A Continuum of Care to Catch Those Who Fall Through the Cracks

by Sandra Yin

(June 2006) Mortality statistics paint a bleak picture about maternal and child health globally. Each year, more than 500,000 women worldwide die from complications related to pregnancy. About 4 million newborns (babies within their first month of life) die annually, as do more than 10 million children under age 5.¹

Yet most of these deaths—which tend to occur in low- and middle-income countries—are preventable. (See table for rates of infant mortality across a range of low-, middle-, and high-income countries.) Unfortunately, cost-effective health care that could save the lives of millions of mothers, newborns, and children is not always available to those who need it most.

Infant Mortality Rate and Gross National Income Per Capita, Selected Countries, 2004

Country	Number of deaths	GNI PPP per capita (USD)*
Sierra Leone	165	790
Niger	152	830
Haiti	74	1,680
India	62	3,100
Russian Federation	17	9,620
Finland	3	29,560

*GNI PPP per capita is the 2004 gross national income in purchasing power parity (PPP) divided by midyear population. GNI PPP refers to gross national income converted to international dollars using a purchasing power parity conversion factor. International dollars indicate the amount of goods and services one could buy in the United States with a given amount of money. Data are from the World Bank.

Sources: Save the Children, State of the World's Mothers 2006: The Complete Mothers' Index (2006); and C. Haub, 2005 World Population Data Sheet of the Population Reference Bureau (2005).

For example, more than 60 million women deliver at home without skilled care, and more than 3 million babies die as stillbirths.² Newborns can also fall through the cracks of health systems because they traditionally have been overlooked by both safe-motherhood and child-survival policies and programs.

Managing Care in a More Unified Way

But a new approach that focuses on offering a "continuum of care" to reach those mothers, newborns, and children in need is gaining momentum. Just as the household-to-hospital continuum of care is designed to ensure a seamless arc that spans the home, community, health center, and hospital, the maternal-newborn-child health continuum of care would manage the care of all in a more unified way than in the past.

"The maternal-newborn-child health continuum of care is an approach to healthcare that has great potential to save thousands of lives each year by catching those who used to fall through the gaps and by more effectively using scarce resources," says Erin Sines, a policy analyst at the Population Reference Bureau and lead author of a Saving Newborn Lives policy brief entitled The Maternal-Newborn-Child Health Continuum of Care: A Collective Effort to Save Lives.

Historically, maternal, newborn, and child health policies and programs have generally functioned in isolation—targeting interventions to only one group at a time and ignoring important connections between groups. But the whole equals more than the sum of its parts. Linking interventions in packages could save millions of lives at a lower cost than separate initiatives by allowing for greater efficiency in training, monitoring and supervision, and use of resources. Grouping interventions will also help families more easily access and take advantage of them.

The Fate of All Three Groups Is Tightly Linked

The continuum of care approach is based on the assumption that the health care of mothers, newborns, and children are tightly linked. In developing countries, if a mother dies in childbirth, her newborn will almost certainly die as well. And her older children are more likely to suffer from disease.

In addition, when mothers are malnourished, ill, or receive inadequate care, their newborns face a higher risk of disease and premature death. Nearly one in every four newborns in developing countries is born with low birth weight—largely due to their mothers' poor health and nutritional status, which makes infants more vulnerable to infection and puts them at higher risk of developmental problems.³

Universal coverage of 16 proven newborn health interventions could avert up to 72 percent of all newborn deaths, according to the Bellagio Study Group on Child Survival.⁴ These interventions include skilled attendants at birth; access to emergency obstetric care; immediate and exclusive breastfeeding; keeping the newborn warm, and if needed, resuscitated; care of low birth-weight infants; and treatment of infection. An estimated 63 percent of child mortality would be prevented with 99 percent coverage of effective and available interventions.⁵

Mothers could also potentially fare much better. The World Bank has estimated that 74 percent of maternal deaths could be averted if all women had access to interventions that address complications of pregnancy and childbirth, especially emergency obstetric care.⁶

Already at Work Around the World

The continuum of care approach has already been adopted by several groups and nations:

In 2005, the Child Survival Partnership, an international advocacy initiative, expanded its focus of reducing child mortality to include maternal and newborn health, with the newborn serving as a bridge between child and maternal health interventions and strategies.
The new global Partnership for Maternal, Newborn, and Child Health (PMNCH) has adopted the continuum of care approach as one of its guiding principles to improve the health and survival of mothers, newborns, and children. Members include donor agencies, professional associations, and academic institutions.
Members of the PMNCH and the government of Ethiopia are now working to support a national plan to expand and improve health services by following a continuum of care model.
The government in India has added a newborn component to its existing integrated management of childhood illness program. As part of the program, health workers and community nutrition and child development workers visit newborns at home three times within the first 10 days. Workers promote exclusive breastfeeding, early recognition of illness, and management of complications.

Saving the millions of women, newborns, and children who die each year from preventable causes poses a formidable challenge. Creating a maternal-newborn-child health continuum of care can result in considerable progress toward achieving these goals. A continuum of care lends one voice to the interconnected fields of maternal, newborn, and child health and helps ensure that the needs of each group are included in policies and programs.

Sandra Yin is associate editor at the Population Reference Bureau.

References

World Health Organization (WHO), The World Health Report 2005: Make Every Mother and Child Count (Geneva: WHO, 2005); and Robert Black, Saul Morris, and Jennifer Bryce, "Where and Why Are 10 Million Children Dying Every Year?" The Lancet 361, no. 9376 (2003): 2226-34.
Rudolf Knippenberg et al., "Systematic Scaling Up of Neonatal Care in Countries," The Lancet Neonatal Survival Series, no. 3 (March 2005); and Jelka Zupan and Elizabeth Aahman, Perinatal Mortality for the Year 2000: Estimates Developed by WHO (Geneva: WHO, 2005).
Anne Tinker and Elizabeth Ransom, "Healthy Mothers and Healthy Newborns: The Vital Link," Population Reference Bureau and Saving Newborn Lives Initiative (April 2002).
Gary L. Darmstadt et al., "Evidence-Based, Cost-Effective Interventions: How Many Newborn Babies Can We Save?" The Lancet 365, no. 9463 (2005): 977-88.
Gareth Jones et al. and The Bellagio Child Survival Study Group, "How Many Child Deaths Can We Prevent This Year?" The Lancet 362, no. 9377 (2003): 65-71.
Adam Wagstaff and Mariam Claeson, The Millennium Development Goals for Health: Rising to the Challenges (Washington, DC: World Bank, 2004).