Increased utilisation and quality: a focus on inequality and a learning health system approach-explaining Nepal's success in reducing maternal and newborn mortality 2000-2020.

INTRODUCTION: Maternal mortality in Nepal dropped from 553 to 186 per 100 000 live births during 2000-2017 (66% decline). Neonatal mortality dropped from 40 to 21 per 1000 live births during 2000-2018 (48% decline). Stillbirths dropped from 28 to 18 per 1000 births during 2000-2019 (34% decline). Nepal outperformed other countries in these mortality improvements when adjusted for economic growth, making Nepal a 'success'. Our study describes mechanisms which contributed to these achievements. METHODS: A mixed-method case study was used to identify drivers of mortality decline. Methods used included a literature review, key-informant interviews, focus-group discussions, secondary analysis of datasets, and validation workshops. RESULTS: Despite geographical challenges and periods of political instability, Nepal massively increased the percentage of women delivering in health facilities with skilled birth attendance between 2000 and 2019. Although challenges remain, there was also evidence in improved quality and equity-of-access to antenatal care and childbirth services. The study found policymaking and implementation processes were adaptive, evidence-informed, made use of data and research, and involved participants inside and outside government. There was a consistent focus on reducing inequalities. CONCLUSION: Policies and programmes Nepal implemented between 2000 and 2020 to improve maternal and newborn health outcomes were not unique. In this paper, we argue that Nepal was able to move rapidly from stage 2 to stage 3 in the mortality transition framework not because of what they did, but how they did it. Despite its achievements, Nepal still faces many challenges in ensuring equal access to quality-care for all women and newborns.

Approaching the SDG targets with sustained political commitment: drivers of the notable decline in maternal and neonatal mortality in Morocco.

BACKGROUND: Between 2000 and 2017/2018, Morocco reduced its maternal mortality ratio by 68% and its neonatal mortality rate by 52%-a higher improvement than other North African countries. We conducted the Exemplars in Maternal and Neonatal Health study to systematically and comprehensively research factors associated with this rapid reduction in mortality over the past two decades. METHODS: The study was conducted from September 2020 to December 2021 using mixed methods, including: literature, database and document reviews, quantitative analyses of national data sets and qualitative key-informant interviews at national and district levels. Analyses were based on a conceptual framework of drivers of health and survival of mothers and neonates. RESULTS: A favourable political and economic environment, and a high political commitment encouraged prioritisation of maternal and neonatal health (MNH) by aligning evidence-based policy and technical approaches. Five main factors accounted for Morocco's success: (1) continuous increases in antenatal care and institutional delivery and reductions socioeconomically-based inequalities in MNH service usage; (2) health-system strengthening by expanding the network of health facilities, with increased uptake of facility birthing, scale-up of the production of midwives, reductions in financial barriers and, later in the process, attention to improving the quality of care; (3) improved underlying health status of women and changes in reproductive patterns; (4) a supportive policy and infrastructure environment; and 5) increased education and autonomy of women. CONCLUSION: Our study provides evidence that supportive changes in Morocco's policy environment for maternal health, backed by greater political will and increased resources, significantly contributed to the dramatic progress in reducing maternal and neonatal mortality. While these efforts were successful in improving MNH in Morocco, several implementation challenges still require special attention and renewed political attention is needed.