ReviewContinuum of care for maternal, newborn, and child health: from slogan to service delivery
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?
Section snippets
Defining the continuum of care
The term was initially applied in the 1970s to the integration of research and practice for provision of a continuum of care for elderly people.10 In subsequent decades, use of the term has broadened, although it most commonly refers to individual patient care and case management, and to promotion of appropriately directed care with a series of linkages to ensure that no patient is lost to follow-up. A systematic review11 showed that most of the 638 papers on the continuum-of-care approach
Building the continuum of care with health-service packages
Studies suggest that high coverage and quality of essential packages could avert about 67% of neonatal and child deaths in 60 priority countries worldwide.24 These analyses have included packages for maternal and child health, basic and emergency obstetric care, and postnatal care.24 A functional continuum can increase client and provider satisfaction.11 At the public-health level, linkages between integrated packages can maximise the efficiency with which the scarce human and financial
Packages of interventions for delivery within the continuum of care
Several Lancet Series have dealt with periods along the continuum of care, such as sexual and reproductive health28 and maternal,20 neonatal,18 and child19 survival. Other Series will focus or have focused on nutrition29 and the links between early-life events, poverty, and the environment of long-term development.30 These Series have increased attention on the goals of universal coverage of effective interventions for health of mothers, newborn babies, and children and of reduction of
Operational strategies to strengthen care and linkages between levels of care
Both supply of services and demand for care need to increase. At the clinical-care level the predominant challenge is human resources. Table 2 outlines key barriers and operational solutions according to service-delivery approaches. Community mobilisation can increase demand for care and improve access through communication (eg, radios and mobile phones) and community referral solutions (eg, stretcher teams, transport cooperatives, and maternity waiting homes) to better connect households and
Tracking and accelerating coverage along the continuum of care
Figure 3 shows coverage indicators for selected packages for the health of mothers, neonates, and children along the continuum of care for sub-Saharan Africa and south Asia.5 Even in the world's worst-off regions, population-based outreach packages of antenatal care and immunisation had good coverage (figure 3). Compliance with immunisation was reasonable, as shown by high coverage of immunisation for diphtheria, pertussis, and tetanus, which ranged from 83% at the first dose to 65% for the
Towards scaling up an effective continuum of care
Elements that affect the functionality of health systems—human-resource capacity, health-facility infrastructure, supply systems, financial resources, government stewardship, district-level management, and monitoring—will also impinge on efforts to scale up packages for health of mothers, neonates, and children within the continuum.50, 55 Systematic identification of local challenges; attention to underlying causes of ill health; and adaptation of package complexity in terms of healthworker
From slogan to saving lives
The continuum of care for maternal, neonatal, and child health is much more than a slogan. If the eight proposed packages could be implemented to reach most families worldwide, then every year the lives of up to two-thirds of 10 million babies and children could be saved,35, 45 and many of the half million maternal deaths and 3·2 million stillbirths prevented. This would accelerate progress towards MDGs 1, 4, 5, and 6: to improve maternal health; reduce child mortality; combat infectious
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