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Health system redesign for equity in maternal and newborn health must be codesigned, country led, adapted to context and fit for purpose
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  • Margaret E. Kruk, Sanam Roder-DeWan, Kojo Nimako, Nana AY Twum-Danso, Archana Amatya and Ana Langer
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    Response letter
    • Margaret E. Kruk, Professor of Health Systems Harvard T.H. Chan School of Public Health
    • Other Contributors:
      • Sanam Roder-DeWan, Family Physician
      • Kojo Nimako, Post-Doctoral Fellow
      • Nana AY Twum-Danso, Adjunct Assistant Professor
      • Archana Amatya, Obstetrician and Gynecologist and Public Health Specialist
      • Ana Langer, Professor of the Practice of Public Health

    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...

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    Conflict of Interest:
    None declared.