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ا جة الصحية لشق ا تو ط

5

ا جد الع ونوا دعلا

Invited review

Reducing the burden of maternal and child morbidityand mortality in the Eastern Mediterranean Region?

Yes, we can Mahmoud Fahmy Fathalla1

ABSTRACT Maternal and child morbidity and mortality are a major public health, development and human rights

challenge globally and in the WHO Eastern Mediterranean Region. The Region is diverse, with high-, middle-

and low- income countries, many suffering from political instability, conflicts and other complex development

challenges. Although progress has been made towards Millennium Development Goals 4 and 5, it has been uneven

both between and within countries. This paper makes an analysis of the strengths, weaknesses, opportunities and

threats to improving maternal and child mortality and morbidity with a focus on the Region. In answer to the

question whether we can reduce the burden of maternal and child morbidity and mortality in the Region: yes, wecan. However, commitment and collaboration are needed at the country, regional and international levels.

1Professor of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, University of Assiut, Assiut, Egypt.

ك ي ذل ت ن ، ن ؟سو ت ش يق إ اط اه م ةضرم اي ف ءب اص ع ن إ و

ة وة نة حو ا ف جوت ي اد سو ش ق ف اط اه ةر ا ت : صل ا دع ا ، خد ة ضن دب خد ةسو رخأ خد ةتر دب ،ون س ق ا .ةا ة ةظن سو ش ق ر 5 4 ر و د ت رح ت ا غ ف نة. د اد اع ص ا رس دع دب ر ،و ا ض طو ةقو ذ دت .دح ع د ك ب د ب ا د إ ، ة ةئمعء ا رة ا ا دب اك ا وح ؤ و .ق ف اط اه ةر ا ى ف دده

ق دل. نطو د ع اب و ا ز أ ، و ق ف اط اه

La réduction de la charge de la morbidité et de la mortalité maternelles et infantiles est effectivement possibledans la Région de la Méditerranée orientale

RÉSUMÉ La morbidité et la mortalité maternelles et infantiles constituent un défi majeur en matière de santépublique, de développement et de droits de l’homme au niveau mondial ainsi que dans la Région OMS dela Méditerranée orientale. La Région est hétérogène et comprend des pays à revenus élevé, intermédiaireet faible, dont plusieurs connaissent une instabilité politique, des conflits ainsi que d’autres problèmes dedéveloppement complexes. Malgré les progrès accomplis vers la réalisation des objectifs du Millénairepour le développement 4 et 5, des inégalités ont été observées aux niveaux régional et national. Le présentarticle analyse les forces, faiblesses, opportunités et menaces en matière d’amélioration de la mortalité etde la morbidité maternelles et infantiles dans la Région. La réponse à la question de savoir si nous pouvonseffectivement réduire la charge de la morbidité et de la mortalité maternelle et infantile dans la Région estaffirmative. Un engagement et une collaboration sont néanmoins nécessaires aux niveaux national, régionalet international.

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EMHJ • Vol. 20 No. 1 • 2014 Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientale

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The challenge

I is esimaed ha every year in he WHO Easern Medierranean Region(EMR) around 923 000 children under

5 years o age sill die as a resul o com-mon childhood diseases and 39 000 women o childbearing age die as a re-sul o pregnancy-relaed complicaions[1]. Moraliy figures are indicaive o amuch greaer magniude o morbidiyand disabiliy. Maernal and child mor-aliy and morbidiy are no only a majorpublic healh challenge in he Regionand worldwide, hey are also a develop-men challenge, explicily highlighed

as 2 o he 8 Millennium DevelopmenGoals (MDGs) [2]. Sae moherhoodis also a human righ o women hashould be respeced, proeced andimplemened [3].

EMR is a diverse region ha in-cludes high-income counries in whichsocioeconomic developmen has pro-gressed considerably over he las 4 dec-ades; middle-income counries whichhave well-developed healh service de-

livery inrasrucures bu ace resourceconsrains; and low-income counries

which lack resources or healh. Manycounries o he Region are sufferingrom poliical insabiliy, conflics andoher complex developmen challenges.

Progress in he Region owards heMDGs has been variable [4]. MDG 4,relaing o reducion o under 5 moral-iy, has been achieved by 4 counriesonly, while anoher 9 counries areon rack and 10 counries are unlikelyo achieve he goal, based on currenrends. MDG 5, relaing o reducion inmaernal moraliy, has been achieved

by 6 counries, while 8 counries are onrack and 9 are no expeced o achievehe goal, based on curren rends.

Worldwide, o he 75 counries wheremore han 95% o all maernal and childdeahs occur, 10 counries are rom heRegion: Aghanisan, Djiboui, Egyp,Iraq, Morocco, Pakisan, Somalia, SouhSudan, Sudan and Yemen [5].

Can we reduce theunacceptable burden ofmaternal & child morbidityand mortality in EMR?

o answer his quesion we need o un-derake a SWO analysis, o examineour srenghs, weaknesses, opporuni-ies and hreas, a echnique widely usedin he business world [6]. Apar romanswering he quesion o easibiliy oachieving he goals, he analysis will beuseul in guiding he sraegy o deal wihhe challenge. Te analysis presenedhere is no mean o be comprehensive.Te aim is o highligh some salienareas or each elemen o he analysis.

Strengths

wo areas o srengh give us encour-agemen and confidence. Firs, evi-dence-based inervenions are alreadyknown, have been esed, have beenshown o work and can have an impac.Secondly, many counries worldwide insimilar socioeconomic siuaions haveachieved success.

Evidence-based interventionsare already known

Evidence-based packages o inerven-ions are already available in a con-inuum o care or maernal and childhealh [7]. For saer moherhood, preg-nancy mus be a volunary choice orhe woman and she should have accesso prenaal care, delivery by skilled birhatendans and lie-saving emergency

obseric care i needed [8]. Evidence- based inervenions are available o deal wih he main causes o under-5 childmoraliy: diarrhoea, pneumonia, mea-sles, malaria, HIV/AIDS, birh asphyxia,preerm delivery, neonaal eanus andneonaal sepsis. Child survival inerven-ions are easible o deliver wih highcoverage in low-income setings [9].

While all elemens o he evidence- based packages should be implemenedin he Region, 2 areas need more em-phasis: amily planning and perinaal

healh. Family planning has an impacon moher and child, apar rom oher

benefis. An unm e need or amilyplanning, paricularly or modern meh-ods and or spacing and/or limiing o

childbearing, has been demonsraed incounries o he Region where demo-graphic and healh surveys have beenconduced. Te unme need or am-ily planning ranged rom 8% o 20% omarried women o reproducive age oknown eriliy [10]. Childhood deahsin EMR are increasingly concenraedin he firs monh o lie [5] and evi-dence-based inervenions need o beinensified o reduce perinaal moraliy.

Progress has been made

Beween 1990 and 2011, under-5 mor-aliy declined in EMR by 41%, maernalmoraliy declined by 42% beween 1990and 2010, and he Region winessed anumber o success sories [1]. Exchangeo experiences and muual learning be-ween counries can pay dividends .

Weaknesseswo areas o weakness in he EMRshould be aken ino consideraion andneed o be addressed. Te firs is heconsrains o he healh-care sysems.Te second is he lack o evidence-

base d ino rmaion rom counri es oguide policy- and decision-making.

Health care systems

Healh sysems in he Region ace manychallenges ha are generally cross-cuting in naure and apply o moscounries irrespecive o socioeconomicand healh saus o heir populaions[11]. Te 3 main inpus needed ora healh-care sysem o uncion are:human capial, physical capial and con-sumables [12]. An appropriae balance

bewe en hese inpus is necessary orgood uncioning o he sysem. Inves-mens in hese are ofen imbalanced,however, paricularly in counries wihlimied resources. Te bias is owards an

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increased invesmen in physical capial,a he expense o human capial and con-sumables. Governmens and exernal aidagencies have conribued o his unbal-anced inpu mix by ocusing on highly

vis ibl e inves men s wihou adequaeconsideraion o he need or oher in- vesmens and he recurren coss haensure proper uncioning o he sysem[12]. A healh-care sysem ha is soundin srucure may no be sound in unc-ion, as he experience in some counrieshas demonsraed [13]: “Good anaomydoes no mean good physiology” [14].

Te overall healh workorce densiyin he Region is below he global aver-

age o 4 skilled healh workers per 1000populaion. Eigh counries (Aghani-san, Djiboui, Iraq, Morocco, Pakisan,Somalia, Sudan and Yemen) are classi-fied as acing a crisis in human resourcesor healh [15].

Evidence-based informationfor policy- and decision-making

Almos 40% o counries in he Region

have inadequae or weak civil regisra-ion mechanisms and vial saisics,and only 25% have saisacory sysems.Overall, hese sysems serve only 5.3%o he populaion in he Region [15].

Te Commission on Inormaionand Accounabiliy proposed he ol-lowing core indicaors o monior heimpac o inervenions and develop-men o programmes: maernal mor-aliy raio; under-5 moraliy rae and

he proporion o newborn deahs;children under 5 years o age who aresuned; demand or amily planningsaisfied (me need or conracepion);adequae anenaal care coverage (aleas 4 visis during pregnancy); avail-abiliy o anireroviral prophylaxisor HIV-posiive pregnan women opreven moher-o-child ransmissiono HIV and anireroviral herapy orHIV-posiive pregnan women who are

reamen-eligible; skilled atendan a birh; posnaal care or mohers and babies wihin 2 days o birh; exclusive

breaseeding or he firs 6 monhs olie; 3 doses o combined diphheria-e-anus-perussis immunizaion coverage;and availabiliy o anibioic reamenor pneumonia [5].

When daa are colleced, hey should be viewed and analysed hrough an eq-uiy lens. Naional averages and overallcoverage raes can mask gross inequi-ies. Inequiies in healh represen hemos imporan challenge acing manycounries o he Region [4]. Inequiyis paricularly eviden or inervenionsha require a uncioning healh sysem.Counries achieving rapid progress in in-ervenion coverage have accomplished

his primarily by improving coverage inhe poores wealh quiniles [5].

Even when naional inormaionsysems are lacking, some inormaioncan sill be gahered and pu o use oguide pracices, decisions and policies.Confidenial enquiries ino he causeso cases o maernal moraliy provideone such model. Tey can be con-duced a he communiy, healh careaciliy, disric, regional or naional level

[16]. Experience has shown ha he useo hese reviews can have a significanimpac even wihou any subsanialincrease in public expendiure.

Opportunities

Scienific research, including healhsysems research, is providing opporuni-ies ha can be seized o improve he

coverage o maernal and child healhservices in EMR. Tese include inno-

vaions in echnologies appropriae orlow-resource setings, and improvingservice delivery and coverage hroughask shifing and mobile healh iniiaives.

Innovations in appropriatetechnology

Low-cos innovaions, made more avail-able in low-resource counries, can con-

ribue o saving he lives o mohers andchildren [17]. Tese include, amongohers: he non-pneumaic ani-shock

garmen o slow excessive bleedingafer childbirh and sabilize he moherunil she can be reaed a an emergencycare aciliy; magnesium sulphae, aa cos o less han a dollar per dose, o

preven and rea lie-hreaening con- vul sio ns amo ng wom en wi h sev erepre-eclampsia and eclampsia; chlorhex-idine, a low-cos anisepic o reduce herisk o lie-hreaening inecions via henewly cu umbilical cord; and Roavac®,an affordable new vaccine o proecchildren rom roavirus inecion, a opcause o deadly diarrhoea in developingcounries. So-called “kangaroo care”, a

way o holding a preerm or ull-erm in-

an so ha here is skin-o-skin conac beween he inan and he person hold-ing i, can be an alernaive o neonaalinensive care incubaors [18].

Task shift ing

Access o care may be imp roved byraining and enabling mid-level andlay healh workers o perorm specificinervenions ha migh oherwise beprovided by cadres o workers wih

longer and/or more specialized rain-ing. Such ask-shifing sraegies migh be paricularly atracive o EMR coun-ries which lack he means o improveaccess o care wihin a shor period oime. A WHO Guidance Panel made119 recommendaions or appropriaeask shifing: 36 or lay healh workers,23 or auxiliary nurses, 17 or auxiliarynurse midwives, 13 or nurses, 13 ormidwives, 8 or associae clinicians, 8 or

advanced level associae clinicians and 1or non-specialis docors [19].

Lay or communiy healh workers, who have no received a ormal proes-sional or paraproessional cerificae oreriary educaion degree, can be rainedand uilized, according o he WHOrepor, o promoe he upake o ma-ernal and newborn-relaed healh care

behaviour and services, o provide con-inuous social suppor during labour (in

he presence o a skilled birh atendan)and o adminiser misoprosol o preven posparum hae morr hage when

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skilled birh atendans are no presenand oxyocin is no available [20].

A nu mb er o co un r ie s in su b-Saharan Arica have successully usednon-physicians o perorm major emer-

gency obserical surgery. In anzania,or example, assisan medical officersprovide mos o his surgery ouside omajor ciies. Sudies have demonsraedno significan differences beween hecare o assisan medical officers andmedical officers in erms o oucomes,risk indicaors or qualiy o care [21].

Mobile health (mHealth)

Wi h ov er 6 bi ll io n mo bi le ph on e

subscripions spread across a worldpopulaion o over 7 billion, mobile ech-nologies are rapidly peneraing even hemos remoe corners o he world. For

women and newborns in many low- andmiddle-income counries, he rapid ex-pansion o mobile phone echnology in-rasrucure presens an unprecedenedopporuniy o increase access o healhcare and o save lives [22,23]. Womencan be provided wih inormaion

services by phone. Communiy-basedhealh workers can be provided wihpoin-o-care decision suppor ools.Daa can also flow hrough a healhsysem in real-ime, and deliver criicalinormaion o suppor women’s andproviders’ needs in a imely and efficienmanner. A his ime, alhough mHealhapplicaions are in he ormaive sage,he evidence or heir effeciveness andimpac is growing rapidly.

Threats

wo paricular caegories o hreas inhe EMR may be impeding progressowards MDGs 4 and 5. Te firs in-cludes naural disasers, armed conflics,and poliical insecuriy and insabiliy.Te second is emergence o new healhhreas. Tese hreas can have a dual

impac on maernal and child healh: adirec impac on mohers and children who are vulnerable populaion groups,

and an indirec impac by divering heofen limied resources available ormaernal and child healh.

The threat of natural and man-made disasters

EMR is a high-risk region or nauralhazards such as earhquakes, floods anddrough. Poliical insabiliy and civilconflic are posing new hreas. In hepas 2 years, 13 counries in he Regionhave experienced such emergencies,

wih more han 42 mill ion peopl e a-eced [15]. Emergency preparednessand response are a prioriy area orcounries in EMR. Disasers, wheher

naural, or man-made as is ofen hecase, will adversely affec he implemen-aion and achievemens o child andmaernal healh programmes.

Vaccinaion agains poliomyeli is isan example o how armed conflic, insecu-riy and poliical insabiliy hinder univer-sal coverage. All counries o he Regionare ree rom polio, excep Aghanisanand Pakisan, where conflic, accessproblems and disinormaion among he

populaion have hindered progress inhe counries and are posing he hrea ospread o oher polio-ree counries [24].

Emergence of new healththreats

Te HIV epidemic has coninued ospread hrough he Region. Alhoughhe overall prevalence in he generalpopulaion is sill low, he proporiono newly ineced people among all

people living wih HIV is he highesglobally [1]. Where i is prevalen, HIVinecion will be an imporan cause orchild and maernal moraliy. I can alsodrain resources rom maernal and childhealh programmes. HIV worldwide hasa vocal advocacy consiuency, whichmaernal and child healh do no have.Te Accounabiliy Commission reporor 2013 cies such an example [5]. Al-hough mos o he counries reviewed

began wih low coverage levels or care-seeking or pneumonia and or preven-ion o moher-o-child ransmission

o HIV, afer 5 years he coverage wasconsiderably greaer or HIV preven-ion in every counry. Some counrieseven experienced drops in coverage orpneumonia. Te repor noed ha his

was in spie o he ac ha pneumoniaand diarrhoea ogeher accoun or 2million child deahs each year (nearly 15imes he number o child deahs caused

by AID S). Te mes sag e is no abo ucuting he resources allocaed or HIV,

bu o call or he same level o ateniono be exended o oher leading killers o

women and children.

Anoher emerging healh hrea hais causing considerable concern in he

Region is he Middle Eas respiraorysyndrome coronavirus [25].

Yes, we can

Tis analysis o he srenghs, weakness-es, opporuniies and hreas answershe quesion wheher we can reduce he

burden o maernal and child morbidiyand moraliy in he Region: yes, we can.Bu he conclusion has o be qualified.

We can, provided we have he commi-men and we collaborae ogeher a hecounry, regional and inernaional levelowards he objecive.

A solemn commi men o coll abo-raion was made on 30 January 2013 inDubai, when he minisers o healh anddelegaes o counries o he EMR, rep-resenaives o Unied Naions agenciesand inernaional, regional and naional

insiuions paricipaing in he High-levelMeeing on Saving he Lives o Mohersand Children: Rising o he Challenge,pledged o “accelerae progress on maer-nal, newborn, child and adolescen healhhrough naional acion and inernaionalcooperaion, o hold hemselves ac-counable or collecive progress owardshis goal, and on behal o all mohers,adolescens and children in he Region,recommi o give every woman he bes

opporuniy or sae delivery so ha everychild has he bes possible sar in lie” [26].

Competing interests: None declared.

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