Health system redesign for equity in maternal and newborn health must be codesigned, country led, adapted to context and fit for purpose

In this edition of BMJ Global Health , Roder-DeWan and colleagues suggest ways in which we might rethink care models to close the equity gap in maternal and newborn health.1 Their analysis article follows from the work of the Lancet Global Health Commission on High-Quality Health Systems , proposing design reforms with quality at the centre.2 The authors suggest that all childbirth care services should be moved to hospitals in all countries, combined with improvements in (1) the quality of care provided in these facilities; (2) transportation from home to hospital; and (3) continuity of care through hub-and-spoke arrangements. We agree in principle with the need to shift childbirth care services towards higher level facilities. The quality of care provided to women and their newborns in low and middle-income countries (LMICs) is inadequate.1 Economic development and advances in communication and transportation should redefine the paradigm of proximity to care.1 Also Kruk and colleagues estimated that more lives are lost today due to substandard care than due to limited geographical access.3 So it is important to rethink where and how childbirth care should be made available. However, such health system redesign needs to respond to local needs and bottlenecks—that is, redesign must centre human resources, particularly midwifery providers ; respond to the local context ; and be fit for purpose . To cite Lynn Freedman, ‘ The point is not that global strategies, evidence-based guidelines, or high-level monitoring and accountability initiatives are inherently wrong or unnecessary. But when they consume most of the oxygen in the room, drowning out voices and signals coming from the ground, they distort both understanding and action. ’ 4 Redesigning maternal and perinatal care needs to be done with a view to strengthening district health systems in a sustainable and crisis-resilient …