Learning from success: the main drivers of the maternal and newborn health transition in seven positive-outlier countries and implications for future policies and programmes

Abstract

Currently, about 8% of deaths worldwide are maternal or neonatal deaths, or stillbirths. Maternal and neonatal mortality have been a focus of the Millenium Development Goals and the Sustainable Development Goals, and mortality levels have improved since the 1990s. We aim to answer two questions: What were the key drivers of maternal and neonatal mortality reductions seen in seven positive-outlier countries from 2000 to the present? How generalisable are the findings?We identified positive-outlier countries with respect to maternal and neonatal mortality reduction since 2000. We selected seven, and synthesised experience to assess the contribution of the health sector to the mortality reduction, including the roles of access, uptake and quality of services, and of health system strengthening. We explored the wider context by examining the contribution of fertility declines, and the roles of socioeconomic and human development, particularly as they affected service use, the health system and fertility. We analysed government levers, namely policies and programmes implemented, investments in data and evidence, and political commitment and financing, and we examined international inputs. We contextualised these within a mortality transition framework.We found that strategies evolved over time as the contacts women and neonates had with health services increased. The seven countries tended to align with global recommendations but could be distinguished in that they moved progressively towards implementing their goals and in scaling-up services, rather than merely adopting policies. Strategies differed by phase in the transition framework-one size did not fit all.

Keywords: Child health; Health policy; Health systems evaluation; Maternal health; Public Health.

Figure 1. Mortality trajectories in the seven positive-outlier countries (2000–2017/2019) across the transition framework phases (log-scale maternal mortality ratio by sum of neonatal mortality and stillbirths per 1000 births). Inset is of two low-mortality Indian states and three high-mortality Indian states (log-scale maternal mortality ratio by neonatal mortality per 1000 live births).

Figure 2. Trajectories of institutional births in the seven positive-outlier countries (nearest years to 2000–2019) across the transition framework phases. Boxes show the median and IQR of all countries by phase, according to household surveys 2000–2020.

Figure 3. Place of birth (hospital, lower-level facility, home) (A) across the transition framework phases; and (B) the trajectories for the seven positive-outlier countries (nearest years to 2000–2019).

Figure 4. Caesarean-section rate trajectories among the poorest quintile in the seven positive-outlier countries (nearest years to 2000–2019) across the transition framework phases. Boxes show the median and IQR of all countries by phase, according to household surveys 2000–2020. In phase V, the upper bound of the IQR is truncated and should be 35%.

Figure 5. Total fertility rate trajectories in the seven positive-outlier countries (nearest years to 2000–2019), across the transition framework phases. Boxes show the median and IQR of all countries by phase, according to household surveys 2000–2020.