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When thousands of delegates travel to the latest Women Deliver conference in Copenhagen this month, they will see both a list of “best win” ideas aimed at improving maternal health, and a “social enterprise challenge” that showcases the projects intended to deliver them.
These initiatives are examples of a growing focus, on the part of researchers, practitioners and funders, to better match resources with evidence for policies that work to reduce unnecessary illness and death in mothers — and with the projects that can best implement them. While progress has been made in recent years, a substantial mismatch remains.
“If only the process was rational,” says Prof Joy Lawn, director of the Maternal, Adolescent, Reproductive and Child Health (March) Centre at the London School of Hygiene and Tropical Medicine. “Twenty years ago, I had the idea that this was how people thought: look at the biggest burden, the evidence and what should we do. Most of the money in fact goes either to the things that have the best marketing or the countries that are the darlings.”
There is little doubt that advances have been made in tackling women’s and children’s health in recent decades, a process that has been partly accelerated by the Millennium Development Goals (MDGs) since 2000.
As an independent expert review concluded last year, child mortality fell by nearly two-thirds between 1970-2013. That still left 6.3m children under five dying annually, however, and the MDG objective of a 4.4 per cent reduction each year was missed. The drop in maternal mortality was also below target and much of the improvement took place in a handful of countries, with widespread disparities remaining around the world.
Economic growth in emerging countries, above all in China, has been a substantial contributor to progress. Investments in sanitation and global health programmes have also helped — not least the acceleration in uptake of vaccines, treatment for HIV and insecticide-treated bed nets, diagnostics and drugs to tackle malaria.
But the allotment of funding remains a problem. Prof Lawn says that while such success has resulted in the declining burden of infectious diseases, these programmes “are still getting the lion’s share even while their contribution to total deaths is falling”.
While the availability of cheap diagnostics has helped treat millions of cases of malaria each year, it has also revealed that many fevers in children previously suspected to be caused by the parasite were in fact symptoms of other diseases — which have so far seen scant investment in either diagnostics or drugs.
Also, while a substantial effort in diagnosing and using simple treatments to prevent HIV passing from mothers to babies has sharply reduced unnecessary infection, the application of similar techniques with a simple dose of antibiotics to depress the transmission of syphilis has been largely neglected.
Each of these so-called “vertical programmes” comes at a considerable cost. For far less money, cheap forms of contraceptive could be more widely distributed to the estimated 225m women who currently would like family planning but have no access to it. Such access would substantially reduce complications during childbirth, improving the health of mothers and remaining children alike.
Prof Lawn says there is also need for more emphasis on stillbirths, of which there are 2.6m each year. “New-born deaths are on the agenda because of child survival targets, and people are paying attention,” she says. “Stillbirths are not mentioned at all, although they have a huge impact on families.”
Other important interventions include the 2030 Innovation Countdown compiled by Path, a Seattle non-profit group which highlights innovations such as the wider use of the drug oxytocin to prevent post-partum haemorrhage; simple blood pressure monitors to identify pre-eclampsia; and “kangaroo” mother care, which promotes the benefits of maintaining skin-on-skin contact between mothers and newborns.
Efforts are under way to modify existing products and implement new ones. Last month, GlaxoSmithKline won regulatory approval for a reformulated version of the antiseptic chlorhexidine, which has reduced infections when applied to the umbilical cord stump soon after birth. The health organisations Saving Lives at Birth and the Innovation Working Group have both worked on developing marketplaces to match projects with funders.
Substantial effort is still required to understand why innovations work in practice, and how far failures are due to flaws in programmes or their implementation.
Meanwhile, there are calls for health reforms that affect entire systems or societies. Adolescent health, the provision of universal health coverage or efforts to reduce violence and increase equality for women could make a significant difference but will demand ambitious overhaul of the status quo.