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To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal–perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal–perinatal health; and accelerate progress through evidence, advocacy, and accountability.

In the concluding paper of this Series about midwifery, we look at the policy implications from the framework for quality maternal and newborn care, the potential effect of life-saving interventions that fall within the scope of practice of midwives, and the historic sequence of health system changes that made a reduction in maternal mortality possible in countries that have expanded their midwifery workforce. Achievement of better health outcomes for women and newborn infants is possible, but needs improvements in the quality of reproductive, maternal, and newborn care, alongside necessary increases in universal coverage. In this report, we propose three priority research areas and outline how national investment in midwives and in their work environment, education, regulation, and management can improve quality of care. Midwifery and midwives are crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health; now and beyond 2015.

This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.

Background Appropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many high burden regions. Despite its importance, geographical access is rarely audited systematically, preventing integration in national-level maternal health system assessment and planning. In this study, we develop a uniquely detailed set of spatially-linked data and a calibrated geospatial model to undertake a national-scale audit of geographical access to maternity care at birth in Ghana, a high-burden country typical of many in sub-Saharan Africa. Methods We assembled detailed spatial data on the population, health facilities, and landscape features influencing journeys. These were used in a geospatial model to estimate journey-time for all women of childbearing age (WoCBA) to their nearest health facility offering differing levels of care at birth, taking into account different transport types and availability. We calibrated the model using data on actual journeys made by women seeking care. Results We found that a third of women (34%) in Ghana live beyond the clinically significant two-hour threshold from facilities likely to offer emergency obstetric and neonatal care (EmONC) classed at the ‘partial’ standard or better. Nearly half (45%) live that distance or further from ‘comprehensive’ EmONC facilities, offering life-saving blood transfusion and surgery. In the most remote regions these figures rose to 63% and 81%, respectively. Poor levels of access were found in many regions that meet international targets based on facilities-per-capita ratios. Conclusions Detailed data assembly combined with geospatial modelling can provide nation-wide audits of geographical access to care at birth to support systemic maternal health planning, human resource deployment, and strategic targeting. Current international benchmarks of maternal health care provision are inadequate for these purposes because they fail to take account of the location and accessibility of services relative to the women they serve.

Geographic accessibility to health facilities represents a fundamental barrier to utilisation of maternal and newborn health (MNH) services, driving historically hidden spatial pockets of localized inequalities. Here, we examine utilisation of MNH care as an emergent property of accessibility, highlighting high-resolution spatial heterogeneity and sub-national inequalities in receiving care before, during, and after delivery throughout five East African countries. We calculated a geographic inaccessibility score to the nearest health facility at 300 x 300 m using a dataset of 9,314 facilities throughout Burundi, Kenya, Rwanda, Tanzania and Uganda. Using Demographic and Health Surveys data, we utilised hierarchical mixed effects logistic regression to examine the odds of: 1) skilled birth attendance, 2) receiving 4+ antenatal care visits at time of delivery, and 3) receiving a postnatal health check-up within 48 hours of delivery. We applied model results onto the accessibility surface to visualise the probabilities of obtaining MNH care at both high-resolution and sub-national levels after adjusting for live births in 2015. Across all outcomes, decreasing wealth and education levels were associated with lower odds of obtaining MNH care. Increasing geographic inaccessibility scores were associated with the strongest effect in lowering odds of obtaining care observed across outcomes, with the widest disparities observed among skilled birth attendance. Specifically, for each increase in the inaccessibility score to the nearest health facility, the odds of having skilled birth attendance at delivery was reduced by over 75% (0.24; CI: 0.19-0.3), while the odds of receiving antenatal care decreased by nearly 25% (0.74; CI: 0.61-0.89) and 40% for obtaining postnatal care (0.58; CI: 0.45-0.75). Overall, these results suggest decreasing accessibility to the nearest health facility significantly deterred utilisation of all maternal health care services. These results demonstrate how spatial approaches can inform policy efforts and promote evidence-based decision-making, and are particularly pertinent as the world shifts into the Sustainable Goals Development era, where sub-national applications will become increasingly useful in identifying and reducing persistent inequalities.

As a creeping process, salinisation represents a significant long-term environmental risk in coastal and deltaic environments. Excess soil salinity may exacerbate existing risks of food insecurity in densely populated tropical deltas, which is likely to have a negative effect on human and ecological sustainability of these regions and beyond. This study focuses on the coastal regions of the Ganges–Brahmaputra delta in Bangladesh, and uses data from the 2010 Household Income and Expenditure Survey and the Soil Resource Development Institute to investigate the effect of soil salinity and wealth on household food security. The outcome variables are two widely used measures of food security: calorie availability and household expenditure on food items. The main explanatory variables tested include indicators of soil salinity and household-level socio-economic characteristics. The results of logistic regression show that in unadjusted models, soil salinisation has a significant negative effect on household food security. However, this impact becomes statistically insignificant when households’ wealth is taken into account. The results further suggest that education and remittance flows, but not gender or working status of the household head, are significant predictors of food insecurity in the study area. The findings indicate the need to focus scholarly and policy attention on reducing wealth inequalities in tropical deltas in the context of the global sustainable deltas initiative and the proposed Sustainable Development Goals.

ObjectivesTo investigate how the quality of maternal health services and travel times to health facilities affect birthing service utilisation in Eastern Region, Ghana.DesignThe study is a cross-sectional spatial interaction analysis of birth service utilisation patterns. Routine birth data were spatially linked to quality care, service demand and travel time data.Setting131 Health facilities (public, private and faith-based) in 33 districts in Eastern Region, Ghana.ParticipantsWomen who gave birth in health facilities in the Eastern Region, Ghana in 2017.Outcome measuresThe count of women giving birth, the quality of birthing care services and the geographic coverage of birthing care services.ResultsAs travel time from women’s place of residence to the health facility increased up to two2 hours, the utilisation rate markedly decreased. Higher quality of maternal health services haves a larger, positive effect on utilisation rates than service proximity. The quality of maternal health services was higher in hospitals than in primary care facilities. Most women (88.6%) travelling via mechanised transport were within two2 hours of any birthing service. The majority (56.2%) of women were beyond the two2 -hour threshold of critical comprehensive emergency obstetric and newborn care (CEmONC) services. Few CEmONC services were in urban centres, disadvantaging rural populations.ConclusionsTo increase birthing service utilisation in Ghana, higher quality health facilities should be located closer to women, particularly in rural areas. Beyond Ghana, routinely collected birth records could be used to understand the interaction of service proximity and quality.

Background The COVID-19 pandemic has resulted in profound and far-reaching impacts on maternal and newborn care and outcomes. As part of the ASPIRE COVID-19 project, we describe processes and outcome measures relating to safe and personalised maternity care in England which we map against a pre-developed ASPIRE framework to establish the potential impact of the COVID-19 pandemic for two UK trusts. Methods We undertook a mixed-methods system-wide case study using quantitative routinely collected data and qualitative data from two Trusts and their service users from 2019 to 2021 (start and completion dates varied by available data). We mapped findings to our prior ASPIRE conceptual framework that explains pathways for the impact of COVID-19 on safe and personalised care. Results The ASPIRE framework enabled us to develop a comprehensive, systems-level understanding of the impact of the pandemic on service delivery, user experience and staff wellbeing, and place it within the context of pre-existing challenges. Maternity services experienced some impacts on core service coverage, though not on Trust level clinical health outcomes (with the possible exception of readmissions in one Trust). Both users and staff found some pandemic-driven changes challenging such as remote or reduced antenatal and community postnatal contacts, and restrictions on companionship. Other key changes included an increased need for mental health support, changes in the availability and uptake of home birth services and changes in induction procedures. Many emergency adaptations persisted at the end of data collection. Differences between the trusts indicate complex change pathways. Staff reported some removal of bureaucracy, which allowed greater flexibility. During the first wave of COVID-19 staffing numbers increased, resolving some pre-pandemic shortages: however, by October 2021 they declined markedly. Trying to maintain the quality and availability of services had marked negative consequences for personnel. Timely routine clinical and staffing data were not always available and personalised care and user and staff experiences were poorly captured. Conclusions The COVID-19 crisis magnified pre-pandemic problems and in particular, poor staffing levels. Maintaining services took a significant toll on staff wellbeing. There is some evidence that these pressures are continuing. There was marked variation in Trust responses. Lack of accessible and timely data at Trust and national levels hampered rapid insights. The ASPIRE COVID-19 framework could be useful for modelling the impact of future crises on routine care.

Tropical delta regions are at risk of multiple threats including relative sea level rise and human alterations, making them more and more vulnerable to extreme floods, storms, surges, salinity intrusion, and other hazards which could also increase in magnitude and frequency with a changing climate. Given the environmental vulnerability of tropical deltas, understanding the interlinkages between population dynamics and environmental change in these regions is crucial for ensuring efficient policy planning and progress toward social and ecological sustainability. Here, we provide an overview of population trends and dynamics in the Ganges–Brahmaputra, Mekong and Amazon deltas. Using multiple data sources, including census data and Demographic and Health Surveys, a discussion regarding the components of population change is undertaken in the context of environmental factors affecting the demographic landscape of the three delta regions. We find that the demographic trends in all cases are broadly reflective of national trends, although important differences exist within and across the study areas. Moreover, all three delta regions have been experiencing shifts in population structures resulting in aging populations, the latter being most rapid in the Mekong delta. The environmental impacts on the different components of population change are important, and more extensive research is required to effectively quantify the underlying relationships. The paper concludes by discussing selected policy implications in the context of sustainable development of delta regions and beyond.

Purpose Adults with a personality disorder diagnosis have a high prevalence of co-occurring autism and attention deficit hyperactivity disorder (ADHD). However, there is often no defined pathway within mental health services to meet the needs of this population, and a lack of evidence or consensus on the optimal approaches to identification, treatment and support for neurodivergent people with a personality disorder diagnosis. There has been little exploration of the views of this population on the care they receive in community mental health services. Therefore, the aim of this project was to understand the experiences and perspectives of neurodivergent people with a personality disorder diagnosis, to inform a clinical pathway which is effective, safe, sustainable and equitable. Methods Ten qualitative interviews were conducted with women with a diagnosis of, or had been referred for a diagnosis of, autism or ADHD, and a diagnosis of personality disorder. Interviews were analysed using reflexive thematic analysis. Results Five key themes emerged; staff factors (understanding and skills, attitudes and communication), pathways and processes (access to services and barriers to support), involving and enabling (through adaptations and empowerment), support and clinical interventions (experience of individual therapies and groups, and opportunities to evaluate support), and diagnosis and identification (the impact and accuracy of diagnosis). Conclusions This study highlights gaps in current practice as well as personal preferences about identity and experiences of misdiagnosis. It identifies the components of an integrated clinical pathway, that include a person-centered, formulation-driven approach to assessment and reasonable adjustments; peer-led psychosocial support; adapted transdiagnostic psychological therapies; and embedded co-production. Clinical and research priorities are discussed.