To argue that strengthening health systems makes the difference between successes and reversals in maternal and newborn health has become a cliché.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 This consensus contrasts with the paucity of empirical documentation of the long-term efforts to adapt and strengthen health systems in support of maternal and newborn health.
Of the low-income and middle-income countries with currently more than 5 million inhabitants, 48 had a maternal mortality ratio of 200 per 100 000 livebirths or more in 1990 (Afghanistan, Angola, Bangladesh, Benin, Bolivia, Burkina Faso, Burundi, Cambodia, Cameroon, Chad, Côte d'Ivoire, Democratic Republic of the Congo, Dominican Republic, Eritrea, Ethiopia, Ghana, Guatemala, Guinea, Haiti, Honduras, India, Indonesia, Kenya, Lao, Madagascar, Malawi, Mali, Morocco, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Peru, Rwanda, Senegal, Sierra Leone, Somalia, South Sudan, Sudan, Tanzania, Togo, Uganda, Yemen, Zambia, and Zimbabwe). 21 of these 48 countries reduced this maternal mortality ratio by at least 2·5% per year between 1990 and 2000, and again between 2000 and 2010,15 a median drop in maternal mortality ratio of 63% over 20 years (appendix p 15).16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 These 21 countries are all either on track or making good progress towards Millennium Development Goal 5;15 in many of the other countries the hoped for 75% drop in maternal mortality15 is unlikely to have occurred before 2015.
These 21 countries made substantial efforts to enhance uptake of health services. Where data were available, they showed substantial increases in facility birthing (figure 1A). This increase in facility birthing contrasts with the slower or no progress made by 17 countries without a sustained or rapid reduction in maternal mortality ratio, for which sequential data on facility birthing were available (figure 1B). Five of those countries made slow but steady gains in facility birthing (Haiti, Honduras, Mali, Senegal, and Uganda). Three experienced drops in mortality from a high baseline, with little progress in facility-birthing (Chad, Nigeria, and Niger). Finally, the remaining nine countries made little or no progress or had a reversal in either maternal mortality ratio or facility birthing.
The evolution of the proportion of births attended by a midwife, auxiliary midwife, or nurse-midwife was documented in 15 of the 21 countries with sustained improvement in maternal mortality ratio: in four (Bangladesh, Bolivia, India, and Pakistan), although professional care at birth has increased, the proportion of births attended by a midwife, auxiliary midwife, or nurse-midwife has decreased in favour of those attended by medical doctors. In Burkina Faso, Cambodia, Indonesia, Malawi, Morocco, and Nepal, and to a lesser extent in Bangladesh and Eritrea, this proportion has increased (figure 2).
Key messages
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Effective coverage in the countries reviewed has crucially depended on the investment in the overall service delivery network and facility birthing. The expansion of the service network has kickstarted a virtuous cycle of uptake of care by mothers, deployment of midwives to both meet and generate increased demand, pressure to lift financial barriers and further uptake of maternal care.
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Attention for quality of care in the countries reviewed has taken off only when uptake of care had already substantially increased. Until very recent years they have given little or no attention to what midwives and doctors can do to curb overmedicalisation and promote respectful woman-centred care.
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The deployment of midwives in the countries reviewed has been the result of managerial choices to accelerate and operationalise universal access to care. Endorsement in the national political arena came only later in the process, once appreciation by the population of the successful deployment of midwives became apparent and civil society more vocal and assertive.
As a complement to the other papers28, 29 in this Series about midwifery, this paper documents the constellation of health-system efforts in support of maternal and newborn health in four of these 21 countries: Burkina Faso, Cambodia, Indonesia, and Morocco. These four countries have shown sustained and substantial reduction of maternal and newborn mortality while deploying midwives as a core constituent of their strategy (appendix p 1–14). These countries have shown gains in facility birthing in every wealth asset quintile (figure 3A) and the proportion of births attended by a midwife, auxiliary midwife, or nurse midwife has increased in the four lowest quintiles (Cambodia, Indonesia, and Morocco) or in all five quintiles (Burkina Faso; figure 3B).
