Continuum of care for maternal, newborn, and child health: from slogan to service delivery

Summary

The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths. The continuum for maternal, newborn, and child health usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). We define a population-level or public-health framework based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children. These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one. The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes. Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care. Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.

Introduction

The continuum of care has recently been highlighted as a core principle of programmes for maternal, newborn, and child health, and as a means to reduce the burden of half a million maternal deaths, 4 million neonatal deaths, and 6 million children who die between the ages of 1 month and 5 years.1, 2, 3 The continuum of care is a recurrent theme in the World Health Report 2005¹ and The Lancet Neonatal Survival Series.² The continuum also provides the foundation for the conceptual framework of the Partnership for Maternal, Newborn and Child Health (PMNCH)⁴ and Opportunities for Africa's Newborns.⁵ The Global Business Plan for Millennium Development Goals 4 and 5, which was called for at the World Health Assembly 2007, also emphasises the continuum of care.⁶

The goal of this approach is to avoid dichotomies, between either mothers and children, places of service delivery, or single health issues (table 1).7, 8 Within the continuum, all women should have access to reproductive health choices and care during pregnancy and childbirth, and all babies should be able to grow into children who survive and thrive.⁹

The continuum-of-care approach has been used as a rallying call for integration of programmes for maternal, neonatal, and child health, but often without a clear application. Rapid escalations in investment, related to MDG 4 for child health and MDG 5 for maternal health, have increased the need for a solid framework for implementation and assessment. Who is the continuum of care for, and what are the essential service-delivery packages within it? What coverage does such care have? What are the challenges to building and tracking results for an effective continuum of care within existing health systems?