Building a post-COVID-19 health system: Insights from Strategies to End Preventable Maternal Mortality

By Nisha Singh, Advocacy Officer, White Ribbon Alliance

The COVID-19 pandemic has awoken the world to some hard truths: our global health systems are weak, and inequities and challenges often hit pregnant women and newborns the hardest.

Before COVID-19, many pregnant women in low- and middle-income countries already had difficulty accessing health facilities, skilled birth attendants and quality care. Now, these same health facilities lack the financing, equipment and adequate worker coverage that are so desperately needed for COVID-19 patients, let alone pregnant and laboring women. In the era of COVID-19, we see that women are likely to face disproportionately negative impacts on their sexual and reproductive health as resources are channeled away from these essential services. Additionally, we are hearing wrenching stories of women losing their lives in childbirth due to COVID-19 response measures, such as lockdowns and curfews, that impede laboring women’s ability to travel to facilities. Without active intervention and a women-centered response, COVID-19 could undo decades of effort to reduce maternal and child mortality, and lead to an  additional 56,700 maternal deaths and 1,157,000 additional child deaths within the next six months. The actions we take right now can mitigate that.

As global health leaders seek to address COVID-19 while protecting the health and rights of pregnant women and newborns, they must  take a fresh look at existing guidance, including Strategies toward Ending Preventable Maternal Mortality (EPMM). This direction-setting report released by the World Health Organization (WHO) in 2015 outlines global targets and strategies for reducing maternal mortality in the Sustainable Development Goals (SDG) period. The same EPMM Strategies that promote measures to tackle the social and structural drivers of maternal death and disability – such as socio-economic status, women’s empowerment, healthcare financing and rights protection – are key to any long-term COVID-19 response.

Over the past few years, White Ribbon Alliance (WRA), as a collaborator on the Improving Maternal Health Measurement Capacity and Use (IMHM) project led by the Women & Health Initiative of the Harvard T. H. Chan School of Public Health, has elevated attention to the EPMM Strategies in various countries. In partnership with FCI program of Management Sciences for Health, White Ribbon Alliance worked closely with the Women & Health Initiative, national governments, local partners and multilateral organizations including WHO and the United Nations Population Fund, to organize a series of multi-stakeholder national dialogues on maternal health. The most recent dialogues took place in Mexico (July 2019), Pakistan (October 2019) and Nigeria (March 2020).

National dialogues examined maternal health measurement as one key approach to ending preventable maternal mortality, and spurred participants to consider the broader systemic factors driving maternal mortality and their related solutions. For example, stakeholders identified the following key themes as relevant and meaningful to their country contexts – themes that take on even more urgency in the era of COVID-19:

  • Allocate adequate resources and effective healthcare financing (Mexico, Pakistan, Nigeria)
  • Apply a human rights framework to ensure that high-quality reproductive, maternal and newborn healthcare is available, accessible and acceptable to all who need it (Mexico, Pakistan, Nigeria)
  • Strengthen health systems to respond to the needs and priorities of women and girls (Mexico, Pakistan)
  • Address inequities in access to and quality of sexual, reproductive, maternal and newborn healthcare (Mexico)
  • Ensure country ownership, leadership, and supportive legal, regulatory and financial frameworks (Nigeria)

Dialogue participants resolved to take action on these themes, for example, through a transparent and health budget allocation with annual multisectoral review (Nigeria), provincial budget advocacy strategies that incorporate community participation and government accountability mechanisms (Pakistan), and  commitments by the Ministry of Health to incorporate prioritized EPMM indicators in the revision of its maternal health strategy  (Mexico).

Since the conclusion of the dialogues, COVID-19 has commanded the attention of governments everywhere. Focus has pivoted to stopping the spread of the virus. This, in turn, has diverted much needed investment for reproductive, maternal and newborn health and has threatened to undo gains in these areas that were already so hard-won. COVID-19 has exposed the weaknesses in our health systems that continue to disproportionately exacerbate vulnerabilities for women and newborns. Now, evidence from previous outbreaks, such as Ebola in 2014, and current modeling  suggest that – without interventions to ensure that reproductive, maternal, newborn and child health services are upheld as essential services during COVID-19 – the indirect effects of COVID-19 and reduced health coverage may lead to more deaths than those directly from the virus. If our health systems, care-seeking patterns and national health budgets are permanently channeled away from these efforts and we do not take strides now to build our health systems back better, rather than settling for the old normal, this could lead to lasting effects on maternal and child mortality.

Our response to this pandemic is an opportunity to come together and set forth a vision and action plan for rebuilding the world’s systems of care to be better and stronger. It is our responsibility to apply our collective knowledge and frameworks like the EPMM Strategies to build a new system that uses rights-based frameworks in healthcare delivery; supports innovation, coordination and efficiency in country-level health systems; and elevates the experiences of women and girls to ensure that quality healthcare is available, acceptable and accessible to all. There are a few important places where we should start. We must ensure that reproductive, maternal and newborn health stakeholders have a seat at the decision-making table for COVID-19, that reproductive, maternal and newborn health are prioritized in COVID-19 action plans and that recommendations from the national dialogues are prioritized in the pandemic response.

Addressing the social and structural determinants of health is imperative to ending preventable maternal mortality and overcoming a global pandemic. We must bring these conversations together as we chart the path forward.