Ministerial Consultation - Maternal, Newborn and Under-Five Child Health

Monday, March 29, 2010
9 a.m. to 12 p.m.
111 Sussex Drive, Ottawa, Ontario

Context

Following the Prime Minister's January 2010 announcement of Maternal, Newborn and Child Health as a G-8 initiative, the Minister of International Cooperation chaired a consultation with practitioners and experts with direct experience in maternal, newborn and under-five child health, globally and in Canada, to seek their views and to inform Canadian International Development Agency (CIDA) policy as it contributes to a Government of Canada G-8 position and shapes CIDA's strategy and programming on children and youth.

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Objectives

• Garner views and opinions on the the critical intervention points that should be prioritized (e.g. pregnancy, delivery, postpartum, newborn).
• Obtain information on approaches and interventions based on best practices that are proven to have the greatest impact on reducing maternal, newborn and under-five child mortality.
• Identify the key Canadian assets and expertise that can be mobilized to tackle maternal, newborn and under-five child health issues.
• Explore how best to define and ensure results in developing countries.

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Minister's Opening Remarks

The Minister of International Cooperation welcomed the participants, as Canadian medical practitioners and experts on maternal, newborn and under-five child health, and thanked them for their interest and willingness to share their knowledge and experience with CIDA in preparation for the G-8 Summit in June. After an overview of CIDA's priorities and programming, the Minister launched the consultation indicating that CIDA is looking at effective ways of achieving results and demonstrating value in the context of CIDA's Strategy on Children and Youth as the basis for the Maternal, Newborn and Child Health initiative. She also invited participants to offer observations on how to improve accountability and ways of evaluating and making better use of data for improving maternal and child health outcomes.

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Round Table - Session I

Question 1: What are the critical intervention points that should be prioritized to improve maternal, newborn and child health (e.g. pregnancy, delivery, postpartum, newborn)?

Question 2: In considering best practices, what approaches and interventions (e.g., nutrition, health systems, vaccines) are proven to have the greatest impact on reducing maternal, newborn and under-five child mortality in the context of developing countries?

Coordination and local ownership
Coordination of care was stressed to prevent the inefficiencies of the silo approach to providing health care services to avoid redundancy and enhance a more comprehensive approach to maternal, newborn and child health. Aid organizations were encouraged to work in close partnership with the country being assisted, and to help build capacity in the country by training local health workers and applying flexible approaches (e.g. transfer of functions, task shifting) for basic interventions where high incidence of mortality occurs. In that regard, three main delays raising mortality rates in many developing countries were noted: delays in triage and case identification; transport of patients to the health care facility, when available; and treatment and risk evaluation. Participants also emphasized that child mortality and health can best be measured at the regional level. As such, a crosscutting approach to program delivery and monitoring can contribute to improved health outcomes while also building system-wide capacity.

Continuum of Care
It was pointed out that maternal, newborn health and infant health issues are interlinked, and discussion focused on the continuum of care whereby infant health programs are interrelated with those of maternal health. As such, programs need to be managed through a broad approach or strategy where child and maternal health initiatives are addressed collectively. Strong evidence exists that a holistic approach enhances health outcomes, as opposed to segmented interventions. A number of participants cautioned against adopting a strict medical approach, and suggested the need for family and community outreach as well, including upstream preventative care (e.g. pre-pregnancy health, adolescent health, beginning stages of reproductive health), family planning and reproductive technology, and social and economic interventions. Many also observed that to be successful, maternal health programs need to be comprehensive, from pre-pregnancy through antenatal care and delivery, and provide ongoing support to mothers and their newborn and young children, such as nutrition programs (maternal, antenatal, and postnatal). Many noted that policy makers need to recognize the importance and benefits of breastfeeding as a way to reduce infant mortality rates and improve child health outcomes. Participants also highlighted the importance of consideration and sensitivity to indigenous local culture and traditions and encourage positive social changes that improve mothers' and children's access to the health care they need.

Comprehensiveness
Many commented about the importance of improving the education of mothers and girls as a way to improve their knowledge; increase their access to health care, clean water, and nutrition; and enhance economic security and safety. By focusing on early childhood (i.e., up to the age of five), other goals, including education and security, could all be addressed in an integrated manner, encompassing not only physical health, but social and cognitive development as well. Moving beyond the focus of Millennium Development Goals four and five, some suggested that an emphasis needs to be placed on increasing the number of under-five children who are "ready to learn" by the time they reach primary school in order to ensure that today's children in developing countries live to their full potential as adults.

Strengthening Community Capacity
The discussion turned to the best ways to build capacity and what basic curriculum, medicines, and other diagnostic and treatment tools should be provided to the developing country's health care workers. There was general agreement on the need to improve the lack of accurate methods and tools to measure the impact of critical interventions to improve maternal, newborn and under-five child health. Reliance on informal or untrained caregivers, whose inability to detect illnesses and diseases that contribute to maternal, newborn and child mortality, is a complicating factor. The need for continuing education to help health care workers in developing countries upgrade their skills was also raised, as well as encouraging better cooperation between universities and governments to broaden the skill levels of nurses and help them provide needed multidisciplinary services. To achieve a minimum standard and quality of training of front-line health workers, work needs to be done to support curriculum and training programs focused on the needs of mothers and children. The expertise, experience, and capacity of Canadian health professionals, institutions, and academics should be used within Canada's international efforts in maternal, newborn and child health. Building networks or improving connectivity among health care workers in Canada and those in developing countries is occurring independently of CIDA and should be incorporated as an effective tool to support its maternal, newborn and child health work.

Evidence and Measurement
It was recommended that existing technology (e.g. cellular networks) be used to support the provision of health services as well as decision making. For example, cell phones have been used as a public-information tool to disseminate health information and as a measurement tool to collect data that would help inform program decision making and direct the appropriate interventions and resources to priority health care needs. In this regard, a critical intervention matrix should serve to prioritize treatment in maternal health care and to ensure it is tailor-made to the specific needs of the village, district, or country. Mapping of need, incidence of disease, and illness, as well as access to service and trained health workers, would improve effectiveness and help provide needed support more appropriately. Evidence-based guidelines in child health care, such as the infant resuscitation program "Helping Babies Breathe," also help guide programming for each stage of a child's development, while the Integrated Management of Childhood Illness, developed by UNICEF and WHO, offers a multitude of training measurements and strategies for health workers involved in health care for children aged one month to five years. These instruments can be applied anywhere.

Need for Data to Evaluate Appropriate Interventions
The discussion turned to the importance of gathering hard data to identify the problems in program implementation. Examples cited include the registration of live births (to improve a child's chance of being protected) and the need for an improved determination of their exact cause of death (to reduce child mortality rates). Robust data collection requires collaboration among governments, non-governmental organizations, and health care workers. The need to identify, track, and measure meaningful indicators needs to be improved and accelerated.

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Round Table - Session II

Question 3: What are the key Canadian assets and expertise that can be mobilized to tackle maternal, newborn and under-five child health issues?

Question 4: How will we define and ensure advancement and realize desired results in developing countries?

Identified Priorities:

Subnational Focusing (district, regional)
To achieve success in maternal, newborn and child health, participants identified the need for a greater focus at the regional and district levels, and the involvement of community health care workers. For effective programming and measuring health system targets and outcomes, a district-based model of program delivery and accountability for certain health outcomes has been applied successfully around the globe. Evaluation systems are needed, and it was suggested that measurements of real impact data (e.g. deaths, nutritional levels) at the district level would provide more accurate information, for example, on the actual nature or cause of infant deaths in many regions, where more than 80 percent of child deaths occur without the child ever attending a hospital.

Women's and Children's "One Stop Care" Centres
The idea of "one-stop care centres," including services in health care, early childhood education and nutrition, was noted not only for the care of mothers, but also for the care of children (i.e. 0 to five years). The outcome measures would be decreases in malnutrition, diseases, and deaths. Participants also touched on the need to help avoid back-to-back-to-back pregnancies through improved access to contraceptives and family planning. In terms of "one-stop shopping" care for children under five years, community support centres could provide parenting and caregiver support, child care and basic preschool education, as well as nutrition information and primary health care.

Impact of Poverty
A focus on the economic obstacles mothers face in providing essential care for their children was highlighted. Mothers in developing countries often face the difficult choice between earning an income or breastfeeding. Mothers typically are forced to choose to stop breastfeeding. Policy makers were encouraged to consider the implications of poverty along with the social and health considerations of mothers and their care of under-five children.

Strengthening International Networks
Strengthening networks between Canadian institutions and those in developing countries was proposed as a way to broker ideas, transfer knowledge, and capitalize on Canadian expertise and experience while working toward local ownership and capacity in-country. Mention was made of the recommendation of the UN Report on Social Determinants of Health and Early Childhood Development for establishing a global interagency network for ongoing collaborative work in maternal and infant health. It was noted that Canada is in a good position to put together such a network to foster international cooperation, reduce existing duplication of agency activities, and help prioritize issues and needed activities in developing countries while strengthening data collection.

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Summary of Key Comments and Recommendations from the Consultation

At the conclusion of the consultation, the moderator presented a brief summation of the key comments and recommendations emanating from the day's discussion:

• the importance of developing-country ownership of policy and programs;
• the importance of the continuum-of-care approach;
• the value of partnerships and networks (e.g. North-South, South-South, local community champions, district-agency) to ensure better coordination, foster data/knowledge sharing, and support the effectiveness of CIDA's international development activities;
• request opportunity for ongoing partnerships and dialogue between CIDA and Canadian practitioners and experts in maternal, newborn and under-five child health;
• the critical need for effective measurement tools/evaluation systems and networks for data and expertise sharing for increased accuracy in measurement to know what works and what does not so as to improve capacity development and coordination;
• the added value of a more comprehensive approach that acknowledges key factors to health, such as improvements to education, nutrition, gender equality, access to health services, and economic opportunities for women; and
• the importance of integrated approaches at the community level that provide comprehensive help and support for both mothers and children in, among other interventions, health care, nutrition, child care, and education.

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Participants

Canadian Medical Practitioners and Experts

Dr. Robert (Bob) Armstrong - Chief of Pediatric Medicine at the BC Children's Hospital
Dr. Jennifer L. Brenner - Pediatrician, Alberta Children's Hospital and Associate Clinical Professor, University of Calgary
Dr. Jean Chamberlain*- Founding Director of Save the Mothers, Uganda, and Assistant Professor with the Department of Obstetrics and Gynecology (St. Joseph's Hospital) at McMaster University
Dr. Jan Christilaw - Obstetrician-Gynecologist , President of the BC Women's Hospital & Health Centre and Clinical Professor, Department of Obstetrics-Gynecology, University of British Columbia
Dr. Ruth Collins-Nakai* - Pediatric Cardiac Surgeon based in Edmonton, Alberta, and representing the Canadian Medical Association
Dr. Lori Hanson* - Assistant Professor in Community Health and Epidemiology at the University of Saskatchewan, Saskatoon
Dr. JoAnn Harrold - Neonatologist, Medical Director of Neonatal Transport with the Children's Hospital of Eastern Ontario
Dr. Jody Heymann - Canada Research Chair in Global Health and Social Policy (Joint Appointment with Epidemiology and Biostatistics) at McGill University
Dr. John C. LeBlanc - Pediatrician, Izaak Walton Killam Health Centre in Halifax, and Associate Professor of Pediatrics, Psychiatry, Community Health and Epidemiology at Dalhousie University
Dr. Heather MacDonnell - Pediatrician, Children's Hospital of Eastern Ontario, and member of the Advisory Committee for the Office of Global Health with the University of Ottawa's Faculty of Medicine
Dr. Reginald Sauve - Pediatrician and Epidemiologist, University of Calgary and the Alberta Children's Hospital
Ms. Cathy Séguin - Vice-President of International Affairs, Hospital for Sick Children, Toronto, Ontario
Dr. Anne Snowdon - Associate Professor, Faculty of Nursing, University of Windsor
Dr. Peter von Dadelszen - Senior Clinician Scientist, Child and Family Research Institute, and Associate Professor of Maternal Fetal Medicine, University of British Columbia
Dr. Mark Walker - Senior Scientist in Clinical Epidemiology and Assistant Professor of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Ottawa
Dr. Robin Walker - Neonatologist, Vice-President of Medicine,Izaak Walton Killam Hospital for Children in Halifax, and Professor of Pediatrics, Dalhousie University
Dr. Alvin Zipursky - Pediatrician, Chairman and Executive Director of the Program for Global Pediatric Research, Hospital for Sick Children, Toronto, Ontario

* Denotes participation by conference telephone link

Canadian International Development Agency

The Honourable Beverley J. Oda, Minister of International Cooperation (Chair)
Ms. Christine Hogan, Vice-President, Strategic Policy and Performance Branch, CIDA (Moderator)
Ms. Amy Mills, Director of Policy, Office of the Minister of International Cooperation