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We thank Hanson and colleagues for their editorial response1 to our paper, Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap2. Reassessment of care models for childbirth in low-income countries is urgently needed to change stubbornly flat trajectories of maternal and newborn mortality. The central point of our paper is that the current childbirth care model that sends one-third or more of pregnant women to deliver in under-equipped, understaffed, low-volume health clinics in the highest mortality countries is not evidence-based, ethical or equitable and that convergence with global best practice—delivery in highly skilled facilities—is long overdue.
Hanson and colleagues note that primary care facilities might perform better if they were “staffed and equipped to standard”, but evidence does not support this strategy3. For example, the most rigorous randomized study in this field, the Better Birth Study, showed that despite extensive coaching and support, primary care facilities in India failed to reduce mortality over control facilities4. High and middle-income countries have long determined that low birth volumes and lack of surgical and advanced care make primary care delivery unadvisable. This clinical reality is no different in low-income settings.
Other points that Hanson and colleagues make align with the core arguments we offer for health system redesign. We agree that redesign should focus...
Other points that Hanson and colleagues make align with the core arguments we offer for health system redesign. We agree that redesign should focus on highly skilled providers and not just facilities. Hanson et al highlight the importance of midwifery-led care and we concur: we call midwifery a potential “cornerstone” of health system redesign and address midwifery-led models in detail in Table 1. However, even the most competent midwife would not be able to save a woman’s life in a remote primary care facility if she needs an emergency hysterectomy or blood transfusion. Anyone who has managed a severe post-partum hemorrhage or an asphyxiated newborn knows that it takes a system to save a life. Our central arguments for redesigning maternity care include eliminating the need to find emergency transport and having unstable patients travel long distances on poor roads. The majority of neonatal deaths occur in the first three days of life 5 and any major effort to reduce neonatal mortality must address these challenges.
We concur with Hanson that hospitals are not the only places for delivery; freestanding maternity centers proximate to advanced care can provide excellent services. Ultimately, the decision on the best configuration of delivery facilities will be made by countries to fit local health systems and resources. We agree that no single approach will fit all settings, even within a single country, and we do not propose any such model. As we say in the paper, governments will lead the charge for system redesign and reforms need to be pursued with full consultation of leaders from multiple sectors, the population, providers, and managers and carefully tracked and evaluated.
Hanson et al argue that our claim that the majority of women are now living relatively close to hospitals is overly optimistic. While multiple studies have documented this6,7, any particular woman’s access clearly depends on the local context, which is why we propose that regions contemplating redesign conduct feasibility assessments that measure access to care and consults women and health workers, as the government of Kakamega County in Kenya is doing now.
We recognize that our paper challenges the status quo and we thank Hanson and colleagues as well as the paper’s reviewers, other maternal and newborn health experts, and national policymakers for their careful analysis of redesign; their input has unquestionably improved the concept. We acknowledge that reorganizing health systems is daunting and that many details remain to be worked out. But as COVID-19 has forced the world to take a fresh look at how health systems are working for people and the clamor for universal health coverage is growing, let’s be bold in demanding higher standards for the world’s poorest families.
Margaret E. Kruk
Nana AY Twum-Danso
1. Hanson C, Waiswa P, Pembe A, Sandall J, Schellenberg J. Health system redesign for equity in maternal and newborn health must be codesigned, country led, adapted to context and fit for purpose. BMJ Global Health 2020; 5(10): e003748.
2. Roder-DeWan S, Nimako K, Twum-Danso NAY, Amatya A, Langer A, Kruk M. Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap. BMJ Global Health 2020; 5(10): e002539.
3. Larson E, Gage AD, Mbaruku GM, Mbatia R, Haneuse S, Kruk ME. Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster-randomised study in rural Tanzania. Tropical medicine & international health : TM & IH 2019; 24(5): 636-46.
4. Semrau KEA, Hirschhorn LR, Marx Delaney M, et al. Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India. New England Journal of Medicine 2017; 377(24): 2313-24.
5. Sankar MJ, Natarajan CK, Das RR, Agarwal R, Chandrasekaran A, Paul VK. When do newborns die? A systematic review of timing of overall and cause-specific neonatal deaths in developing countries. J Perinatol 2016; 36 Suppl 1(Suppl 1): S1-S11.
6. Juran S, Broer PN, Klug SJ, et al. Geospatial mapping of access to timely essential surgery in sub-Saharan Africa. BMJ Global Health 2018; 3(4): e000875.
7. Gage AD, Carnes F, Blossom J, et al. In Low- And Middle-Income Countries, Is Delivery In High-Quality Obstetric Facilities Geographically Feasible? Health Affairs 2019; 38(9): 1576-84.