Episode 72
Sustaining Maternal Health Gains
In this episode of Connecting Citizens to Science, we conclude our three-part miniseries on improving maternal and newborn healthcare. Host Dr. Kim Ozano and her guests explore how to sustain quality improvements in health systems and progress toward maternal and newborn Sustainable Development Goals (SDGs) by 2030. Dr. Rael Mutai, Regional Technical Advisor for Maternal and Newborn Health at the Liverpool School of Tropical Medicine Kenya, and Dr. Nicholas Furtado, Senior Medical Advisor at Global Fund, share their insights on the successes and challenges of embedding sustainable practices in maternal and newborn healthcare systems across Kenya, Tanzania, and Nigeria. (see 'useful links' for the other episodes from the series).
Chapter List:
00:00:00 – Introduction to Sustainability and SDG Goals
00:01:52 – Progress Towards Maternal and Newborn Health indicators
00:04:50 – Global Landscape: The Impact of the Pandemic
00:06:37 – Addressing Inequities within Countries
00:09:26 – Healthcare Workers and Sustainable Outcomes
00:12:22 – Intersectionality and Broader Determinants of Maternal Health
00:17:38 – Advice and Call to Action for Sustainable Solutions
In this episode:
Dr. Rael Mutai - Regional Technical Advisor (MNH), Liverpool School of Tropical Medicine Tropical Kenya
Rael is a public health specialist with over 21 years’ of experience in health and development. She is passionate about health systems strengthening, Sexual Reproductive Health and Rights and Quality Maternal and Newborn Health. Rael has been involved with the quality improvement programme in the last 3 years, as the Regional Technical Adviser for Kenya and Tanzania. The Programme uses global evidence customised to country context for improved maternal and newborn outcomes. The programme has addressed gaps in ANC-PNC service delivery through capacity building of healthcare workers and integrated approaches to care.
Dr. Nicolas Furtado - Senior Medical Advisor, Global Fund
Nicolas is a Senior Medical Advisor with the Health System Strengthening Technical Advice and Partnerships team at the Global Fund. He is deeply engaged in efforts to strengthen primary healthcare systems globally, particularly focusing on improving maternal and newborn health outcomes and now focusing on improving access to medical oxygen and respiratory care. Throughout his work, Nicolas has been instrumental in addressing key challenges such as the impact of the COVID-19 pandemic, healthcare inequities, and the need for sustainable, locally adapted solutions. He advocates for simple, effective, and culturally appropriate interventions to ensure quality care at the point of service delivery.
Useful links:
- Strengthening the Health Workforce for Maternal and Newborn Care - Connecting Citizens to Science - In the second episode of our three-part miniseries, " Transforming Maternal and Newborn Health", we focus on how capacity strengthening in healthcare can transform maternal and newborn care outcomes. The discussion highlights the critical role of health workers, from nurses to doctors, and the importance of building skills, teamwork, and communication to improve early diagnosis and reduce complications. Experts share insights on training approaches, challenges faced, and the transformative impact of mentorship and continuous professional development in Kenya, Tanzania, and beyond. This episode offers valuable lessons for health systems strengthening and sets the stage for our next conversation on sustainability.
- Quality Innovations in Maternal and Newborn Health - Connecting Citizens to Science - In this first episode of our three-part miniseries, "Transforming Maternal and Newborn Health," we dive into a groundbreaking quality improvement programme that has made significant strides in integrating HIV, tuberculosis, and malaria services into antenatal and postnatal care across Kenya, Nigeria, and Tanzania. We explore emerging evidence on how health systems can adapt and respond to changing landscapes, including the impact of COVID-19, to deliver better outcomes for mothers and newborns. Featuring insights from leading experts, we discuss the challenges, successes, and innovative approaches that have strengthened the capacity of health workers and improved access to essential care. This episode sets the stage for the next discussions on capacity building and sustainability, making it a must-listen for anyone interested in global health and health systems strengthening.
- Quality Improvement of Integrated HIV, TB and Malaria Services in ANC & PNC | LSTM
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Transcript
Dr. Kim Ozano: Hello listeners and welcome to Connecting Citizens to Science.
Speaker:I'm Dr.
Speaker:Kim Ozano, and this is a podcast where we discuss current research and debates in global health.
Speaker:This is the final episode of our three- part miniseries where we have been hearing insights from the Quality Improvement Programme for the integration of HIV, TB and malaria services in antenatal and postnatal care.
Speaker:And we've been hearing about these lessons from Nigeria, Tanzania, and Kenya.
Speaker:Our previous two episodes have been excellent in sharing some of the research findings, including adaptability to changing health landscapes, scanning and scoping for mental health and domestic violence, and capacity strengthening of the health workforce to improve the health outcomes for mothers and babies.
Speaker:But today we are really focused on sustainability and applying those lessons to progress towards achieving maternal and newborn sustainable development goals by 2030.
Speaker:Dr. Rael Mutai: In the period between 2015 and up to 2023, we know that there was significant progress but as of 2023, the general consensus is that the progress had stagnated.
Speaker:Dr. Kim Ozano: I'm pleased to have with us today Dr.
Speaker:Rael Mutai, who is the Regional Technical Advisor for Maternal and Newborn Health and the Country Director in Kenya from the Liverpool School of Tropical Medicine.
Speaker:Rael has been our wonderful co host for the last two episodes, but today she joins us as a guest to share her valuable insights on sustainability.
Speaker:We are also joined by Dr.
Speaker:Nicholas Furtado, who is a senior medical advisor at the Health System Strengthening Technical Advice and Partnerships team at Global Fund.
Speaker:So, without further ado, let's start this wonderful discussion on sustainability for maternal and newborn health.
Speaker:Welcome to the podcast, both.
Speaker:Let's start with you, Rael.
Speaker:Talk to us a little bit more about the Sustainable Development Goals and Maternal and Newborn Health and how we are progressing towards those globally and within the countries where you are working.
Speaker:Dr. Rael Mutai: Thank you very much, Kim.
Speaker:It's indeed a pleasure again to be in this podcast, and today as a guest, happy to see all of you.
Speaker:Now, looking at the three countries where we've been working in Nigeria, in Kenya, in Tanzania, looking at the SDGs and specifically SDG three the critical indicators of interest there are on maternal mortality ratio.
Speaker:That is the number of women that die for every 100,000 live births that happen.
Speaker:We are also interested in the coverage for skilled birth attendants.
Speaker:That is for all the women who go to deliver.
Speaker:What proportion in any country is being attended to by a skilled health professional?
Speaker:And finally, and but not least, we also look at the numbers of neonatal mortality ratio.
Speaker:That is the number of newborns that die for every hundred live births.
Speaker:They are the goals, targets of interest under SDG 3 are universal health coverage, which we know that is one of the pathways that countries have accepted to really enable us to make progress.
Speaker:Now looking at Kenya, Nigeria, and Tanzania, in the period between 2015 and up to 2023, we know that there was a significant progress but as that was made, but of 2023, the general consensus is that the progress had stagnated.
Speaker:So, to get to the target of 140 per 100,000 women that die for every 100,000 live births that happen or even 70 per 100,000 per country, it is going to it means that a lot more effort needs to be put and you as you know that the maternal and newborn health, they are so interlinked that whatever happens to the mothers happens to the babies.
Speaker:Where we have high maternal mortality, the trends are more or less the same, but there is slightly better progress as far as neonatal mortality is concerned.
Speaker:But you know that whatever happens during delivery, if it is not well managed, you could lose the mother, we could lose the baby.
Speaker:Interventions need to be strengthened around that area and of course, the critical question always is that for most countries, the proportion of women getting a skilled attendance at birth has gone up.
Speaker:In fact, for Kenya, it's at 89%.
Speaker:In Tanzania, it's about the same.
Speaker:In Nigeria, it is slightly lower.
Speaker:Which means that women are accessing the service, but women are still dying.
Speaker:Meaning that there is something about the quality of service, and this quality is about the competencies of the healthcare workers.
Speaker:It's about the essential supplies that are needed to provide the equipment that is needed to take care of those women and all these have to do with the health system.
Speaker:It is actually beyond the healthcare worker.
Speaker:It is the whole health system that needs to be revamped.
Speaker:Dr. Kim Ozano: Wow, that really gives me an impression of how things are going, and you said there was a lot of progress up till about 2023.
Speaker:And then we've seen some stagnation.
Speaker:Nick welcome to the podcast.
Speaker:It's a pleasure to have you here.
Speaker:How does this fit with the global landscape for maternal and newborn health?
Speaker:Dr. Nicolas Furtado: I completely agree with Rael's assessment that it's a mixed picture in terms of the progress that has been made but, also the fact that we have to acknowledge a level of stagnation in what was expected to reach the SDG targets by 2030.
Speaker:And as clearly mentioned, the antenatal/postnatal care platform or the channel of care at the primary health care level needs a little bit more strengthening.
Speaker:There are different qualitative aspects that need to be brought and understood.
Speaker:Root causes need to be understood and solutions need to be collaboratively developed to make sure that the most highly accessed platform for care that is for women, for mothers and their babies, newborn babies.
Speaker:Is actually providing the kind of care that needs to address the targets and bring down the targets, both for maternal mortality ratio as well as for neonatal mortality.
Speaker:In the global landscape, one additional piece that we need to understand is the impact of the pandemic that we have just emerged out of that has caused some of the weakening on this very strong platform.
Speaker:As mentioned in Kenya, the skilled attendance is 89 percent which is higher than even the averages that you see across similar countries.
Speaker:The same can be said about Tanzania.
Speaker:But I think we have to go down to see how health systems need to be strengthened, and from my point of view, we need to look at everything from the point of view of capacity building at the level of the provider as well as the availability of consumables that are required.
Speaker:Simple things at the point of care that will enable the work of the skilled attendant to ensure the quality of antenatal, the perinatal and postnatal care.
Speaker:Dr. Rael Mutai: Yeah, thank you very much, Nick.
Speaker:I think those are very strong points from the global perspective.
Speaker:We realise that in many countries there is this issue of the average looks good, but if you go further, subnational level, to the districts they are some disparities and that is why perhaps the progress is not moving as fast as we could.
Speaker:I don't know what are your thoughts in terms of how can we address these inequities within countries?
Speaker:Dr. Nicolas Furtado: So you hit upon at a strategic level we need to ensure that we are providing quality of care
Speaker:and besides just improving quality of care, I think the equity of coverage, or the effective quality of care, that is provided across different areas and you'll find the root causes of that are very different.
Speaker:Sometimes it's about conflict.
Speaker:There are parts of certain countries that conflict or challenging context s prevent people from accessing care.
Speaker:So what are the root causes of those inequities?
Speaker:We have to look at that.
Speaker:Is it psychosocial?
Speaker:Is it socioeconomic?
Speaker:Is it due to conflict?
Speaker:Certain areas of certain countries are more prone to conflict than others, and besides quality, we have to look at equity and then the root causes of those inequities that are leading to differences in maternal mortality and neonatal mortality.
Speaker:Dr. Kim Ozano: Is it something around rural versus urban, or are there certain areas where really we need further innovations because the context in countries is changing quite rapidly?
Speaker:Dr. Rael Mutai: For instance, let's say in the case of Kenya, we have a country, okay, it's not as vast as some other African countries, but we have counties that are quite remote, very vast.
Speaker:The health facilities are still far away, they are not within the five-kilometre recommended radius for the residents to be able to access the facilities.
Speaker:So you'll find that in such a context, in the event of an emergency, when a mother needs emergency obstetric care, for instance, for instance, if there is a complication like postpartum haemorrhage, they start bleeding after delivery, the rule is that they should be able to reach the next facility within two hours.
Speaker:So if the road infrastructure is bad, there are no vehicles to take them to the next facility.
Speaker:It really becomes a difficult situation because all effort will be made, but the chances of reaching where care is available within the shortest time may not necessarily...
Speaker:it tends to work against the client, and then you may also find, because of that remoteness of that, the healthcare workers also may not be there.
Speaker:Healthcare workers in as much as governments make efforts to try and post healthcare workers to those remote facilities, keeping them there.
Speaker:Sometimes it's not possible.
Speaker:So you have few healthcare workers and sometimes also they are not upskilled continuously because the work area is very dynamic.
Speaker:The healthcare workers needs to be upskilled on a regular basis and a mechanism actually should be there to track that.
Speaker:Dr. Kim Ozano: And around the conversation of sustainability, you know, that's really what we're focused on today.
Speaker:Maybe this is a question for you, Nick.
Speaker:We see since COVID, we've seen increases in mental health issues, increases in domestic violence, gender inequities and migration increasing as well.
Speaker:What effect does all of these kind of challenges have on achieving maternal and newborn health goals?
Speaker:Dr. Nicolas Furtado: You bring up some of the most profound reasons that can affect health and wellbeing overall.
Speaker:But in the case of being a mother or looking after a newborn, these um, factors that you mentioned are even more profound because you can't stop a pregnancy.
Speaker:Pregnancy, it's part of a life process, of a life course, of a life cycle.
Speaker:And these are going to happen whether you have a conflict, whether you have money, you don't have money.
Speaker:Women are going to get pregnant and then they will need to have a delivery in a safe space and they will have a child or a newborn who's going to need to be supported to grow and develop over an entire life.
Speaker:And impact such as impact of conflict, the impact of of pandemics, of weather changes, of climate change, of the infrastructure is going to have a profound impact on this and what we have seen over the last, the four years of the pandemic and the resultant economic downturns in countries that have already been at a very low point in development has been very profound.
Speaker:And in terms of maternal and neonatal mortality, there have been huge stagnations.
Speaker:A lot of the progress that was was projected and targeted for these four years that we're coming out of has been either levelling off, or in some cases where the impact has been huge there's even been declines in some of the progress that have been made.
Speaker:So a lot of these key factors, the determinants of good care, of wellbeing and growth and development very important throughout all the work that we are doing.
Speaker:In addition to this, the response to the health system, there's a lot of responses of the overall macroeconomic economic situation.
Speaker:The situation that ministries of finance find themselves in and all of those have impacts on how work shapes out over the SDGs.
Speaker:Dr. Rael Mutai: Of course, during Covid we know that the supply systems were generally disrupted, so supplies would not get to the facilities.
Speaker:Some of the facilities were repurposed and clients would not even access ANC or skilled delivery because their facility was now a COVID centre or something like that.
Speaker:So, we can see that a climatic event, a pandemic and all this will disrupt access to services, meaning that the outcomes tend to worsen.
Speaker:And that is why now currently we are thinking in terms of intersectionality of factors.
Speaker:It is beyond the biomedical, sometimes, the reason why a mother or a baby dies is not because of what happened in that health facility.
Speaker:It is about the bigger picture of the things that are happening around them and there is really need to look into how all these determinants that are outside the health system, are coming together to impact on how women and children fair in each and every country.
Speaker:Dr. Kim Ozano: I think that's a really excellent point.
Speaker:And, focusing on the biomedical model often, doesn't allow us to look at the wider barriers that come from the social elements of living and the cultural aspects as well in different places in different countries and, I think it would be useful Nick, you represent a health system strengthening technical advice and partnership team and Rael has really highlighted that this is a health systems issue that cuts across so many different sectors and, we often see working in silos.
Speaker:So how do we overcome this and what are the innovations looking forward?
Speaker:Dr. Nicolas Furtado: One of the things about how systems work, and not just health systems, is that they adapt.
Speaker:The work that we are doing with Takeda, the COVID pandemic struck right in the middle just as we were launching the second year of the work.
Speaker:And from the point of view of capacity building, we had to reinvent the whole approach of how you're going to deliver this at a country level, we couldn't travel.
Speaker:There was no way of actually visiting facilities.
Speaker:So, we had to develop an entire new package of capacity building, which included, hybrid approaches to communicating information to providers of monitoring, of evaluating the impact of these services and these these capacity building interventions.
Speaker:So, I think one thing about crisis is that they bring in new innovation.
Speaker:So, in the context of say supply chain, for instance, different methodologies for providing, key supplies to health facilities, different ways of funding facilities so that they could source supplies at the local level, different approaches for those that were not possible before were found to be very effective during the pandemic.
Speaker:So, crisis can be can be can have like negative effects, but can also lead to innovations to overcome those negative effects.
Speaker:We saw that across the health system across many programmes, not just antenatal/postnatal care but HIV, TB, malaria programmes, and in some cases, some of the interventions have actually been continued because new ways of working to support like telemedicine and so on and so forth, have been continued and to great effect after the pandemic.
Speaker:I think innovative ways always found to overcome these obstacles, adaptive systems can respond to those crises.
Speaker:Dr. Rael Mutai: Yes.
Speaker:So, thinking about sustainability, sustainable development for capacity building of health care workers, for instance, because this has been the core of this programme.
Speaker:I think, what happens is in most sites, you find that there is no structured approach to upskilling of workers, especially once they're already in post, they are trained well in their pre-service schools, but when they are in post, the approach to that capacity building is not well structured in many places.
Speaker:So, I think one of the things that is required is how governments working with universities should work together with donors to be able to really gather the local evidence on what is working.
Speaker:For instance, if mentorship is an effective approach because one healthcare worker who is experienced and has attended a training can reach out to many more healthcare workers within their facility.
Speaker:That is something that is useful and can be replicated at a higher scale, and chances are that the training, the capacities, the competencies will be passed on from one generation to another.
Speaker:The other one is like a blended learning approach as opposed to a full training where healthcare workers have to close the health facility to go for training.
Speaker:They can do part of the training while they're working.
Speaker:and just may leave for, a couple of days to be able to do maybe the practical aspects of their training.
Speaker:But it may be even the bigger thing is to see how funding for these kinds of training can really be part of the domestic financing of the health system in every country.
Speaker:Because when it's part of the budgets within the national or subnational level, then we are guaranteed that these things will take place.
Speaker:And of course, performance tracking system should be in place to ensure that frequent, maybe every year or after two years, the healthcare worker should go through certain practical competencies to make them really efficient and confident to deliver the services, to make sure that the mothers and the babies are getting the best possible care that they could get in those facilities.
Speaker:Dr. Kim Ozano: And we've seen the evidence in Episode 2 of the practical application of those competencies and the real difference it makes to mothers and babies in the longer term as well as the short term.
Speaker:I think this conversation has been really quite insightful.
Speaker:We've heard a lot about adaptation and embedding those innovations.
Speaker:Rael, really nice to hear your call, we need to know what works.
Speaker:We need the evidence and to make sure it's a collaborative effort to apply that evidence as well.
Speaker:I especially like the intersectional lens approach and looking beyond the biomedical focus.
Speaker:We always like to end our podcast with a piece of advice and we're going to take that a step further today by asking for a call to action for anyone listening to this podcast who is also experiencing stagnation in maternal and newborn health.
Speaker:So, Nick, we'll start with you.
Speaker:A piece of advice for anyone working in this field and a call to action please.
Speaker:Dr. Nicolas Furtado: I would say that what has worked and what will continue is what is simple and effective at the point of care.
Speaker:Interventions that are very much either fitting in with what is possible, what is available to provide the best quality of care without too much of external support.
Speaker:So, in terms of advice, what we found from this programme also is the fact that when you have a small, simple, culturally acceptable, adaptive, and even affordable kind of interventions that will work, those are the ones that are most easy to sustain.
Speaker:And then in terms of a call to action, I think it's very simple.
Speaker:I think this is probably one of the most important areas of work that needs to continue, and I think we need to keep advocating for maternal and newborn health going forward.
Speaker:Let's not lose the focus of that because there are a lot of other waves coming like climate change and the effect of climate on health and so on.
Speaker:I think those are very important, but they have to be still focused down on the largest group of individuals that are vulnerable, so I would say continued advocacy, continued action on this area.
Speaker:Dr. Kim Ozano: So localised, affordable solutions and not to forget about this very important goal that affects so much of the population, even as climate change and other issues arise.
Speaker:Very good call to action there.
Speaker:Thank you very much.
Speaker:Rael your last piece of advice and call to action on this miniseries.
Speaker:Dr. Rael Mutai: I think what I can say is that the healthcare worker is at the centre of maternal and newborn healthcare.
Speaker:So, midwives and nurses provide on average more than 90 percent of the services that women and children need.
Speaker:So, investing in this kind of healthcare workers will really take us a long way in getting to the SDG targets.
Speaker:And these kinds of investment would entail considering other innovative approaches.
Speaker:For instance, a midwifery led model of care, because midwives have been found to be really effective in taking care of mothers and newborns.
Speaker:So there is really a need for countries to consider such approaches for us to be able to make an impact, whether even in context where healthcare workers may be few, for as long as you have a competent nurse, a competent midwife, the women and children will be assured of quality health care.
Speaker:Dr. Kim Ozano: What a great way to end this miniseries.
Speaker:A call there for a midwifery model of care to protect mothers and babies moving forward.
Speaker:So as always, thank you to our wonderful guests, Dr.
Speaker:Nick Furtado and Dr.
Speaker:Rael Mutai for sharing with us their very valuable insights.
Speaker:To our listeners, this is the last of this miniseries, sadly, on improving quality care in maternal and newborn health.
Speaker:However, our upcoming episodes are equally interesting as we warm up for the 8th Global Symposium on Health Systems Research in Nagasaki, Japan.
Speaker:So, look out for the next episode, where we will be discussing the theme of this symposium, which is building just and sustainable health systems, centring people and protecting the planet.
Speaker:Following this, we will be podcasting from the symposium, bringing you some of the discussions from the halls.
Speaker:So, whether you can join us in Japan, and do say hello if you're there, or if you can't, this will be opportunity for you to find out some of the innovations that are coming out of the symposium.
Speaker:Thank you for listening and have a good day.
