setting for EPMM:

process and timeline

In January 2013, projections for ending preventable maternal death were made by The United

Nations Children’s Fund (UNICEF), the WHO and the US Agency for International Development

(USAID) and shared with partners. They were discussed at a consultation in April 2013 on Accel-

erating Reduction in Maternal Mortality convened by the WHO that included technical experts,

stakeholders from country programmes, professional associations, multilateral agencies, mater-

nal health advocates and donors. The discussions were highlighted in a commentary in August

2013

(71)

and a strategy paper was drafted for a meeting of the African Union in August 2013

(72).

Building on the April 2013 discussions, an EPMM Working Group has since been work-

ing together with various members and hosting in-country and regional dialogues, webinars,

a blog series, and other means to seek inputs and ideas from around the world to move this

agenda forward.

In April 2014, representatives from 34 countries (many of whom were challenged with high

rates of maternal mortality), came together in Bangkok, Thailand with global partners for a con-

sensus meeting on targets and strategies for EPMM. The meeting was convened by WHO, the

United Nations Population Fund (UNFPA), the USAID, the Maternal Health Task Force (MHTF),

and the Maternal and Child Health Integrated Program (MCHIP), with support from agencies and

donors and inputs from the EPMM Working Group. A strong consensus was forged in support

of targets and a broad strategic framework for moving towards ending all preventable mater-

nal deaths

(73)

Following the Bangkok consensus meeting, these targets and the broad strategic framework

for their achievement were circulated widely among country stakeholders and global develop-

ment partners, and were brought forward by Member States at the World Health Assembly in

May 2014, where participating delegates petitioned for their inclusion in the resolution on the

Every Newborn Action Plan (ENAP), which were subsequently included as an annex to the ENAP.

The EPMM Working Group core planning team convened a writing group, and key informant

interviews were conducted to solicit inputs to inform a draft paper, elaborating on the stra-

tegic framework developed by consensus in Bangkok in April 2014. The draft EPMM targets

and strategies were presented at the PMNCH Partners’ Forum in Johannesburg, South Africa

on 2 July 2014 and simultaneously posted online on the WHO website (http://www.who.int/

reproductivehealth/topics/maternal_perinatal/epmm/en/) for comments from the public and

sent to the ocial WHO Members States for country consultation. Through a systematic process,

all 31 reviews received during the public comment period along with the feedback received from

42 WHO Member States (African Region (7), Region of the Americas (8), Eastern Mediterranean

Region (5), European Region (13), South-East Asia Region (1), Western Pacic Region (7)), were

evaluated and decisions on how to address each comment were made by consensus.

Strategies toward ending preventable maternal mortality (EPMM)

Annex 2. Accelerating reduction of

maternal mortality strategies and

targets beyond 2015: 8–9 April 2013,

Geneva, Switzerland

List of Participants

Professor Richard Adanu

(teleconference)

Dean, School of Public Health

University of Ghana

Accra, Ghana

Dr Chris Agboghoroma

SOGON Secretary General

Chief Consultant Obstetrician & Gynaecologist

Abuja, Nigeria

Dr Leontine Alkema

Assistant Professor

Department of Statistics & Applied Probability

Saw Swee Hock School of Public Health National

University of Singapore

Singapore

Prof Sabaratnam Arulkumaran

President

International Federation of Gynecology and

Obstetrics (FIGO)

United Kingdom

Dr Atmarita

Head, Program and Coordination Division

National Institute for Health Research and

Development (NIHRD)

The Ministry of Health

Jakarta Pusat, Indonesia

Dr Martina Baye Lukong

Technical Adviser N°2

Ministry of Public Health

Yaounde, Cameroon

*Dr Tewodros Bekele

Director General for Health Promotion and Disease

Prevention

Ministry of Health

Addis Ababa, Ethiopia

Dr Luc de Bernis

Senior Maternal Health Advisor

Technical Division

UNFPA Geneva Oce, Switzerland

Dr Himanshu Bhushan

Deputy Commissioner

Maternal Health

Ministry of Health and Family Welfare

New Delhi, India

*Dr John Borrazzo

Chief

Division of Maternal and Child Health

US Agency for International Development

United States of America

*Dr Maximillian Bweupe

Ministry of Health

Lusaka, Zambia

Ms Clara Calvert

London School of Hygiene & Tropical Medicine

United Kingdom

Dr Isabella Danel

Associate Director of Global Health Programs

Center for Disease Control (CDC)

United States of America

Ms Alison Gemmill

PhD Student

Department of Demography

University of California, Berkeley

United States of America

Professor Wendy Jane Graham

School of Medicine and Dentistry

University of Aberdeen

United Kingdom

Strategies toward ending preventable maternal mortality (EPMM)

Dr Rakesh Gupta

Commissioner FD & Mission Director

Department of Health & Family Welfare

Government of Haryana

India

Dr Marge Anne Koblinsky

Senior Maternal Health Advisor

Maternal and Child Health Division,

HIDN, US Agency for International Development

United States of America

Dr Gita Maya Koemarasakti

Director of Maternal Health

Ministry of Health of Indonesia

Jakarta, Indonesia

Dr Ariel Pablos-Méndez

(teleconference)

Assistant Administrator for Global Health

US Agency for International Development

United States of America

Dr Tim Poletti

Health Adviser

Australian Permanent Mission

1211 Geneva 19

Switzerland

Professor Thomas W. Pullum

Director of Research

MEASURE DHS Project

ICF International

United States of America

*Dr Florina Serbanescu Senior Health Scientist

Center for Disease Control (CDC)

United States of America

Dr Jerey Michael Smith

Jhpiego/Johns Hopkins University

Director

Maternal Health, MCHIP

United States of America

Ms Mary Ellen Stanton

Reproductive Health Advisor

Center for Population, Health and Nutrition

US Agency for International Development

United States of America

Dr Nina Strøm

Senior Adviser SRHR

Global Health Section

Department of Global Health, Education and

Research, NORAD

Norway

* Unable to attend.

Ms Petra Ten Hoope-Bender

International Confederation of Midwives

The Netherlands

Ms Mary Nell Wegner

Executive Director

Maternal Health Task Force

Harvard School of Public Health

United States of America

Dr Danzhen You

Statistics and monitoring specialist

UNICEF New York

United States of America

Secretariat

Family, Women’s and Children’s Health Cluster

(FWC)

Dr Flavia Bustreo, Assistant Director-General

Department of Reproductive Health and

Research (RHR)

Dr Marleen Temmermann, Director

Oce of the Director

Ms Anna Whelan, Adviser

Ms Elisa Scolaro, Junior Professional Ocer

Research Capacity, Policy and Programmes

Strengthening (RCP)

Dr Lale Say, Coordinator

Dr Doris Chou, Medical Ocer

Dr Ozge Tuncalp, Consultant

Improving Maternal and Perinatal Health (MPH)

Dr Metin Gülmezoglu, Lead Specialist

Department of Maternal, Newborn, Child and

Adolescent Health (MCA)

Dr Elizabeth Mason, Director

Department of Maternal, Newborn, Child and

Adolescent Health / Epidemiology,

Monitoring and Evaluation (MCA/EME)

Dr Matthews Mathai, Coordinator

Department of Information, Evidence and

Research/Health Statistics and Informatics/

Mortality and Burden of Disease (IER/HIS)

Dr Colin Mathers, Coordinator

Partnership for Maternal and Child Health

(PMNCH)

Dr Carole Presern, Executive Director

Strategies toward ending preventable maternal mortality (EPMM)

Annex 3. Targets and strategies

for ending maternal mortality:

16–17 January 2014, Geneva,

Switzerland

List of Participants

Ms Carla Abou Zahr

Consultant

*Prof Sabaratnam Arulkumaran

President

International Federation of Gynecology and

Obstetrics (FIGO)

United Kingdom

Dr Isabella Danel

Centre For Global Health

Centers for Disease Control and Prevention

United States of America

Dr Lynn Freedman

Director of Averting Maternal Death and Disability

Program (AMDD)

Colombia University

United States of America

Dr Marge Anne Koblinsky

Senior Maternal Health Advisor

Maternal and Child Health Division, HIDN

US Agency for International Development

United States of America

Prof Joy Lawn

Director of MARCH

London School of Hygiene & Tropical Medicine

United Kingdom

Dr Issac Malonza

Country Director

Jhpiego

Nairobi, Kenya

Ms Betsy McCallon

Executive Director

White Ribbon Alliance for Safe Motherhood

United States of America

*Dr Thomas W. Pullum

Director of Research

MEASURE DHS Project

ICF International

United States of America

Ms Mary Ellen Stanton

Reproductive Health Advisor

Center for Population, Health and Nutrition

United States of America

Ms Ann Starrs

President

Family Care International

United States of America

Ms Petra Ten Hoope-Bender

International Confederation of Midwives

The Netherlands

Dr Luc de Bernis

Senior Maternal Health Advisor

UNFPA Geneva Oce

Switzerland

Ms Susana Edjang

UNFPA Geneva Oce

Switzerland

*Dr Laura Laski

Sexual and Reproductive Health Branch

UNFPA

United States of America

Dr Rima Jolivet

Consultant

Maternal Health Task Force

Harvard School of Public Health

United States of America

*Dr Ana Langer

Department of Global Health and Population

Harvard School of Public Health

United States of America

Strategies toward ending preventable maternal mortality (EPMM)

Ms Mary Nell Wegner

Executive Director

Maternal Health Task Force

United States of America

World Health Organization

Family, Women’s and Children’s Health Cluster

(FWC)

Dr Flavia Bustreo, Assistant Director-General

Department of Reproductive Health and

Research (RHR)

Dr Marleen Temmerman, Director

Oce of the Director

Dr Rajat Khosla, Human Rights Advisor

Ms Elisa Scolaro, Technical Ocer

Adolescents and at-Risk Populations

Dr Lale Say, Coordinator

Dr Doris Chou, Medical Ocer

Maternal Perinatal Health, Prevent Unsafe

Abortion

Dr Metin Gülmezoglu, Coordinator

Department of Maternal, Newborn, Child and

Adolescent Health (MCA)

Dr Elizabeth Mason, Director

Epidemiology, Monitoring and Evaluation

Dr Matthews Mathai, Coordinator

Policy, Planning and Programmes

Dr Bernadette Daelmans, Coordinator

WHO Oce at the United Nations

Dr Rama Lakshminarayanan

Senior Advisor

Unitred States of America

Partnership for Maternal and Child Health

(PMNCH)

Dr Carole Presern, Executive Director

Dr Andres de Francisco Serpa, Coordinator

Ms Lori McDougall, Senior Technical Ocer

* Unable to attend.

Strategies toward ending preventable maternal mortality (EPMM)

Annex 4. Country consultation on

targets and strategies for EPMM.

14–16 April, 2014, Bangkok, Thailand

List of Participants

AFGHANISTAN

Dr Sadia Fayad Ayubi

Ministry of Public Health

Kabul, Afghanistan

Dr Aweed Dehyar

MoPH Deputy Minister for Health care provision

Kabul, Afghanistan

Dr Mohammad Haz Rasooly

Afghanistan National Public Health Institute

(ANPHI)

Kabul, Afghanistan

Dr Tahir Mohammad

UNPFA, NPO

Afghanistan

BANGLADESH

Dr Azizul Alim

Ministry of Health and family Welfare

Dhaka, Bangladesh

Dr Sayed Abu Jafar Md. Musa

Director PHC and Line Director MNC&AH,

Director General of Health Services

Dhaka, Bangladesh

Dr Mohammed Sharif

Director MCH Service and Line Director MCRAH,

Dhaka, Bangladesh

BRAZIL

Dr Juan José Cortez Escalante

Department for Analysis of Health Data

Secretariat for Health Surveillance

Ministry of Health

Brasilia DF, Brazil

CAMEROON

*Mr Kamen Lele Benjamin

Chef de la Cellule des Information Sanitaires

Ministère de la Santé Publique

Yaounde, Cameroun

*Dr Martina Baye Lukong

Technical Adviser N°2

Ministry of Public Health

Yaounde, Cameroun

CHAD

Dr Guidaoussou Dabsou

Division du système information sanitaire

Ministère de la Santé Publique

Ndjamena, Chad

Dr Hamid Djabar

Directeur General Adjoint des Activites Sanitaires

Ndjamena, Chad

ETHIOPIA

Dr Teodros Bekele

Director General for Health Promotion and Disease

Prevention

Ministry of Health

Addis Ababa, Ethiopia

Dr Mengistu Hailemariam Damtew

Maternal and Newborn Health Advisor

Federal Ministry of Health

Addis Ababa, Ethiopia

GHANA

Dr Patrick Kuma Aboagye

Ghana Health Service

Accra, Ghana

Strategies toward ending preventable maternal mortality (EPMM)

GUATEMALA

Dr Marco Vinicio Arévalo Varas

Vice ministro de Hospitales

Guatemala

GUINEA

*Dr Rémy Lamah

Minister of Health

Guinea

Dr Madina Rachid

Head of the SRH Department

Guinea

HAITI

Dr Reynold Grand-Pierre

Directeur de santé de la famille

Ministère de la Santé Publique et de la Population

(MSPP)

Port-au-Prince, Haiti

INDIA

Dr Dinesh Baswal

Deputy Commissioner

Ministry of Health and Family Welfare

Government of India

New Delhi, India

Dr Rattan Chand

Chief Director

Ministry of Health and Family Welfare

Government of India

New Delhi, India

INDONESIA

Dr Atmarita

National Institute for Health Research and

Development (NIHRD)

Ministry of Health

Jakarta Pusat, Indonesia

Dr Gita Maya Koemara Sakti

Directorate General of Nutrition, Maternal and

Child Health

Jakarta Pusat, Indonesia

Dr Rina Herartri

Study Center Unit in BKKBN

Indonesia

Dr Melania Hidayat

NPO RH, UNFPA

Indonesia

KAZAKHSTAN

Mr Kanat Sukhanberdiev

Coordinator

BTN for Kazakhstan

Astana, Kazakhstan

KENYA

Khadija Abdallah

UNICEF Kenya Country Oce

Maternal and Newborn Health Specialist

Nairobi, Kenya

Mr Isaac Matonyi Malonza

Country Director, Jhpiego

Nairobi, Kenya

LAO PEOPLE’S DEMOCRATIC REPUBLIC

Dr Founkham Rattanavong

Ministry of Health

Vientiane, Lao People’s Democratic Republic

MALAWI

Mrs Fannie Kachale

Director

Reproductive Health Unit

Blantyre, Malawi

Dr Lennie Kamwendo

Acting Chief of the Board of Trustees

White Ribbon Alliance for Safe Motherhood

Blantyre, Malawi

MEXICO

Dr Luis Manuel Torres Palacios

Secretaria de Salud de México

Mexico DF

MOROCCO

Dr Mouna Bousseane

Direction des Hôpitaux et des Soins Ambulatoires/

Division des Soins Ambulatoires

Ministère de la Santé

Rabat, Morocco

Dr Had Hachri

Chef de la Division des Soins Ambulatoires

Direction des Hôpitaux et des Soins Ambulatoires

Ministere de la Santé

Rabat, Morocco

Strategies toward ending preventable maternal mortality (EPMM)

MYANMAR

Dr Khin Thida

Project Ocer SRH-Project

Myanmar Medical Association

Myanmar

Dr Win Aung

National Program Ocer, RH/ARH –training

UNFPA- Myanmar

NEPAL

Dr Padam Bahadur Chand

Chief Public Health Administrator

Ministry of Health and Population

Kathmandu, Nepal

Mr Kusum Thapa

Jhpiego Nepal EDC

Kathmandu, Nepal

NIGERIA

Dr Aderemi Najeem Azeez

Federal Ministry of Health

Abuja FCT, Nigeria

Dr Oladosu Ojengbede

University of Ibadan

Nigeria

OMAN

Dr Elsayed Medhat

Senior Consultant Adviser

Health and Epidemiology Information

Ministry of Health

Muscat, Oman

PAKISTAN

Mr Riaz Hussain Solangi

White Ribbon Alliance for Safe Motherhood

Islamabad 44000, Pakistan

PERU

Ms María Esther Salazar López

Epidemiological Surveillance of the Department of

Clinical Epidemiology

Ministry of Health

Lima, Perú

PHILIPPINES

Dr Zenaida Recidoro

National Center for Disease Prevention and

Control

Department of Health

Philippines

SAUDI ARABIA

Dr Hala Aldosari

Planning and Development

Ministry of Health

Saudi Arabia

Dr Rafat Taher

Head of Information Centre

Ministry of Health

Saudi Arabia

Dr Mohammed Zamakhshary,

Assistant Deputy Minister for

Planning and Training

Ministry of Health

Saudi Arabia

SENEGAL

Dr Doudou Sene

Ministère de la Santé et de l’action sociale

Dakar, Senegal

THAILAND

Prof Ounjai Kor-Anantakul

Department of Obstetrics and

Gynaecology Faculty of Medicine

Prince of Songkla University

Hadyai, Songkla, Thailand

Prof Pisake Lumbiganon

President Elect, The Royal Thai College of

Obstetricians and Gynaecologists

Director, WHO Collaborating Centre for Research

Synthesis in Reproductive Health

Faculty of Medicine, Khon Kaen University

Khon Kaen, Thailand

Mrs Chujit Nacheeva

Statistician

Ministry of Public Health

Nonthaburi, Thailand

Prof Wiboolphan Thitadilok

President, RTCOG

Bangkok Thailand

Strategies toward ending preventable maternal mortality (EPMM)

Dr Nuttaporn Wongsuttipakorn

Deputy Director– General, Department of Health,

Ministry of Public Health

Thailand

TOGO

Dr Yawa Djatougbé Apetsianyi

Regional Health Director,

Région Maritime du Togo

Togo

Dr Solange Toussa-Ahossu

Executive Director of l’ATBEF

Togo

TURKEY

Dr Sema Sanisoglu

Head of Women and Reproductive Health

Department

Public Health Agency of Turkey

Ministry of Health

Ankara, Turkey

Prof Yaprak Ustun

Medical Faculty

Woman Health and Maternity Department

Bozok University

Ankara, Turkey

UNITED REPUBLIC OF TANZANIA

Dr Neema Rusibamayila Kimambo

Ag. Director, Preventive Services

Ministry of Health and Social Welfare

Dar es Salaam, United Republic of Tanzania

ZAMBIA

Dr Davy Misheck Chikamata

The Permanent Secretary

Ministry of Health

Lusaka, Zambia

Dr Elwyn Chomba

Department of Paediatrics and Child Health

University Teaching Hospital

Lusaka, Zambia

Dr Caroline Phiri Chibawe

Director Mother and Child Health

Ministry of Community Development

Lusaka, Zambia

RESEARCH PARTNERS

Dr Fernando Althabe

Department of Mother and Child Health Research

Institute for Clinical Eectiveness and

Health Policy (IECS)

Buenos Aires, Argentina

Dr Shams El Arifeen

Scientist and Director

Child and Adolescent Health Division

International Centre for Diarrhoeal Disease

Research (ICDDR) B

Dhaka, Bangladesh

Prof Aette McCaw-Binns

Department of Community

Health and Psychiatry

University of the West Indies

Kingston, Jamaica

Prof Roland Edgar Mhlanga

Department of Health

Mpumalanga,South Africa

Dr Joachim Osur Oduor

AMREF

Nairobi, Kenya

INTERNATIONAL PARTNERS

Dr Koki Agarwal

Director, MCHIP

Jhpiego

United States of America

*Dr Peter Byass

Umeå Centre for Global Health Research

Umeå University

Sweden

Ms Susan Bree

International Confederation of Midwives

New Zealand College of Midwives, Inc.

New Zealand

Dr Isabella Danel

Centre For Global Health

Centers for Disease Control and Prevention

United States of America

*Dr Lynn Freedman

Director of Averting Maternal Death and Disability

Program (AMDD)

Colombia University

United States of America

Strategies toward ending preventable maternal mortality (EPMM)

*Prof Wendy Graham

Immpact, School of Medicine and Dentistry

University of Aberdeen

United Kingdom

Dr Rima Jolivet

Consultant

Maternal Health Task Force

Harvard School of Public Health

United States of America

Dr Marge Anne Koblinsky

Senior Maternal Health Advisor

Maternal and Child Health Division, HIDN

US Agency for International Development

United States of America

Dr Ana Langer

Department of Global Health and Population

Harvard School of Public Health

United States of America

Ms Gillian Mann

Department for International Development

(DFID)

United Kingdom

*Ms Betsy McCallon

Executive Director

White Ribbon Alliance for Safe Motherhood

United States of America

*Helen McFarlane

AUSAID

Australia

Dr Thomas W. Pullum

Director

The Demographic and Health Surveys Program

ICF International

United States of America

Dr Chittaranjan Purandare

Consultant, Obstetrician & Gynecologist

President Elect FIGO

Dean Indian College of Obstetricians and

Gynaecologists

Mumbai, India

Dr Jerey Smith

Jhpiego/Johns Hopkins University

Director

Maternal Health, MCHIP

United States of America

Ms Ann Starrs

President

Family Care International

United States of America

Ms Mary Ellen Stanton

Senior Maternal Health Advisor

Center for Population, Health and Nutrition

US Agency for International Development

United States of America

Ms Mary Nell Wegner

Executive Director

Maternal Health Task Force

Harvard School of Public Health

United States of America

Ms Leilani Hastings

Consultant

Maternal Health Task Force

Mr Timothy Thomas

The Bill and Melinda Gates Foundation

Senior Program Ocer for Family Health Advocacy

United States of America

*Mrs Julia Bunting

International Planned Parenthood Federation (IPPF)

Director Programmes and Technical

*Judith Frye Helzner

Consulting, Harvard School of Public Health

UN PARTNERS

Mr Agbessi Amouzou

UNICEF

New York, United States of America

Mr Wame Baravilala

Regional Adviser

UNFPA-Asia and the Pacic

Regional Oce

Bangkok 10200

Thailand

Ms Maria Isabel Cobos

Associate Population Aairs Ocer

CELADE0/Population Division

Santigo, Chile

Dr Luc de Bernis

Senior Maternal Health Advisor

Technical Division

UNFPA Geneva Oce

Switzerland

*Ms Susana Edjang

UNFPA

New York, United States of America

Strategies toward ending preventable maternal mortality (EPMM)

Dr Maha El-Adawy

Regional Technical Adviser

Sexual and Reproductive Health

United Nations Population Fund

Cairo, Egypt

*Dr Nobuko Horibe

Regional Director

UNFPA

Asia and Pacic– APRO

*Dr Laura Laski

UNFPA

New York, United States of America

*Ms Holly Newby

UNICEF

New York, United States of America

Mr Basil Rodrigues

UNICEF

East Asia Pacic Regional Oce (EAPRO)

Bangkok, Thailand

Dr Nabila Zaka

UNICEF, (EAPRO)

Bangkok, Thailand

WORLD HEALTH ORGANIZATION

SECRETARIAT

Department of Reproductive Health and

Research (RHR)

Oce of the Director

*Dr Marleen Temmerman, Director

Dr Rajat Khosla, Human Rights Advisor

Adolescents and at-Risk Populations (AGH)

Dr Lale Say, Coordinator

Dr Doris Chou, Medical Ocer

Mrs Ann-Beth Moller, Consultant

Maternal and Perinatal Health and Preventing

Unsafe Abortion (MPA)

Dr Joshua Vogel, Technical Ocer

Department of Maternal, Newborn,

Child and Adolescent Health (MCA)

Dr Matthews Mathai, Coordinator, EME

Department of Health Statistics and

Information Systems

Dr Daniel Hogan, Technical Ocer

* Unable to attend.

WHO THAILAND

*Dr Yonas Tegegn

WHO Representative Thailand

*Mr Stephane Guichard

Regional Adviser (Vaccine Supply and Quality)

WHO REGIONAL OFFICES

Regional Oce for Africa (AFRO)

*Dr Leopold Ouedraogo, Regional Adviser

*Dr Innocent Bright Nuwagira,

Monitoring and Evaluation Ocer

Regional Oce for the Americas (AMRO/PAHO)

Dr Bremen de Mucio, Regional Adviser

Regional oce for the Eastern Mediterranean

(EMRO)

*Dr Haifa Husni Madi, Director

*Dr Mohamed Mahmoud Ali, Regional Adviser

Regional oce for Europe (EURO)

*Dr Gunta Lazdane, Programme Manager

Regional oce for South East Asia (SEARO)

Dr Arvind Mathur, Medical Ocer

Regional Oce for the Western Pacic (WPRO)

*Dr Howard L. Sobel, Regional Adviser

WHO Oce at the United Nations (WUN)

Dr Rama Lakshminarayanan

Senior Advisor

New York, United States of America

Strategies toward ending preventable maternal mortality (EPMM)

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Strategies toward ending

preventable maternal

mortality (EPMM)

For more information, please contact:

Department of Reproductive Health and Research

World Health Organization

Avenue Appia 20, CH-1211 Geneva 27, Switzerland

Fax: +41 22 791 4171

E-mail: reproductivehealth@who.int

www.who.int/reproductivehealth

ISBN 978 92 4 150848 3