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RESEARCH BRIEF Integrating Maternal, Newborn and Child Health and Family Planning Services: The Continuum of Care from Pregnancy through Postpartum

www.globalhealth.org

Safe pregnancy and childbirth, healthy children and the ability to control one’s fertility are important goals for families and key indicators of good health. To meet these goals, women need access to health services before, during and after birth. In addition to care for a current pregnancy, women need family planning services to space or prevent subsequent pregnancies. Their children need access to health care immediately after birth and throughout their first years of life to provide a foundation for healthy growth and development. A continuum of care across time and place can help to ensure that mothers, newborns and children receive these services seemlessly and effectively. Historically, the global health community has been unable to integrate maternal, newborn, and child health successfully and comprehensively.1 However, in the past five years, support has reemerged to promote a continuum of care strategy to improve maternal, newborn and child health.2 During this period, several influential documents have highlighted this concept, including the 2005 World Health Report, the Lancet Neonatal Survival and Alma-Ata Rebirth and Revisit Series, the Partnership for Maternal, Newborn and Child Health (PMNCH), and the 2009 State of the World’s Children Report.2, 3 New initiatives, such as USAID’s Maternal and Child Health Integrated Program (MCHIP) and the United Kingdom Department for International Development’s program, Towards 4+5 Consortium, have also called for greater integration of health services. The aim of this report is to present the rationale for and the challenges of integrating services for maternal, newborn and child health (MNCH) and postpartum and long-term family planning (PPFP). While there are medical, logistical and cost-effectiveness reasons for integrating these services, in some contexts, integration may not be the most suitable approach to achieving health goals. A companion paper will examine the process of integrating family planning and maternal,

Key Points A continuum of care across time and place offers an effective approach to care, ensuring that mothers, newborns and children receive health services seemlessly and effectively. Integrating maternal, newborn and child health and family planning services can alleviate obstacles to access and increase the efficiency and decrease the cost of delivering health services. Integrating services may not be the most appropriate appoach to all health programs and poses new technical challenges to governments, donors, implementers, and management. More research is needed to assess the effectiveness of integrated programs to determine the opportunities for integration and to assess where this is an appropriate and useful strategy and where it is not. newborn and child health, including a discussion of practical solutions and common barriers.

The Integration Framework: The Continuum of Care The continuum of care is a well known model that links maternal, newborn, and child health services across time and place (“The Continuum of Care,” pg. 2).4 The continuum starts with adolescence and pre-pregnancy and continues through pregnancy, the postpartum period and beyond. It includes both the mother and infant, and connects obstetric care, family planning, and child health services across household, community, and hospital settings. In addition to averting millions of maternal, newborn and child deaths each year, integrating services across the continuum of care can reduce the


The Continuum of Care10 Across Time Adolescence and pre-pregnacy

Pregnancy

Birth

Postpartum and Newborn

Infancy

Childhood

Linking the Places of Caregiving

Outreach Services

Across Place

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risk of interruptions in care, increase the cost-effectiveness of interventions, and increase the convenience of care by eliminating visits to multiple health facilities for each family member.2, 7, 8 Services in the continuum of care are provided by a broad range of health care professionals (e.g., physicians, nurses and midwives), traditional birth attendants and community health workers. In some cases, these providers focus on disease-specific services, rather than a more inclusive package of care. This can result in missed opportunities to meet a client’s broader range of health needs throughout their lifetime.4, 6 Coordination between these providers is essential to provide a complete package of services, whether this is through the expansion of each health worker’s skill set and offerings, or through an improved system of referrals to other providers and health facilities.3, 4, 9

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Adolescence and Pre-pregnancy: Several challenges are common to both adolescence and the pre-pregnancy period (before a woman’s first pregnancy or between pregnancies). Barriers to both adolescents and young adults accessing reproductive care include a lack of familiarity with the health care stem, concerns of confidentiality, and the inability of health care providers to acknowledge and address their specific health care needs.10, 11 Confounding these issues is marital status. For unmarried adolescents, reproductive health care services are provided within the child health care structure; married adolescents have access to adult reproductive health services, but care may not fully address the unique developmental and biological needs of adolescents.12, 13 Unmarried adults may also encoun-

Health Facilities Primary & Referal Care Communities Households

ter difficulty in accessing contraceptives and face stigmatization in the community.14 These obstacles to care predispose adolescents to adverse outcomes, such as unintended or early pregnancy and HIV/AIDS or sexually transmitted infections (STIs).12 To address these risks, adolescent and prepregnancy reproductive health services should include access to a range of services to prevent and treat STIs and HIV/AIDS.10 Adolescents have immature reproductive and immune systems, putting them at increased risk for acquiring STIs and HIV, and for experiencing complications during pregnancy that can have adverse affects for both mother and baby.15 Since adolescent bodies have not matured enough to handle the physical stress of pregnancy and delivery, adolescents are twice as likely to die from causes related to pregnancy and child birth, and their children are 50 percent more likely to die within the first year of life, compared to women who are older. Antenatal Care:16, 17 Antenatal care visits are an important entry point of expectant mothers into the health care system. They provide an opportunity to a) deliver needed medical attention, b) educate women about pregnancy, delivery, and newborn and infant care, and c) promote health care seeking behaviors. According to the World Health Organization, mothers need at least four antenatal visits at specific times during their pregnancies and women with special health conditions need additional care. Specifically, antenatal visits provide an opportunity for:


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Health care workers to identify potential risk factors and complications for delivery, such as malpresentation or hypertension.

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Health care workers to educate women about danger signs during pregnancy and newborn care.

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Mothers to be screened and treated for infections, including sexually transmitted infections and urinary tract infections.

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Provision of prevention interventions, including nutritional supplements, tetanus toxoid immunization, intermittent preventive treatment of malaria (IPTp), and distribution of insecticide treated bednets (ITNs).

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Health care workers to provide counseling on the dangers of smoking and alcohol use during pregnancy, particularly among pregnant adolescents.18 These drugs increase the likelihood of health complications during pregnancy and after delivery.

Maternal and child health are most closely linked during pregnancy and childbirth, when the health of the mother directly and indirectly affects the health of the developing child. Infectious diseases, including HIV/ AIDS, malaria, syphilis and tetanus, may be transmitted from a mother to her child during pregnancy.19 Pregnancy can increase women’s susceptibility to disease, place them at greater risk of health complications or cause pre-existing conditions to become more pronounced.20 For example, pregnancy may make women more vulnerable to opportunistic infections or accelerate the course of HIV; pre-pregnancy maternal health problems, such as malnutrition or hypertension may result in intrauterine growth restriction, preterm birth, low birth weight or other complications. 19, 20 Low birth weight is the leading factor in 60 to 80 percent of neonatal deaths and increases a newborn’s risk of infection, low blood sugar, and hypothermia.19, 20

Maternal and Newborn Postpartum Care:17 The postpartum period is often considered the most neglected stage in the continuum of care. 4,20 It is a critical time for both mother and infant, as they face increased risk for mortality and morbidity during the postpartum period – 60 percent of all maternal deaths and nearly 4 million newborn deaths occur during the child’s first month of life.20,15,24 Although new mothers are at increased risk of death and illness for at least 42 days after delivery – and some evidence indicates increased risk after the traditional 6 week postpartum period – most women stop receiving skilled care within the first few hours of birth.20, 25, 21 Given that 60 percent of infant deaths occur during the first month of life, newborns must be monitored for their well-being, particularly low birth weight and preterm babies.15 However, intensive care is not needed to save many of these babies; about one-third could be saved with simple care, including:19 »

Identifying small babies prior to birth

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Assessing low birth weight babies for danger signs and provide specific care to assist in survival and weight gain

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Providing extra support for breastfeeding, including expressing milk and cup feeding

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Paying extra attention to warmth promotion, such as skin-to-skin care.

Newborns should be treated for infections, including syphilis, tetanus and HIV. A child born to an HIV positive mother should receive appropriate antiretroviral treatment immediately after birth and HIV testing and the appropriate ARV regime afterwards. If the mother is HIV positive, exclusive breastfeeding for six months is recommended, as exclusive use of breast milk carries

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Labor and Delivery Care:17 Childbirth is a critical stage for both mother and child. Women are at the greatest risk of death within the first 48 hours after delivery; between 25 and 45 percent of all neonatal deaths occur during their first 24 hours of life.20, 21 Fifteen percent of births are estimated to need emergency obstetric care, but many women do not have access to such services.22 Hemorrhage, obstructed labor, and sepsis are the three leading causes of death during this period, collectively accounting for approximately 45 percent of maternal mortality. 19, 21, 23

Many maternal deaths could be prevented by the presence of skilled birth attendants and access to emergency obstetric care both of which is crucial to safe childbirth. During labor, trained health care workers monitor women for problems and complications, including prolonged or obstructed labor, malpresentation, or hypertension. Immediately following delivery of the child, women may need assistance with the removal of the placenta or the administration of antibiotics, and newborns may need resuscitation, warmth promotion to prevent hypothermia, (e.g., skin-to-skin contact after birth) or attention to other complications, including infection or congenital defects.

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Prevention of Mother-to-Child Transmission of HIV The prevention of mother-to-child transmission (PMTCT) of HIV is crucial to reducing the incidence of pediatric AIDS. Globally, it is estimated that more than 90 percent of the total 2 million children under the age of 15 living with HIV were infected as a result of mother-to-child transmission of the virus.32 Without intervention, the risk of transmitting HIV from mother to infant is between 15-30 percent, but this risk can be reduced to two percent through antiretroviral prophylaxis, obstetrical, interventions, and safe breastfeeding.32, 33 HIV-positive women have an increased risk of maternal mortality, increasing pregnant women’s vulnerability to malaria, tuberculosis, and complications at birth.33 In order to scale-up coverage and meet the needs of HIV-positive mothers and their children, PMTCT programs should be integrated with maternal, newborn and child health and family planning services. There are four primary components of PMTCT: »

Prevention of HIV infection. Adolescents and women should have access to prevention, testing and counseling services. They should also receive information on abstinence and safe sex practices, such as condom use and partner involvement.

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Prevention of unintended pregnancies. Adolescents and women should have access to information and services to plan, space and prevent pregnancies.

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Prevention of HIV transmission. HIV-positive pregnant woman are at risk of transmitting HIV to their infant through pregnancy, delivery, or breastfeeding. It is particularly important to prevent infection in pregnant or lactating women, as they are at greater risk of transmitting the virus to their infants than women infected prepregnancy.34 HIV testing and counseling are part of the routine antenatal package, and many countries have “opt-out” policies in which testing is recommended and women must choose to decline.34 During pregnancy, HIV-positive women on antiretroviral therapy should continue their treatment in accordance with WHO guidelines and women who have not yet started antiretroviral treatment or who cannot access treatment should receive antiretroviral prophylaxis to prevent transmission of HIV to the child.35 Other obstetrical interventions include elective caesarean delivery and avoiding breastfeeding.35

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Provision of care, treatment and support for mothers and children living with HIV. It is essential to continue to link PMTCT services with maternal and child health services after pregnancy and delivery, as HIV-positive mothers and children are more vulnerable to other health problems, including co-infection and malnutrition.34 If the baby is HIV-negative at birth, immunization clinics and baby-wellness visits provide opportunities for routine testing and counseling throughout infancy and childhood.19 Early testing and treatment for newborns is crucial, as a significant number of HIV-positive infants can be saved by early treatment within the first months of life, but few are actually tested.32

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It is also important to educate HIV-positive mothers about breastfeeding, as about one-third of motherto-child transmission occurs in breastfed children under two years of age.34According to modeling studies, exclusive breastfeeding for six months could prevent the deaths of 25 percent of HIV-exposed children in sub-Saharan Africa.

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The coverage of PMTCT programs ranges widely; in sub-Saharan Africa, coverage ranges from one to 54 percent.33 In 2005, UNICEF reported that less than 25 percent of antenatal care facilities in sub-Saharan Africa provide the minimum package of PMTCT services. In addition, many women lack access to testing, counseling and treatment services. In 2007, less than 25 percent of pregnant women living in low- and middle-income countries were aware of their HIV status, and only about one-third received antiretroviral therapy.34 The provision of postnatal PMTCT services is particularly poor, despite relatively high vaccination rates that indicate continued access to children.19


a significantly lower risk of HIV infection than mixed feeding, if clean water and formula are not available.26

ing childhood and may have impaired cognitive development and congenital defects.19, 23, 31

Infancy and Childhood. In addition to the approximately 4 million newborn deaths, about 5 million children under the age of 5 will die each year.20 Globally, 80 percent of child deaths are due to only a handful of causes: neonatal causes, pneumonia, diarrhea, and malaria.27 Although child mortality has been decreasing over the past 40 years, the average global child mortality rate in developing countries is still more than 12 times higher than in industrialized countries (6 per 1000 live births versus 76 per 1000 live births, respectively) – in some developing countries, the rate is 25 to 30 times as high. 28 29

Maternal health also continues to impact children’s health throughout infancy and childhood. Children born to adolescent mothers also are at elevated risk for poor health outcomes.18 Chronic maternal ill health also affects the quality of life of surviving children, who depend on their mothers for physical, emotional and financial support. Children under 5 who lose their mothers are three to ten times more likely to die than those with living mothers.20, 23

Illness, malnutrition and injuries during infancy and childhood have short- and long-term consequences, including physical disabilities and fewer economic and educational opportunities.30 Undernutrition contributes to 35 percent of child deaths by weakening their ability to fight off infection; preterm and low birth weight infants face greater susceptibility to illness dur-

Integrating access to family planning services throughout the continuum of care can reduce women’s unmet need for contraception, help couples manage birth timing, and help developing countries achieve their goals of reducing fertility rates.11 Research suggests that twice the number of unintended pregnancies occur among

Linking MNCH Planning

and

Postpartum

Family

Integrated Management of Childhood Illness In the mid-1990s, the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) launched the Integrated Management of Childhood Illness (IMCI) strategy to reduce deaths in children younger than 5 years. The strategy is built upon three major objectives: to improve the skills and performance of health care workers, to improve family and community practices, and to improve health systems. This broad, integrated approach to child health marked a clear departure by the WHO from single-technology interventions to treat illness and disease.36 To measure the impact of the program, the WHO also coordinated the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE), which began in 1997. This evaluation measured the impact, costeffectiveness, and immediate health outcomes of IMCI in five countries: Bangladesh, Brazil, Peru, Tanzania and Uganda. 37 Overall, IMCI has been associated with positive health outcomes.38, 39 In Brazil, Uganda, and Tanzania, children receiving care from an IMCI healthcare worker were more likely to receive correct prescriptions for antimicrobial drugs than children who were not receiving IMCI care.40 In addition, these children were “more likely to receive the first dose of the drug before leaving the health facility, to have their caregiver advised how to administer the drug, and to have caregivers who are able to describe correctly how to give the drug at home as they eave the health facility.40 Some evidence also suggests that IMCI is a cost-effective strategy for improving child health. For example, in Tanzania, the cost of providing IMCI per child (US $11.19) was significantly lower than the district cost ($16.09) per year.

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However, the degree of success of this strategy is largely determined by the strength of the health system in which it operates.36 Many countries involved in the MCE study had difficulty scaling-up the program to a national level, and faced human resource constraints and high staff turnover.41 Many countries failed to move past the first step of the program – improving the skills and performance of health care workers – as training facilitators, preparing materials, and conducting follow-up visits took much longer than planned.41 In some countries, lack of uniform messaging from IMCI health care workers across families and communities diminished the overall impact of health promotion, impacting the overall effectiveness of the program.42 Some of these challenges to IMCI could be overcome by strengthening health systems and increasing government support for these programs.42, 43

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women who are not using family planning compared to women who are using family planning.11, 44 In addition, according to a study of 36 developing countries, most women with unmet need for contraception have a desire to use family planning in the future.11 The continuum of care model presents several opportunities for integrating family planning into MNCH services. Optimally, family planning counseling and services should begin early – before the first pregnancy. However, this scenario may be complicated by inaccessibility of family planning services to young women, parental objections to the use of contraception, and cultural or societal norms.11 In addition, those who have never been pregnant may not have ties to the health care system. Although antenatal care visits present opportunities to discuss family planning options, these visits are often reserved for more immediate or pressing issues related to pregnancy and childbirth.15 Delivery at a health facility provides another chance for family planning counseling and services, though the focus during delivery is safe childbirth. In particular, skilled birth attendants can provide information and certain specialized family planning services that may occur during the crucial time immediately after birth, such as IUD insertion or tubal ligation. The postpartum period provides a convenient opportunity to provide family planning education, options and services by maximizing regular maternal and newborn health care visits. With regard to family planning services, the postpartum period extends beyond the usual six week time frame to one year after delivery.15 Postpartum family planning (PPFP) focuses on a very specific population: women who already have had a child and wish to delay or prevent subsequent pregnancy. For example, one study found that 95 to 98 percent of postpartum women do not want another child within two years, yet only 40 percent are using a family planning method.15 The same study found that 30 to 60 percent of these women did not use postpartum family planning because they believed there was little to no risk of pregnancy.11 Thus, counseling during this period could effectively reach the women who have unmet need for contraception, women who are unsatisfied with prior family planning methods and women who have not considered the use of family planning methods.45 Beyond the postpartum period, integrating family planning into facilities and schedules for child health care, eg., well child care and routine immunizaions, can provide a standardized and convenient means for women to access these services.19

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Logistical and Convenience Benefits of Integration One of the major benefits of integrating maternal, newborn and child health and family planning services is the alleviation of distance- and cost-related obstacles to access. Many of the services that mothers and children require can be provided by the same caregiver and/or at the same point of service delivery. This may reduce both the number of visits and the fees associated with accessing services for many women and children. Integrating health care services also provides women and children with more opportunities to enter the health care system for services or referrals. The graph on the opposite page depicts the gap between entry points into the health system and actual service delivery in sub-Saharan Africa. »

Maternal and child health services may be gateways to the health system, as exposure to one type of health care may lead to use of other services and improved health-seeking behavior.58-60 A study of pregnant women in Uttar Pradesh, India, found that women with high levels of antenatal care were up to four times more likely to use a professional at the time of delivery than women with low levels of antenatal care.58 Usage of maternal and child health services also has a positive correlation with the uptake of family planning in Morocco, Guatemala, and Indonesia.60

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Maternal, newborn or child health services provide an important opportunity for health workers to provide referrals to other health services, provide an important opportunity for health workers to provide referrals to other health services, including family planning. For example, a study in Togo examined linking vaccination programs with family planning services by providing referral messages at child immunization sessions.61 The study found that women receiving individual family planning messages at immunization clinics were more likely to access and accept family planning services than women receiving information in a group setting, and that the act of providing referrals did not have a damaging impact on the immunization service being provided.61 Numerous other studies have found similar benefits of integrating immunization and family planning programs.61-62

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The opportunity to obtain multiple services from the same caregiver or at the same point of delivery may reduce the number of trips required to health centers for the mother and her family. Many women


have reported that accessing services at different points of care is both inconvenient (e.g., long travel and waiting times) and costly (e.g., work absenteeism).62-64 More convenient services also may help to increase community and consumer acceptability and uptake.64 Âť

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The integration of services often enables health care workers to provide multiple services at one point of delivery, reducing their travel and time costs related to subsequent visits and thereby reducing the loss to follow up. For example, the insertion of an IUD can easily occur after delivery, eliminating the need for a separate trip to the clinic or the hospital for the procedure. In some cases, women who return for an IUD insertion after birth have actually been turned away because there was no doctor to perform the insertion.46, 50 Eliminating this type of loss to follow up would help to ensure that women and children receive needed services. There is sometimes less stigma attached to using family planning services when they were integrated into the existing maternal, newborn and child health structure.62 In communities where there is opposition to mothers and infants visiting a health clinic if there are no signs or symptoms of ill health, or where stigma attached to family planning, integrated community- or home-based care provides an opportunity to provide needed services in a positive environment.65

Cost-effectiveness of Integration In addition to the health and logistical benefits of linking maternal, newborn, and child health and family planning, integrating services can be a cost-effective approach to service delivery. By eliminating duplicate administrative functions and using common infrastructure and processes, and improving and broadening the skills of health care workers, combining services can increase efficiency while delivering a broad range of services.62, 64-65 Integrated health programs would help to effectively use the already limited human and financial resources allocated to health systems.4, 66 Properly integrated health services could potentially decrease the demand for specialized health workers, as some services can be provided by individuals trained to perform multiple tasks. The ability of workers to cover more interventions may reduce the number of health care workers needed to provide a broad range of services and increase the cost-effectiveness of integration.2, 66 However, integration must be done carefully so as not to overburden health care workers or compromise the quality of services provided.62, 65 Delivering interventions together as part of basic packages has also been shown to result in cost savings.2, 67 For example, a study in Kenya found that the cost of delivering insecticide treated bednets (ITNs) to pregnant women during antenatal care visits was almost five times less than the cost of protecting a child under the

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Examples of the Integration of Maternal, Newborn and Child Health and Family Planning Immediate Insertion of an Intrauterine Device (IUD) The IUD is the second most popular method of family planning worldwide, with nearly 160 million users, and offers a nonhormonal, nonpermanent form of family planning to space or prevent subsequent pregnancies.46-48 They provide a reversible form of contraception for up to 12 years, and most women are able to become pregnant quickly after an IUD is removed.49 IUDs require fewer visits to a health center compared to some hormonal methods, thus requiring less expenditure of time, money, and effort.48 One of the most efficient times to insert an IUD is after delivery. The presence of a skilled health provider trained in IUD insertion allows women to receive counseling on this and other contraceptive methods, and to request IUD insertion. Particularly for women with limited access to medical care, IUD insertion right after delivery at a health center is optimal because: it is convenient – women and trained personnel are available; it is known for certain that the woman is not pregnant; and her need for contraception is likely high.49 »

A study in Peru found that providing women with the option of postpartum IUD insertion not only increased IUD uptake but also increased women’s participation in postpartum obstetric care.50

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In Columbia, one study found that 95 percent of women who had expressed a prior interest in immediate postpartum IUD insertion had it done, compared to only 45 percent of women who had an IUD inserted at a later time. 46

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A study in Honduras found that providing women with the option of IUD insertion immediately after delivery was optimal because they were able to provide IUDs to women who would have not otherwise have considered IUD insertion and were able to ensure that a trained provider was available, which may not be assured if the woman had returned to the clinic at a later time.50

Early Breastfeeding and the Lactational Amenorrhea Method Besides being an economically viable option, breastfeeding provides health benefits to mother and infant. For the baby, exclusive breastfeeding for the first six moths of life provides the infant with minerals and nutrients that decrease risk of mortality and fosters healthy physical and cognitive development.51 Breast milk contains the antibodies that protect infants from the viral and bacterial infections that cause many of the childhood illnesses that lead to childhood mortality and morbidity.52 If mothers are HIV-positive, early and exclusive breastfeeding carries a significantly lower risk of HIV infection than does supplementing with formula or solid foods.26 For the mother, exclusive breastfeeding can be used to delay the return of menses within the first few months postpartum, thus delaying subsequent pregnancy – this method of family planning is called the Lactational Amenorrhea Method (LAM).53 Correct and optimal use of LAM requires strict adherence to three criteria: 1) the mother must practice exclusive or nearly exclusive breastfeeding, 2) the mother must be within 6 months postpartum – after this point, women need to transition to another form of family planning, and 3) menses must not have resumed.53 If all three criteria are met, LAM can be more than 98 percent protective against pregnancy – nearly as effective as many other modern methods, including oral pills, dermal patches or vaginal rings.54 Although LAM is a well known and widely accepted method of family planning, many women who use this method are either unaware of or do not understand the criteria for correct adherence, reducing its effectiveness as a birth control technique.47 AUGUST 2009

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gests that the integration of services may place a severe burden on health care workers that could actually damage their performance. Integrating services will often require health care workers to learn a new skill set in order to provide a broader spectrum of services. This typically necessitates further training and will increase the workload of each health care worker. If the appropriate training and management resources are not provided, health care workers may be overburdened, unprepared and demoralized, resulting in diminished quality of services delivered.62, 65, 72

age of 5 from malaria in a low-income country with an ITN.68 In another study in Peru, in-hospital postpartum IUD insertion was shown to be considerably more costeffective than the same service performed at an outpatient facility.50 In fact, inserting the IUD postpartum in the hospital saved just under $15 USD per procedure.50 Providing individuals with information or services at various points in the continuum of care may also reduce poor health outcomes, and related expenses, in the future. For example, family planning services provided as part of post-abortion care could help to prevent unintended pregnancies and unsafe abortion.45, 65 Similarly, appropriate antenatal care provided at the beginning of a pregnancy could help to prevent anemia, malnutrition, and HIV or malaria infection in the infant.19

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The existence of integrated services does not necessarily guarantee improved access or health equity.66 Many of the same obstacles to care that prevent women and children from accessing specific services may still apply to integrated programs, including location, cost, language, and cultural attitudes towards health care. Integrated services may exacerbate health inequity by pulling multiple interventions into one inequitable delivery mechanism.70 For example, the addition of nutritional supplement distribution to child immunization days that are poorly designed and managed, inaccessible or poorly attended may not significantly increase access to supplements. Similarly, integrated services may reduce the effectiveness of pre-existing services by yoking a functioning program with a dysfunctional one.33

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Integrating services is a challenging technical process that requires coordination of the government, donors, program implementers, and health care workers. Transitions from population-specific to integrated programs require careful planning, including assessments of the costs and resources needed to make the shift, and the new training, supervision, and management needed for the new program.65, 72

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Integrating services also requires a greater level of coordination and support by national governments, multilateral agencies, and donors. Donor funding preferences for disease-specific programs may sway national priorities or implementer activities, making integration unpopular and unlikely.33, 70 Funding earmarks may impede the integration of services by encouraging the duplication of management infrastructure or supply chains.33

Challenges of Integration Although the integration of maternal, newborn and child health services and family planning is beneficial for many reasons, in some cases, integration may not be the most suitable approach to achieving health goals. Vaccination campaigns to eradicate or eliminate disease, such as smallpox, polio, and measles, are examples of highly effective disease-specific programming that requires an intensely focused effort. In addition, integration may place additional, and sometimes insurmountable, burdens on already fragile health care systems. Integrated programming may also inadvertently worsen or exacerbate the quality of health care in situations where multiple interventions are bound together and then delivered in such a manner that limits access. Finally, integrated programs pose new technical challenges to governments, donors, implementers, and management.

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Vertical programs may be effective strategy for disease elimination programs or in response to sudden health threats in countries with weak health systems.70 These programs utilize specialized management, logistics and delivery systems to deliver select interventions.70 Disease-specific programs may be favored by donors, and may be preferred by managers who are disinclined to cooperate with others or share resources.70 However, a broad range of permanent, integrated health services must follow these vertical programs in order to ensure longterm results.71 Integrated programs face many of the same challenges that burden population-specific programs, including lack of funding and other resources, insufficient or inadequately trained staff, and poor supervision and management.62 Some evidence sug-

Research Needs Although integrating services is not a new idea, there are few studies assessing the effectiveness of integrat-


ed programs. More evidence is needed to determine the opportunities for integration and to assess where this is an appropriate and useful strategy and where it is not. In addition, there are very few longitudinal studies of integrated health care, so more evidence is needed to determine which integrated programs have long-term positive impacts. Few studies report the outcome of integrated services for all of their target audiences (mothers, newborns, and children).2, 73 In a review of nearly 500 trials, reviews and studies of maternal, newborn and child interventions, only onethird reported the impact of each intervention on all three age groups. There are several different ways of grouping interventions, such as combining interventions by age, provider, or location. However, there is little research comparing different combinations of interventions.2, 62 It is essential to identify and implement the most effective and cost-efficient packages, given the extremely limited resources allocated to maternal, newborn and child health. Furthermore, no single package of services is appropriate in all contexts – the effectiveness of packages must be assessed in a variety of health systems and countries.2 Integrated care should be tailored to local populations, adding and omitting different interventions as necessary to address the local burden of disease.4 This tailoring can take into account cultural norms that may limit the effectiveness of specific interventions.

question depends largely on the goals that programs are trying to achieve and the context in which they are working. Integrated programs may not be the most appropriate option to achieve disease-eradication goals or respond to sudden outbreaks of disease, but they are a valuable option for a variety of other health goals, such as reducing maternal and child mortality and increasing access to reproductive health services. If properly done, the strategy of MNCH and family planning integration can become the cornerstone of an effective health care system, leading to use of other services. Yet, there is also the risk of straining fragile or developing health systems. Health care workers can be called upon to efficiently deliver multiple services or can become overwhelmed with the challenge of providing care without adequate training or support. And, just as there are logistical and fiscal reasons to combine programs, there are logistical and fiscal challenges to integrating programs in developing countries. Efforts to integrate these services require the efforts of multiple actors – ministers of health and finance, health care providers, researchers, program implementers, donors, and community leaders are but a few of the stakeholders. With the right approach, millions of women and children may finally receive quality, convenient and cost-effective health care.

Considerable research is also needed to identify the most efficient way to manage the transition from single to integrated systems and to identify the most effective ways of managing these new, integrated programs. Given that integrated service packages will need to be scaled-up to achieve widespread coverage, studies are needed to assess various approaches and the associated infrastructure costs essential for bringing services to communities.4 Some evidence indicates that integrating services may strain health care systems – particularly fragile systems – so implementers must exercise caution when scaling up intervention packages.4 There is also a need for research on the effectiveness of management and supervision functions, program administration, and duration of the health care worker training need to expand their skill sets.

Conclusions AUGUST 2009

Conceptually, integrating maternal, newborn and child health with postpartum family planning services makes sense – these populations, services, and needs are integrally linked. The larger question is whether it can be a practical and workable solution to provide health care to millions of women and children. The answer to this

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Glossary Anemia – Low red blood cell (hemoglobin) concentrations. Anemia may be caused by vitamin and mineral deficiencies, and approximately 50 percent can be attributed to iron deficiency.76, 77 Antenatal period – Period of time during pregnancy that begins at conception and ends at birth. The World Health Organization recommends that pregnant women receive at least four checkups during this period of time. Asphyxia – Insufficient intake of oxygen or excessive intake of carbon dioxide in the body. Fetal asphyxia may result from umbilicial cord compression, premature separation of the placenta, or obstruction in placental circulation.76, 78 Exclusive breastfeeding – The practice of feeding an infant by breast milk only - no water, other liquid or solid is given to the infant.43 Family planning – Using contraceptive methods (pills, injectables, intrauterine devices, condoms, implants) and treatment of involuntary infertility, family planning allows individuals and couples to plan and achieve their desired number of children and enables them to time and space births.79 Hemorrhage – Excessive loss of blood from blood vessels. This is the leading cause of maternal death and can occur during pregnancy or after birth. 76, 78 Hypertension –High blood pressure, a condition that often predisposes a person to various diverse conditions or health events, such as stroke or heart failure. This is a common problem for pregnant women, especially during the third trimester.219678 Hypoglycemia – Abnormally low levels of sugar (glucose) in the blood.76, 78 Intermittent preventive treatment of malaria (IPTp) – Treatment administered to pregnant women living in malaria endemic areas to prevent infection. Consists of at least two doses of sulfadoxine-pyrimethamine (SP) during the second and third trimester or three for HIV positive women.80 Intrauterine device (IUD) – A copper or polypropylene object that is inserted into the uterine cavity to prevent pregnancy. The IUD has an estimated pregnancy rate between 2 and 4 percent, and is the second most popular method of family planning worldwide.76

AUGUST 2009

Intrauterine growth restriction (IUGR) – Decreased rate of fetal growth, where the infant’s estimated weight is below the 10th percentile on the intrauterine growth curve

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for gestation age. This may result in leaning disabilities, inability to concentrate on tasks, hyperactivity, and poor fine motor coordination later in childhood.76 Lactational amenorrhea method (LAM) – Method of family planning that uses exclusive breastfeeding to delay the return of menses within the first few months postpartum, thus delaying subsequent pregnancy.43 Low birth weight (LBW) – Unusually low weight of a newborn, usually less than 2500 grams (5.5 pounds) are classified as having low birth weight. Newborns with low birth weight often have mothers who are underweight or undernourished; they are at increased risk of short- and long-term illnesses or disabilities. 76, 78 Malpresentation – Abnormal position of the fetus at birth, making natural delivery difficult and dangerous for the mother and infant. 76,78 Obstructed labor - This condition arises when labor fails to progress normally and the newborn doesn’t descend through the birth canal properly. Obstructed labor is responsible for 10 percent of maternal deaths among women aged 15–44 years in low-income countries. Small-statured and undernourished women are at highest risk for obstructed labor. Prolonged obstructed labor results in injuries to multiple organ systems.28 Postpartum family planning – Family planning services provided to mothers up to a year after their infants’ birth. Family planning services during the postpartum period are critical, as a woman’s fertility returns after pregnancy and the unmet need for services is high. Postpartum period – Period from the first hour after the delivery of the placenta to six weeks after delivery. Family planning programs often use this time to refer to the period of time up to one year after delivery.23 Sepsis – Infection and common cause of death for mothers and newborns. 219619, 78 Stunting – Observed height for age at least two standard deviations below the mean for 0-5 year old children. Wasting is generally used as an indicator of malnutrition or chronic undernutrition. 28 Wasting – Observed weight for height at least two standard deviations below mean for 0-5 year old children. Wasting is generally used as an indicator of malnutrition or chronic undernutrition. 28


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Publications by Research and Analysis The Global Health Council regularly reviews the evidence available regarding global health research and policy. The results of these reviews are shared with our members and partners through research reports, policy briefs, fact sheets, and our website.

New Research Briefs Understanding Private Sector Involvement in Health Systems It is increasingly apparent that governments cannot fully meet the health needs of their people through reliance on public resources alone. The private sector provides an alternative and complementary means of expanding health services, products and infrastructure. The aim of this brief is to provide an overview of the private sector and the role it plays in health systems, and spark a discussion on the strengths and weaknesses of the private sector, and on public-private collaboration. The Commercial Sexual Exploitation of Children The commercial sexual exploitation of children is one of the worst violations of human rights and has severe physical and mental health repercussions. This brief aims to examine the health impacts of child sexual exploitation and reports recent findings of a Global Health Council research project on the sexual exploitation of children in Ethiopia, and a GHC member survey on health service provision for sexually exploited children. Meeting the Reproductive Health Needs of Displaced Women In a world where over 15 million people are refugees and another 26 million people are displaced within their own countries, the ability to access reproductive health services for millions of displaced women is often fraught with difficulty. The availability of reproductive health services are often dependent upon the type of displacement (internal versus external), the entities (UN, NGOs, etc.) that are providing assistance NGOs are providing assistance and the type of reproductive health services that are needed. The aim of this brief is to identify the major reproductive health concerns of women affected by forced migration; and identify the obstacles in providing reproductive health service to this unique population.

Coming This Fall Global Health Funding Needs for 2015: A Price Tag for Health MDGs In order for developing country governments to provide the necessary services to meet the Millennium Development Goals (MDGs) target for health, additional funding and stronger health systems are required. However, there is no consensus of the resource levels needed to achieve these targets. This report provides an overview of some costing estimates and presents a global price tag for the health MDGs. The Impact of Poor Reproductive Health on Families and Communities Poor reproductive health has adverse health, social, and economic implications for women, families and communities, and impacts national, economic and food security at the country level. This research brief examines the connection between reproductive and economic health and explores why promoting reproductive health is essential to reducing poverty and fostering economic growth, development, and security.

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This brief was prepared with support by the David and Lucile Packard Foundation. It was written by, Rachel Hampton, Lillian Benjamin, Michelle Moglia, and Susan Higman.

Integrating Maternal, Newborn and Child Health and Family Planning Services  

Safe pregnancy and childbirth, healthy children and the ability to control one’s fertility are important goals for families and key indicato...