Necessity of Collaboration and Pooling Resources to Ensure Quality Maternal and Neonatal Healthcare

Joy Riggs-Perla
Director, Office of Health and Nutrition
United States Agency for International Development

Thanks to the organizers. Greetings to the audience.

It is a pleasure to have this opportunity to address the Board of Trustees and to share with you some thoughts about USAID's vision for maternal and neonatal health and the importance we place on partnerships.

The title of this talk says it all—no donor agency nor Cooperating Agency (CA), acting alone, can do it all. Even when we have a focused, strategic vision and clearly articulated interventions within our manageable interests, forging partnerships with other Cooperating Agencies, donors, and even across the various departments of one's own agency, is critical for safe motherhood—especially if we ever hope to reduce maternal and neonatal mortality. 

USAID has five Strategic Objectives (SOs):

SO1: Unintended and mistimed pregnancies reduced.

SO2: Deaths, nutrition insecurity and adverse health outcomes to women as a result of pregnancy and childbirth reduced.

SO3: Infant and child health and nutrition improved, and infant and child mortality reduced.

SO4: HIV transmission and the impact of the HIV/AIDS pandemic in developing countries reduced.

SO5: The threat of infectious diseases of major public health importance reduced.

The MNH Program, supported by the Office of Health and Nutrition, should have direct impact on at least two of them: SO2 and SO3—reduction of deaths, nutrition insecurity and adverse health outcomes for women, children and infants.

Arguably, MNH programming could overlap with all five Strategic Objectives. For example:

• Reducing unintended and mistimed pregnancies, thereby reducing unsafe abortion and increasing birth intervals, is an important component in any overall strategy for improving maternal and newborn health and reducing mortality. 

• STD screening and treatment in antenatal care is a key intervention to reduce perinatal mortality and reduces the risk for the mother of HIV infection.

• Bednets and intermittent presumptive treatment with anti-malarials reduce low birthweight and perinatal mortality. Parenthetically, I should mention that we recognize that the majority of infant deaths now occur in the neonatal period, and of those neonatal deaths, the vast majority occur in the first week following birth. These deaths are directly associated with the health of the mother during pregnancy and with events surrounding birth.

Thus we see the potential for maternal health programming to have a significant impact across all Agency Strategic Objectives. Indeed, we have to recognize that maternal health and safe motherhood programming is fundamental to achieving results across Strategic Objectives and to reducing maternal and infant mortality.

Under the Global Bureau/PHN (Population, Health and Nutrition) Strategic Objective 2, the results we want to obtain focus on four areas:

• integration of nutrition into maternal health programming;

• birth preparedness, including antenatal care, behavior change interventions to promote health seeking and healthy behavior, and community mobilization components;

• services for normal delivery; and 

• management of complications of pregnancy, birth, the postpartum period and the newborn.

Obviously, to achieve results in all four areas, and ultimately affect health status, requires work at all levels of healthcare systems from the community to the national level.

Programming for safe motherhood is not vertical. It requires attention to nutrition, human resources development, commodities and logistics, development of service delivery and referral systems, policy development, advocacy, and social mobilization and communications. One-off projects or a shotgun approach to programming won't get us where we want to be.

It also requires that we think seriously about scaling up. This demands that we focus investments on those things that the system can sustain over time.

Moreover, programming for systems is limited to those things USAID has deemed within its manageable interests. For example, global programs can provide technical assistance but cannot renovate facilities or purchase pharmaceuticals and equipment needed to save women's lives.

Obviously it requires partnership between MNH, the missions and the Global Bureau. Even though a flagship program like MNH has a broad mandate, it has to complement, and not duplicate, ongoing activities in countries where it works. It has to respond to mission and host-country government priorities, and find the fit between those and its global mandate. USAID is a very decentralized agency. We can formulate a strategy at global level but it is carried out in the field.

Just in terms of the results we hope to achieve, we encounter the need for partnerships in countries among all agencies concerned and involved with the health of women, children and families. Not just for the purpose of coordination, but to ensure population impact.

• First, maternal health and nutrition interventions, while impor- tant in their own right, are integrally linked with child survival. Developing the links, wherever possible, with child survival programs is crucial for the success of safe motherhood program- ming. For example, safe motherhood programs can link with:

  • EPI (WHO's Expanded Programme for Immunization) activities to ensure that pregnant women receive tetanus toxoid

  • nutrition programs to ensure pregnant women receive micronutrient support during pregnancy and the postpartum period and which support women to breastfeed

  • malaria programs and programs that offer HIV voluntary counseling and testing in pregnancy

To implement these program components, partnerships are needed—among USAID Cooperating Agencies as well as between CAs and other agencies such as CDC, UNICEF and nongovernmental organizations (NGOs).

• Second, safe motherhood programs need to do what they can to ensure that women have access to family planning. Not only will this potentiate the impact of safe motherhood programs—this can improve contraceptive prevalence rates since postpartum women are an underserved group.

• Likewise, postabortion care should be seen within the context of essential obstetrical care and not as a stand-alone maternal health intervention. Forming these kinds of alliances can lead to joint planning and programming that has the potential to advance to scale programs with population impact.

Examples of how partnerships are working:

• Burkina Faso

The MNH Program in Burkina Faso is a concrete example of how such partnerships are constructed. The Burkina Faso program works at each level of the healthcare system. In the community, MNH works with the NGO Plan International to deliver a birth preparedness package that includes mobilizing communities to overcome barriers to care. MNH provides technical assistance in human resource development to ensure that health providers are able to manage normal and complicated deliveries, while UNICEF provides clinics with needed equipment and pharmaceuticals. MNH works with CDC to provide technical assistance in integrating intermittent presumptive treatment into health services and also at community level for women who are unable to access services. And MNH works with the government of Burkina Faso and with other governments in the region to develop national curricula for health providers and national standards and guidelines for safe motherhood services. Through this approach, MNH is able to build a coalition of partners on the ground to improve maternal and newborn services and policies and also to address the problem of service underutilization.

• Nepal

A similar partnership has evolved in Nepal. Here MNH is providing technical assistance to develop a training curriculum for front-line health providers at village level. UNFPA (United Nations Population Fund) has committed funds to implement this training and scale it up. The British Department for International Develop- ment is helping to upgrade health facilities, and MNH is working on strategies for community mobilization to encourage women to seek care. MNH is also conducting operations research in community financing to work out options to eliminate this important barrier to care. MNH is also building on ongoing investments in postabortion care and family planning programs.

Beyond the technical and programmatic reasons for partnerships, we need to recognize that safe motherhood programs need ongoing commitment. All of us working in development understand that governments and international agencies like to demonstrate to the public that they are responding to emerging issues and have the capacity to tackle problems the Congress and constituencies feel are the most pressing priorities. One year that may be reproductive health—the next, infectious diseases—the next, HIV/AIDS. All of these issues may be on our radar screen and we may be moving ahead with programs and strategic plans. However, the priority placed on each issue and consequently the funding levels for these programs will shift.

It does not necessarily mean that the total amount from the public purse to spend on international development will be greater than in previous years. Soft earmarks reduce the amount of discretionary funds available to missions and the global and regional bureaus in Washington. This forces Strategic Objective teams to look for ways to absorb earmarked funds within existing programs in order to "stay the course."

CAs, in turn, will find themselves under pressure to design programs that address several Strategic Objectives simultaneously. It also increases reporting responsibilities and requires CAs and USAID staff to partner with disparate players in order to bring in the expertise needed to carry out programs and to piece together the necessary resources to design a program that has a chance of obtaining results. 

I cannot emphasize how important it will be in the coming years to speak with one voice on this issue. Existing partnerships between USAID, its Cooperating Agencies and the international community need to be strengthened in ways that will enable safe motherhood programs to continue to make progress. That will include reaching out to other potential partners who can support these efforts. It will include mobilizing communities worldwide through the White Ribbon Alliance to recognize that they can have a voice and take action collectively to find ways to overcome the barriers keeping women from services and services from functioning effectively. And it will include getting results—all of us have a responsibility to demonstrate that safe motherhood isn't an unattainable dream but that, together, it is possible to make a difference. 

Thank you.