Women’s health and maternal care services: seizing missed opportunities to prevent and manage preterm birth – BioMed Central

Progress in Women’s and Adolescents’ Health and Reproductive Rights

Over the past decade, advancements in women’s and adolescents’ health and reproductive rights have been uneven globally, with progress in some areas and countries, and stagnation or regression in others. This mixed progress aligns with the challenges of achieving the Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being) and SDG 5 (Gender Equality).

Key Developments

• Introduction of new health policies and technical guidelines, including those targeting preterm birth prevention and management.
• Improved coverage of sexual, reproductive, and maternal health services across countries of varying income levels.
• Reduction in adolescent fertility rates in low- and middle-income countries (LMICs) from 52 per 1000 women aged 15–19 in 2012 to 43 in 2020.

Figure 1 illustrates the timeline of progress in maternal health and preterm birth over the past decade, while Figure 2 shows regional trends in coverage of essential sexual, reproductive, and maternal health services from 2012 to 2022.

Focus on Quality of Care in the SDG Era

Recognizing that increasing intervention coverage alone is insufficient for reducing mortality, the SDG era has emphasized improving the quality of care. Initiatives such as the Network for Improving Quality of Care for Maternal, Newborn and Child Health, established in 2017, aim to ensure high-quality care for every woman, child, and adolescent.

• Empowerment of women has been identified as a critical factor in improving access to vital health services.
• Shift towards woman-centric care models that promote social autonomy and decision-making authority.
• WHO guidelines emphasize respectful, high-quality care before, during, and after childbirth.

Challenges and Social Movements

Despite setbacks in some regions, social movements have driven progress, such as the “Green Wave” movement in Latin America that contributed to the liberalization of abortion laws, advancing reproductive rights in alignment with SDG 5.

Current Status and Inequities

• Global maternal deaths have plateaued since 2015, with 287,000 maternal deaths estimated in 2020, 95% occurring in LMICs.
• Stillbirth rates have declined by about 35% over two decades, yet 1.9 million stillbirths occurred in 2021, predominantly in sub-Saharan Africa and Southern Asia.
• Significant disparities exist in service coverage and quality within and between countries, affecting progress towards SDG 3 targets.

Programmatic Priorities for Maternal and Newborn Health

Effective interventions embedded within the continuum of sexual, reproductive, and maternal health services can improve maternal outcomes, reduce stillbirths, and prevent or mitigate preterm births. These align with SDG 3 and SDG 10 (Reduced Inequalities) by promoting equitable access to quality health services.

Essential Health Care Packages

Four high-impact packages are prioritized:

1. Package 1: Preconception Care
2. Package 2: High-Quality Antenatal Care
3. Package 3: Care Around the Time of Birth
4. Package 4: Postnatal Care

Package 1: Preconception Care

• Ensures equitable access to sexual and reproductive health information and services, enabling informed decisions about pregnancy.
• Reduces adolescent pregnancies, which are linked to higher risks of preterm birth and neonatal complications.
• Example: Chile’s multi-sectoral strategy reduced adolescent fertility rates through training, adolescent-friendly services, contraceptive promotion, outreach, and education support.
• Addresses infertility and the risks associated with assisted reproductive technologies, advocating for policies like single embryo transfer to reduce preterm births.
• Improves nutritional status before and between pregnancies to reduce preterm birth risk.

Package 2: High-Quality Antenatal Care

• WHO recommends a minimum of eight antenatal contacts, starting before 12 weeks’ gestation, to identify and manage risks including preterm birth.
• Includes interventions such as maternal nutrition optimization, infection treatment, and management of gestational diabetes.
• Emphasizes woman-centred care, mental health screening, and support for social determinants of health.
• Group antenatal care models show promise in improving care continuity and intervention coverage.
• Use of predictive tools (e.g., cervical length measurement) to tailor preventive interventions like progesterone therapy and cerclage.

Package 3: Care Around the Time of Birth

• Facility-based births have increased, but quality and coverage of intrapartum care vary widely.
• Critical interventions include antenatal corticosteroids (ACS) for women at risk of preterm birth before 34 weeks, tocolytics to delay labor, magnesium sulphate to reduce cerebral palsy risk, and antibiotics for preterm prelabour rupture of membranes.
• Promotion of delayed cord clamping, early breastfeeding, and kangaroo mother care to improve neonatal outcomes.
• Address rising caesarean section rates, which can increase preterm birth risk, by reducing unnecessary procedures and promoting midwifery continuity of care.

Package 4: Postnatal Care

• First six weeks post-birth are critical for maternal and newborn survival and well-being.
• WHO recommends at least four postnatal contacts, including contraceptive counseling.
• Special support for women with preterm infants, addressing risks of postnatal depression and involving families in newborn care.
• Provision of compassionate bereavement care for families experiencing stillbirth or neonatal death, with training for healthcare providers.

Improving Service Delivery

Successful implementation of the above packages requires well-functioning health systems and aligns with SDG 3 and SDG 9 (Industry, Innovation and Infrastructure).

Key Factors for Sustainable Implementation

• Investment in human resources: training, staffing, and equitable distribution of competent healthcare providers.
• Provision of up-to-date clinical protocols and continuous professional development.
• Ensuring availability of essential medicines, equipment, and infrastructure.
• Strengthening health information systems to collect and report gestational age, birth outcomes, and maternal and perinatal deaths.
• Developing and maintaining effective referral systems for emergency and higher-level care.

Pivotal Actions to Enhance Maternal and Newborn Health

Pivot 1: Integration of Sexual, Reproductive, and Maternal Health Services within Universal Health Coverage (UHC)

Stakeholders including government leaders, health professional associations, civil society, private sector, and development partners must collaborate to embed these services in UHC strategies. This includes:

• Ensuring equitable, high-quality services based on evidence.
• Reducing out-of-pocket expenses and increasing health system investments.
• Expanding family planning services across the life course, including postpartum and adolescence.
• Promoting public health education on behavioral and lifestyle factors affecting preterm birth risk.

Pivot 2: Leveraging Existing Tools for Preterm Birth Management

• Prioritize timely, evidence-based interventions such as appropriate use of antenatal corticosteroids.
• Enhance political commitment and investment to scale up effective interventions in LMICs.
• Improve health information systems and surveillance to monitor preterm births and outcomes.
• Facilitate research and knowledge sharing to overcome implementation barriers.

Pivot 3: Ensuring High-Quality, Respectful, Person-Centred Care

• Close the gap between guidelines and clinical practice to provide respectful care throughout the continuum.
• Promote midwife continuity of care models to improve women’s experiences and outcomes.
• Provide clear, compassionate communication and involve women and families in care decisions.
• Implement compassionate bereavement care and include families’ voices in policy and service development.

Conclusion

Implementing these programmatic priorities and pivots will advance the global agenda to prevent and manage preterm births, improve maternal and newborn health, and reduce stillbirths. These efforts directly contribute to achieving the Sustainable Development Goals, particularly SDG 3 and SDG 5, by promoting equitable access to quality health services, empowering women, and strengthening health systems worldwide.

1. Sustainable Development Goals (SDGs) Addressed or Connected to the Issues Highlighted in the Article

1. SDG 3: Good Health and Well-being
   • The article focuses extensively on improving maternal, newborn, and adolescent health, reducing maternal mortality, preventing preterm births, and improving quality of care.
   • It discusses interventions to reduce stillbirths, maternal and newborn morbidity and mortality, and ensuring universal health coverage (UHC) for sexual, reproductive, and maternal health services.
2. SDG 5: Gender Equality
   • The article highlights women’s empowerment, social autonomy, and decision-making authority as key to improving access to vital sexual and reproductive health services.
   • It addresses adolescent fertility, early pregnancies, and the importance of woman-centered care.
3. SDG 10: Reduced Inequalities
   • Major inequities in coverage and quality of maternal and newborn health services across and within countries are discussed.
   • The article emphasizes equitable access to high-quality services, especially in low- and middle-income countries (LMICs) and underserved populations.
4. SDG 17: Partnerships for the Goals
   • Collaboration among governments, health professional associations, civil society, private sector, and development partners is stressed for integrating sexual, reproductive, and maternal health services within UHC strategies.

2. Specific Targets Under Those SDGs Identified Based on the Article’s Content

1. SDG 3: Good Health and Well-being
   • Target 3.1: Reduce the global maternal mortality ratio to less than 70 per 100,000 live births.
   • Target 3.2: End preventable deaths of newborns and children under 5 years of age, aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births.
   • Target 3.7: Ensure universal access to sexual and reproductive health-care services, including family planning, information, and education.
   • Target 3.8: Achieve universal health coverage, including financial risk protection and access to quality essential health-care services.
2. SDG 5: Gender Equality
   • Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action.
   • Target 5.5: Ensure women’s full and effective participation and equal opportunities for leadership at all levels of decision-making in political, economic, and public life.
3. SDG 10: Reduced Inequalities
   • Target 10.2: Empower and promote the social, economic, and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion, or economic or other status.
4. SDG 17: Partnerships for the Goals
   • Target 17.17: Encourage and promote effective public, public-private, and civil society partnerships.

3. Indicators Mentioned or Implied in the Article to Measure Progress Towards the Identified Targets

1. Maternal Mortality Ratio (MMR)
   • Used to measure progress towards SDG 3 Target 3.1; the article cites estimates of maternal deaths and progress in reducing maternal mortality.
2. Neonatal Mortality Rate and Stillbirth Rate
   • Indicators for SDG 3 Target 3.2; the article discusses stillbirths and newborn deaths, emphasizing the need for quality care to reduce these rates.
3. Coverage of Sexual, Reproductive, Maternal, Newborn, and Adolescent Health Services
   • Indicators include met need for family planning, antenatal care (minimum four visits), skilled attendant at birth, postnatal care coverage, and adolescent fertility rate.
   • These measure progress towards SDG 3 Targets 3.7 and 3.8.
4. Adolescent Fertility Rate
   • Indicator for SDG 5 Target 5.6 and SDG 3 Target 3.7; the article reports reductions in adolescent fertility rates in some countries.
5. Use of Antenatal Corticosteroids (ACS) and Tocolytics
   • Implied indicators for quality of care in preterm birth management, reflecting progress in implementing effective interventions.
6. Caesarean Section Rates
   • Indicator related to quality and appropriateness of care during childbirth, with implications for preterm birth rates.
7. Postnatal Care Coverage
   • Indicator for SDG 3 Target 3.8, measuring the proportion of women and newborns receiving postnatal care within the first days after birth.
8. Health Workforce Density and Distribution
   • Implied indicator for health system readiness and quality of care, relevant to SDG 3 Target 3.8 and SDG 10 Target 10.2.
9. Data Collection and Reporting on Gestational Age and Birth Outcomes
   • Indicators related to health information systems and civil registration vital statistics (CRVS), important for monitoring preterm births and maternal and newborn outcomes.

4. Table: SDGs, Targets and Indicators

SDGs	Targets	Indicators
SDG 3: Good Health and Well-being	3.1: Reduce maternal mortality ratio 3.2: End preventable newborn and under-5 deaths 3.7: Universal access to sexual and reproductive health-care services 3.8: Achieve universal health coverage	Maternal Mortality Ratio (MMR) Neonatal Mortality Rate Stillbirth Rate Coverage of family planning, antenatal care (4+ visits), skilled birth attendance, postnatal care Use of antenatal corticosteroids and tocolytics Caesarean section rates Postnatal care coverage Health workforce density and distribution Gestational age and birth outcome data collection
SDG 5: Gender Equality	5.5: Women’s full participation and equal opportunities 5.6: Universal access to sexual and reproductive health and rights	Adolescent fertility rate Measures of women’s empowerment and decision-making authority (implied)
SDG 10: Reduced Inequalities	10.2: Empower and promote social, economic, and political inclusion	Equity in coverage and quality of maternal and newborn health services by wealth quintile, region, and other factors Health workforce distribution equity
SDG 17: Partnerships for the Goals	17.17: Encourage effective public, public-private, and civil society partnerships	Collaborative initiatives and networks for improving quality of care (implied)

Source: reproductive-health-journal.biomedcentral.com