Lynn P. Freedman

The evidence for emergency obstetric care

We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries.

Practical lessons from global safe motherhood initiatives: time for a new focus on implementation

The time is right to shift the focus of the global maternal health community to the challenges of effective implementation of services within districts. 20 years after the launch of the Safe Motherhood Initiative, the community has reached a broad consensus about priority interventions, incorporated these interventions into national policy documents, and organised globally in coalition with the newborn and child health communities. With changes in policy processes to emphasise country ownership, funding harmonisation, and results-based financing, the capacity of countries to implement services urgently needs to be strengthened. In this article, four global maternal health initiatives draw on their complementary experiences to identify a set of the central lessons on which to build a new, collaborative effort to implement equitable, sustainable maternal health services at scale. This implementation effort should focus on specific steps for strengthening the capacity of the district health system to convert inputs into functioning services that are accessible to and used by all segments of the population.

Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: A theoretical framework and research agenda

Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.

Transforming health systems to improve the lives of women and children

Ambitious quantitative goals for reducing mortality and increasing access to health interventions are nothing new to the areas of child maternal and reproductive health. They are the standard fare of global declarations and national 5-year plans. They come. They go. What makes the Millennium Development Goals (MDGs) different? With health firmly embedded in this wider poverty-reduction initiative which has garnered unprecedented consensus and support from governments and multilateral organisations the global health community has a rare opportunity to break through to new ways of thinking about the obstacles now blocking improvements in the health of women and children and to translate that thinking into bold new steps to meet goals 4 and 5 (table). For the UN Millennium Project Task Force on Child Health and Maternal Health the potential breakthrough lies in putting health systems at the centre of MDG strategies and in addressing these systems not only as delivery mechanisms for technical interventions but also as core social institutions—as part of the very fabric of social and civic life. In high-mortality countries today especially for the poorest populations health systems are frequently the source of catastrophic costs humiliating treatment and deepening social exclusion. But a different way is possible. Health systems can be a vehicle for fulfilling rights for active citizenship and for true democratic development—poverty reduction in its fullest sense. (excerpt)

Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas

Disrespectful and abusive treatment (D&A) of women during childbirth in facilities has evaded the attention of the global health community and of national and local health authorities, including those governing midwifery and other health professions, in countries worldwide, both rich and poor.

Using human rights in maternal mortality programs: from analysis to strategy

This article describes an approach to maternal mortality reduction that uses human rights not simply to denounce the injustice of death in pregnancy and childbirth, but also to guide the design and implementation of maternal mortality policies and programs. As a first principle, programs and policies need to prioritize measures that promote universal access to high quality emergency obstetric care services, which we know from health research are essential to saving womens lives. With that priority, human rights principles can be integrated into programs at the clinical, facility management, and national policy levels. For example, a human rights ‘audit’ can help identify ways to encourage respectful, non‐discriminatory treatment of patients, providers and staff in the clinical setting. Human rights principles of entitlement and accountability can inform mechanisms of community participation designed to improve responsiveness and functioning of health facilities. Human rights principles can inform analysis of health sector reform and its impact on access to emergency obstetric care. Whether applied to the intricacies of human relationships within a facility or to the impact of international financial institutions on health systems, the ultimate role of human rights is to identify the workings of power that keep unacceptable levels of maternal morality as they are and to use the human rights vision of dignity and social justice to work for the re‐arrangements of power necessary for change.

Disrespectful and abusive treatment during facility delivery in Tanzania: a facility and community survey

Although qualitative studies have raised attention to humiliating treatment of women during labour and delivery, there are no reliable estimates of the prevalence of disrespectful and abusive treatment in health facilities. We measured the frequency of reported abusive experiences during facility childbirth in eight health facilities in Tanzania and examined associated factors. The study was conducted in rural northeastern Tanzania. Using a structured questionnaire, we interviewed women who had delivered in health facilities upon discharge and re-interviewed a randomly selected subset 5-10 weeks later in the community. We calculated frequencies of 14 abusive experiences and the prevalence of any disrespect/abuse. We performed logistic regression to analyse associations between abusive treatment and individual and birth experience characteristics. A total of 1779 women participated in the exit survey (70.6% response rate) and 593 were re-interviewed at home (75.8% response rate). The frequency of any abusive or disrespectful treatment during childbirth was 343 (19.48%) in the exit sample and 167 (28.21%) in the follow-up sample; the difference may be due to courtesy bias in exit interviews. The most common events reported on follow-up were being ignored (N = 84, 14.24%), being shouted at (N = 78, 13.18%) and receiving negative or threatening comments (N = 68, 11.54%). Thirty women (5.1%) were slapped or pinched and 31 women (5.31%) delivered alone. In the follow-up sample women with secondary education were more likely to report abusive treatment (odds ratio (OR) 1.48, confidence interval (CI): 1.10-1.98), as were poor women (OR 1.80, CI: 1.31-2.47) and women with self-reported depression in the previous year (OR 1.62, CI: 1.23-2.14). Between 19% and 28% of women in eight facilities in northeastern Tanzania experienced disrespectful and/or abusive treatment from health providers during childbirth. This is a health system crisis that requires urgent solutions both to ensure womens right to dignity in health care and to improve effective utilization of facilities for childbirth in order to reduce maternal mortality.

Defining disrespect and abuse of women in childbirth: a research policy and rights agenda.

PerspectivesIn the field of maternal and newborn health, there have been calls to prioritize the intra-partum period and promote facility delivery to meet maternal and newborn mortality reduction goals. This aim is based on a decade of epide-miological work identifying causes of death, systematically reviewing effective interventions, and modelling the impact of intervention coverage on mortality.

Using a GIS to model interventions to strengthen the emergency referral system for maternal and newborn health in Ethiopia

To show how GIS can be used by health planners to make informed decisions about interventions to increase access to emergency services.

Human rights, constructive accountability and maternal mortality in the Dominican Republic: a commentary

The very publication of the article by Miller et al. in this journal is an important part of the constructive accountability process. Of course the analysis can go deeper. There are unanswered questions: who are the women who have suffered such sub-standard care and borne the brunt of unacceptably high maternal mortality in the Dominican Republic? Is inequity in the health system falling along critical social fault lines so that it needs also to be addressed as an issue of discrimination as well? What role have donors played? What role have health sector reform policies played? What needs to be done at the local level in each facility and at the structural level in the system as a whole to ensure that the norms are followed? The process of strategic assessment and followup described in Miller et al. is the beginning. The seriousness with which the government appears to be taking the issue is an important start. Now all actors have a role in ensuring that this process moves forward that the facts elicited in assessments lead to appropriate measures for the progressive realization of the right to life and to health for the people of the Dominican Republic. Many of us will watch the process hoping that the Dominican Republic will become the next success story for reducing maternal mortality—and that it will use a transparent participatory rights-based approach to do so. (excerpt)