Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality.

This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.

Socio-economic improvements and health system strengthening of maternity care are contributing to maternal mortality reduction in Cambodia.

Maternal mortality has been falling significantly in Cambodia since 2005 though it had been stagnant for at least 15 years before that. This paper analyzes the evolution of some major societal and health system factors based on recent national and international reports. The maternal mortality ratio fell from 472 per 100,000 live births in 2000-2005 to 206 in 2006-2010. Background factors have included peace and stability, economic growth and poverty reduction, improved primary education, especially for girls, improved roads, improved access to information on health and health services via TV, radio and cellphones, and increased ability to communicate with and within the health system. Specific health system improvements include a rapid increase in facility-based births and skilled birth attendance, notably investment in midwifery training and numbers of midwives providing antenatal care and deliveries within an expanding primary health care network, a monetary incentive for facility-based midwives for every live birth conducted, and an expanding system of health equity funds, making health care free of cost for poor people. Several major challenges remain, including post-partum care, family planning, prevention and treatment of breast and cervical cancer, and addressing sexual violence against women, which need the same priority attention as maternity care.

Improving African health research capacity.

The issue of strengthening local research capacity in Africa is again high on the health and development agenda. The latest initiative comes from the Wellcome Trust. But when it comes to capacity development, one of the chief obstacles that health sectors in the region must confront is the migration of health professionals to countries that offer more lucrative opportunities, like those in western Europe. To combat this ''brain drain'', already back in 1984, the Swedish International Development Cooperation Agency (Sida) created a training programme in which healthcare professionals from Africa conducted the bulk of their research in their own countries. However, the model was only partly successful. Several years ago, we assessed the preconditions for the renewal of Sida support for research and research training activities in the region. Based on our work to develop a critical mass of beneficial research capacity in the countries of sub-Saharan Africa, this article suggests several recommendations to both donors and governments that have broad application for general health research issues in the region.

Integrating health interventions for women, newborn babies, and children: a framework for action.

For women and children, especially those who are poor and disadvantaged, to benefit from primary health care, they need to access and use cost-effective interventions for maternal, newborn, and child health. The challenge facing weak health systems is how to deliver such packages. Experiences from countries such as Iran, Malaysia, Sri Lanka, and China, and from projects in countries like Tanzania and India, show that outcomes in maternal, newborn, and child health can be improved through integrated packages of cost-effective health-care interventions that are implemented incrementally in accordance with the capacity of health systems. Such packages should include community-based interventions that act in combination with social protection and intersectoral action in education, infrastructure, and poverty reduction. Interventions need to be planned and implemented at the district level, which requires strengthening of district planning and management skills. Furthermore, districts need to be supported by national strategies and policies, and, in the case of the least developed countries, also by international donors and other partners. If packages for maternal, newborn and child health care can be integrated within a gradually strengthened primary health-care system, continuity of care will be improved, including access to basic referral care before and during pregnancy, birth, the postpartum period, and throughout childhood.

Factors affecting attitudes towards medical abortion in Lithuania.

OBJECTIVE: Surgical abortion in Lithuania is governed by a 1994 ministerial decree that made it legal for any woman 16 or older. This article seeks to determine the key demographic factors in Lithuanian attitudes towards medical abortion, which is currently not legal. METHODS: A random sample of the adult population was asked if they supported medical abortion. The dependent variable of attitude towards medical abortion was tested against the eight independent variables reported for each respondent using Chi-square tests and odds ratios. The effects of the variables upon each other were tested with two logistic regression models. RESULTS: Among the respondents, 62.6% supported access to medical abortion. The independent variables of urban/rural residence, employment status and educational level significantly affected opinion. Overall, education level provided the strongest odds ratio for support of medical abortion. CONCLUSION: The majority of the Lithuanian population supports the legalisation of medical abortion. There is somewhat less support for it in rural areas, among those who are least educated and in certain nonworking population groups. Lithuanian policy-makers should consider responding to popular sentiment and legalising medical abortion.

Confidentiality for adolescents seeking reproductive health care in Lithuania: the perceptions of general practitioners.

Confidentiality is a major determinant of the accessibility and acceptability of sexual and reproductive health care for adolescents. Previous research has revealed that Lithuanian adolescents lack confidence in guarantees of confidentiality in primary health care settings. This study aimed to assess the factors that affect general practitioners' decisions whether to respect confidentiality for Lithuanian adolescents under the age of 18. Twenty in-depth interviews were carried out with a purposive sample of general practitioners. The decision whether to respect confidentiality was found to be influenced by external forces, including the legislative framework and societal attitudes towards adolescent sexuality; institutional features in clinical facilities, such as the presence of a nurse during consultations and the openness of the medical record filing system; and individual factors, including GPs' relationships with adolescents' families and their personal attitudes towards sexual and reproductive health issues. The findings reflect the urgent need for a comprehensive policy to ensure adolescents' right to confidentiality in Lithuanian primary care settings, including legislative reforms, institutional changes in health care settings, professional guidelines and (self-)regulation, and changes in medical training and continuing medical education. Other ways to safeguard confidentiality in adolescent health services, such as establishing youth clinics, should also be explored.

Trends in maternal health/healthcare in low-income countries and the implications on neonatal health.

Maternal health in low-income countries has received increasing attention over the last 15-20 years. Maternal mortality ratios in these countries are mainly still modelled estimates and one cannot discern trends. The introduction of registration systems-giving reliable causes of death-is essential both for monitoring maternal health and fuelling action. Countries with documented success in reducing maternal mortality have used systematic, incremental approaches, often tied to multi-sectoral efforts, including roads, communication links, education, water and sanitation. Improving maternal health requires a reasonably well-functioning health system and this typically requires the reduction of poverty and consistent investment in the health system. Increasingly, policies to improve maternal and newborn health are being implemented, but in the poorest countries the impact is still not discernible. New clinical interventions, such as effective treatment of (pre)eclampsia and post-partum haemorrhage, are often beyond reach of the majority in low-income countries. In summary, progress in maternal health, and the intimately linked perinatal and newborn health, is too slow and requires urgent efforts in poverty reduction and health system strengthening in low-income countries.

Reducing maternal mortality: can we derive policy guidance from developing country experiences?

Developing countries are floundering in their efforts to meet the Millennium Development Goal of reducing maternal mortality by 75% by 2015. Two issues are being debated. Is it doable within this time frame? And is it affordable? Malaysia and Sri Lanka have in the past 50 years repeatedly halved their maternal mortality ratio (MMR) every 7-10 years to reduce MMR from over 500 to below 50. Experience from four other developing countries--Bolivia, Yunan in China, Egypt, and Jamaica-confirms that each was able to halve MMR in less than 10 years beginning from levels of 200-300. Malaysia and Sri Lanka, invested modestly (but wisely)--less than 0.4% of GDP--on maternal health throughout the period of decline, although the large majority of women depended on publicly funded maternal health care. Analysis of their experience suggests that provision of access to and removal of barriers for the use of skilled birth attendance has been the key. This included professionalization of midwifery and phasing out of traditional birth attendants; monitoring births and maternal deaths and use of such information for high profile advocacy on the importance of reducing maternal death; and addressing critical gaps in the health system; and reducing disparities between different groups through special attention to the poor and disadvantaged populations.