How can we improve implementation of life-saving interventions in maternal and newborn health?
October 15, 2017
Herbert B. Peterson, MD
William R. Kenan Jr. Professor of maternal and child health
Professor of obstetrics and gynecology, UNC School of Medicine
We are living in a profoundly important moment in global health. For the first time in human history, global leaders have declared their commitment to the well-being of every person on the planet, including every mother and every newborn child.
With the new United Nations Sustainable Development Goal of achieving “health and well-being for all” by 2030 and the related Secretary General’s “Global Strategy on Women’s, Children’s and Adolescents’ Health” goal of eliminating all preventable deaths among women, children and adolescents by 2030, we have unprecedented political will and a wonderful window of opportunity. Yet, to realize the potential of this moment, we must improve dramatically our ability to implement life-saving interventions at scale, particularly in the low- and middle-income countries, where doing so has been most challenging.
Can we do this? Absolutely! Our hopes for achieving this Sustainable Development Goal for mothers and their newborns are buoyed by the progress we have made. Between 1990 and 2015, we saw worldwide reductions in maternal and child mortality of 45 percent and 53 percent, respectively. This is incredible progress. Looking to the future, there is good reason to believe that the new and rapidly evolving focus of the global health community on implementation science will help us save even more lives.
Q: What are the biggest implementation challenges ahead?
A: Landmark studies in the 1990s showed us that, globally, most maternal deaths occurred because of emergency complications during childbirth. It became clear that we would save the lives of mothers and babies if – and only if – we ensured access to high- quality emergency obstetrical and newborn care services.
That, in turn, meant creating access to trained surgeons, well-equipped operating rooms, safe blood, and adequate medications and supplies. Because 99 percent of all maternal and newborn deaths occur in low- and middle- income countries, creating the capacity to put these services in place in a sustainable way has become a primary implementation challenge. A high proportion of births in these settings still occur outside of hospitals; many women labor and deliver in facilities that are understaffed, underequipped and have no running water or electricity.
It would be a mistake to believe that we don’t have related implementation challenges in the United States. In addition to having some of the highest maternal and infant mortality rates among high-income countries, we also have major health disparities. We continue to struggle with limited health services access, which affects far too many mothers and babies. To solve these problems, our drive to improve global health also must include a focus on health at home.
Q: What would an enhanced focus on implementation look like?
A: We have been remarkably successful in developing effective interventions for saving mothers and babies, but less successful at putting these interventions in place, especially in low-resource settings. Clearly, people do not benefit from interventions they do not experience.
It is imperative that we improve our ability to deliver ” these innovations to the people who need them most. Fortunately, the global health community has recognized the importance of an enhanced focus on implementation – and on science to support it. A recent synthesis of the evidence on implementation science, led by Dr. Dean Fixsen, concluded that successful and sustainable outcomes are contingent upon the interaction between three key components – effective interventions; effective implementation of these interventions; and contexts that support successful implementation.
Fixsen is research professor of maternal and child health at the Gillings School and co-founder of the National Implementation Research Network. Discovering how to maximize the synergy in these interactions is at the heart of the exciting new field of implementation science, which strives to make innovations easier to implement and contexts more supportive of successful implementation.
Q: Are you hopeful that we can close the gap between knowing what we need to do to save mothers and newborns and actually doing it?
A: I am, indeed! The global health community is now focused on this issue and UNC’s World Health Organization (WHO) Collaborating Center is ready and fully committed to helping lead the way. We are working closely with WHO and other United Nations colleagues, as well as other key stakeholders in the public and private sectors, to develop and support programs to ensure that innovations in maternal and newborn health are successfully and sustainably implemented at scale.
Our firm belief is that success on this front is contingent upon the creation of virtuous cycles between research and practice, such that our best research informs practice – and experience gained in practice informs future research. Generating these cycles will require intentional and effective collaborations between scientists, implementers, policy makers and funders. We also must build the capacity that countries need to address their ongoing challenges in implementation. Doing so rapidly will be essential for the scalability and sustainability of our most promising life-saving innovations.
This will take great effort, but mothers and babies the world over deserve quality care. We’re going to do everything we can to see that they receive it.
Some comments from this article also will appear in the journal Obstetrics and Gynecology, as part of the Hale Lecture, “Health and Well-being for All,” delivered by Peterson at the annual meeting of the American College of Obstetricians and Gynecologists, on May 6 in San Diego.
Carolina Public Health is a publication of the University of North Carolina at Chapel Hill Gillings School of Global Public Health. To view previous issues, please visit sph.unc.edu/cph.