General comments: 1. Do have any comments on the guiding principles proposed in the ENAP?

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1 DSW (Deutsche Stiftung Weltbevoelkerung) is an international development and advocacy organisation. We empower young people and communities in low- and middle-income countries by addressing the issues of population dynamics and by improving health as a way to achieve sustainable development. Headquartered in Hanover, Germany, DSW maintains four country offices in Ethiopia, Kenya, Tanzania and Uganda, as well as a liaison office in Berlin, Germany, and Brussels, Belgium. Our aim is to prevent poverty before it occurs. Our focus is on achieving universal access to sexual and reproductive health services and information, which is fundamental to improving health and effectively fighting poverty. General comments: As an organisation focussing on youth and Sexual and reproductive health and rights, we welcome the focus on girls and adolescents, as well as the linkage between maternal and newborn health with reproductive health and access to family planning. Firstly, unintended pregnancies especially among girls and young adolescents are the cause of high rate of maternal and newborn morbidity and mortality. Interventions to prevent unintended pregnancies should be a priority throughout the ENAP. Efforts to allow safe abortion where legal should be part of ENAP. Secondly, ENAP should focus more on the special needs of young people, especially girls of 10 year old onwards. Indeed, adolescent unintended pregnancies present greater risk to the mother s and newborn s health that could have also repercussions through generations on growth failure. In addition, the ENAP should highlight the need for holistic and human rights based approach. Lack of access to family planning is linked not only to health systems but also to cultural and social context, gender inequality and lack of women and girls empowerment and respect to their rights. For this reason, it is key to gain support from men and boys and community leaders to raise awareness, change behaviours and end traditional harmful practices such as early and forced marriages and sexual violence. Finally, research also needs to be mentioned while defining strategies to improve maternal and newborn health. Poverty-related (HIV &AIDS, Tuberculosis and Malaria) and neglected tropical diseases (PRNDS) are among the first indirect causes of maternal mortality and affect newborn health: indeed PRNDS lead to anaemia and worsens under nutrition of the pregnant women and girl; this contributes to newborns low birth weight. In addition, some PRNDS are also transmissible from mother to child. Many solutions to diagnose, prevent and treat PRNDs, as well as maternal mortality prevention tools) are often still lacking or unsuitable to the conditions of individuals and communities (length of treatment, preservation, climate resistant drugs, etc.). Therefore, ENPA should call for collaborative action between public, private and civil society to research and development for health solutions. 1. Do have any comments on the guiding principles proposed in the ENAP? Guiding principles: (see additions to the original text in bold). Firstly, integration of family planning and sexual and reproductive health should be clearly included so that we have a world where every pregnancy is wanted : Guiding principle (a) on country leadership attention should also be dedicated to good quality reproductive, sexual, maternal and newborn health service. Guiding principle (b) on integration with family planning and sexual health should be highlighted to reflect 17-20: Providing every

2 woman and every newborn with good-quality care requires integrated service delivery with coordinated health system approaches between multiple programmes, stakeholders and initiatives across the continuum of reproductive, sexual, including universal access to modern family planning, maternal, newborn. In addition, men involvement needs to be part of any action towards maternal and new born health. Guiding principle ( c ): Equity: Equitable and universal coverage of high-impact interventions, and a focus on reaching the most vulnerable and poorest population groups are central to realizing the right of every woman and every newborn, girl and boy, to health, through the involvement of men and community leaders. Thirdly, on Guiding principle (e), many poverty related and neglected tropical diseases (PRNDs) have impact on pregnant women and girls and newborns health. Poverty-related diseases are HIV & AIDS, tuberculosis and malaria. Neglected tropical diseases (NTDs) are parasitic and bacterial infections that thrive in parts of the world with unsafe water, poor sanitation and limited access to healthcare. PRNDs are among the leading indirect cause of maternal mortality and are transmitted to newborn, generating health issues (low weight, congenital infections, etc). 20% of maternal deaths are due to pre-existing or concurrent diseases that complicate the pregnancy or are aggravated by it 1. These include malaria, TB and HIV & AIDS. In South Africa, HIV has been the leading contributor to maternal mortality since 1998 (Black et al. 2009: 293) 2. Pregnant women are four times more likely to contract malaria and twice likely to die from malaria than other adults. In Africa, malaria in pregnancy is responsible for 400,000 cases of severe maternal anaemia and 200,000 new born deaths each year. Placental infection, premature birth and low birth weight (a significant factor of infant mortality) are also caused by maternal malaria. In addition, severe maternal anaemia increases the risk of perinatal complications 3. Tuberculosis is the third leading cause of death globally among women in their reproductive years (15-44 years). Mother-to-child transmission of tuberculosis is estimated to be 15 per cent within three weeks of birth (TBVI 2013 :12) 4. Women and children are disproportionately affected by NTDs (WHO 2013b: 21) 5. Neglected tropical Diseases (NTDs) also greatly impair reproductive health, increase the transmission of STIs and promote stigma and gender equality. For instance, female genital schistosomiasis (especially of the lower genital tract) has been identified as an important co-factor in HIV transmission in rural areas of Africa where S. haematobium and HIV & AIDS are co-endemic. (Hotez 2009: 1) 6. Congenital infections (mother-to-child) for toxoplasmosis and malaria as well as Chagas disease and leishmaniasis also occur. Congenital transmission of Chagas disease happens in about 1-10% of cases, which can lead to clinical manifestation from birth and even the possibility of transmission to second 1 WHO The World Health Report 2005: Make every mother and child count. Available at: 2 Black, Vivian, Sebhastian Brooke and Matthew F. Chersich Effect of Human Immundeficiency Vorus Treatment on Maternal Mortality at a Tertiary Center in South Africa. Obstetrics & Gynecology 114(2, part 1,): Malaria Consortium Malaria the Challenges. Available at: 4 TBVI TB Vaccine Research and Development: A business case for investment. Available at: 5 WHO.2013.Sustainaing the drive to overcome the global impact of neglected tropical diseases: second WHO report on neglected tropical diseases. 6 Hotez, Peter J Empowering Women and Improving Female Reproductive Health through Control of Neglected Tropical Diseases. PLoS Neglected Tropical Diseases, 3(11): 1.

3 generation. Visceral leishmaniasis can also be transmitted to foetuses by their mothers (WHO 2013b: 21) 7. Hookworm infection contributes to approximately 7% of the 20% of maternal deaths caused by anaemia in Africa 8.The infection can cause serious health risks during pregnancy and childbirth and to the new born, including anaemia, under nutrition and low birth weight (Global Network Neglected Tropical Diseases 2013a: 1) 9. Chronic schistosomiasis, like hookworm infection, is also a major cause of anaemia in Africa, affecting an estimated 10 million pregnant women in Africa alone, half of whom consequently develop anaemia and complication during pregnancy (Samuels and Rodriguez Pose 2013: 5) 10. Schistosomiasis. Often diagnostics tools to prevent, diagnose and treat PRNDs are either still lacking or unsuitable to the conditions of individuals and communities in developing countries, for instance due to the length of the treatment or the need for advanced technology to conserve a drug or provide an appropriate diagnosis. Prevention tools & medication, diagnosis tools and cures are still needed for HIV & AIDS; while some drugs exist for Tuberculosis and Malaria but are either old or on a limited range of molecules leading to risk of drugs resistance. Treatments are often unsafe or inadequate to be used by pregnant women and/or newborn such as anti-malaria drugs 11. Likewise, research and development is on-going on key reproductive health solutions such as dual vaginal ring research 12, the pericoital pill research 13 as well as maternal health solution (Oxytocin in Uniject 14, Anti-Shock Suit 15, clean delivery kit 16 ). In the last decade, 43 new diagnostics, vaccines and drugs have been registered to tackle PRNDs (Policy Cures 2012: 15) 17. Therefore under Innovation, the need for further R&D on PRNDs and sexual, maternal and newborn health solutions should be highlighted: Evidence has been accumulating over the past decade of strategies that broaden the coverage of interventions for newborns and reduce mortality. Nevertheless, innovative thinking is needed about ways to reach and address the needs of the poorest and most underserved populations, with adequate, affordable, accessible and of quality health solutions (being diagnosis, prevention, vaccines or treatment). Developing new and improve health solutions for poverty-related and neglected tropical diseases and sexual and maternal health and optimizing the application of knowledge of which interventions and strategies are most effective still need more research and development. 7 WHO.2013.Sustaining the drive to overcome the global impact of neglected tropical diseases: second WHO report on neglected tropical diseases 8 WHO.2013.Sustaining the drive to overcome the global impact of neglected tropical diseases: second WHO report on neglected tropical diseases 9 Global Network Neglected Tropical Diseases. 2013a. Links to Maternal and Child Health. Available at: 10 Samuels, Fiona and Romina Rodriguez Pose. Why neglected tropical diseases matter in reducing poverty. Working Paper 3(July): Policy Cures Saving Lives and Creating Impact: EU investment in poverty-related and neglected diseases. Available at: online.org/fileadmin/user_upload_en/pdf/gh_r_d_eu/new/saving_lives_and_creating_impact_dsw- PC_New_Report.pdf 12 See 13 See 14 See 15 See 16 See 17 Policy Cures Saving Lives and Creating Impact: EU investment in poverty-related and neglected diseases. DSW. Available at: online.org/fileadmin/user_upload_en/pdf/gh_r_d_eu/new/saving_lives_and_creating_impact_dsw- PC_New_Report.pdf

4 We also have several suggestions on the text explaining the guiding principles. 1 : «the neonatal mortality rate decreased only by 36%, from 33 deaths/1000 live births to 21 deaths/1000 live births over the same period.1 4: It could be considered to speak of women and girls instead of women throughout the document and to make clear how many of these pregnant women are still girls and thus even more vulnerable. Sexual and reproductive health and rights need to be acknowledged in the continuum of care. It recognizes that survival of newborns is a sensitive marker of a health system s response to its most vulnerable citizens and calls upon all stakeholders to improve access to and quality of health care including Sexual and reproductive health and rights for pregnant women or girls and newborns, within the continuum of care that spans pregnancy, childhood and adolescence 5: the impact between generations need to be taken into account; at DSW this is for instance an issue that we address in our holistic Adolescent Nutrition Support program in Ethiopia in partnership with UNICEF: The intrinsic link between the survival, health and nutrition of newborns and the survival, health and well-being of the mother has been corroborated. In addition, the links between pregnant women and girls and newborn health have intergenerational consequences (UNSCN 1992). Small adult women are more likely to have low-birth-weight babies, and children born with a low birth weight are more likely to have growth failure during childhood. Thus, in turn, girls born with a low birth weight are more likely to become small adult women. This cycle is accentuated by high rates of teenage marriage and teenage pregnancy, as adolescent girls are even more likely to have low-birth-weight babies. The situation is more aggravated due to the gender inequality and related sexual and reproductive health problems. Male preferences of families worsen the situation among married and unmarried girls. Therefore improving pregnant women and girls and new born health improve health of the whole population. 9: maternal mortality linked to unsafe abortion should be mentioned. It is estimated that every year women die from complications of pregnancy and childbirth, and women die from complications of unsafe abortion each year. Deaths due to unsafe abortion remain close to 13% of all maternal deaths. ( 10: limited access to family planning services and commodities also contribute to the low decrease rate in new born mortality: Access to quality health services for women and children is not guaranteed, resulting in stark disparities in coverage of interventions, between and within countries. In the past decade. Limited access to family planning services and adequate commodities result in high met need for Family planning with 222 million women who want plan and prevent pregnancies not being able to access modern family planning method. However, 11: Information on link between age of mother and newborn mortality could be added: Adolescent pregnancies are extremely risky for the newborn and the mother: complications from pregnancy and childbirth are the leading cause of death among girls aged years in many low- and middle-income countries. Stillbirths and newborn deaths are 50% higher among infants born to adolescent mothers than among those born to mothers aged years. Infants of adolescent mothers are also more likely to have low birth weight, which can have a long-term impact on their health and development. ( Their bodies are not mature enough to the pregnancy, they often suffer from

5 malnutrition, and they are less likely to obtain skilled care before, during and after childbirth. 12: the role of men involvement should be stressed in the social determinants as well: Low education levels, gender discrimination and a lack of empowerment prevent women from seeking health care and making the best choices for themselves and their children s health, thereby resulting in perilous delays and unnecessary deaths. This is also compounded by the lack of support from the male counterparts as part of psycho social support for the mother as well as the new born as well as provision of proper family diets. Critically, lack of male involvement in the maternal and new born process, including knowledge of the needs of a pregnant mother and the crucial dates has been cited as one cause of newborn and maternal mortality. Income in sub Saharan Africa is male dominated and thus increased awareness to men and boys of the need to invest their income to the mother and child has to continue being impressed upon. 12 also needs to recognise the role of culture and its impact on issues such as gender empowerment, as well as decision making and make involvement in prevention of neonatal deaths: Complex humanitarian emergencies catalyse dramatic movements of people, including pregnant women and newborns, and compromise access to functional health systems. Culture has a great impact on issues such as gender empowerment, as well as decision making and make involvement in prevention of neonatal deaths 12: finally on this paragraph, women and girls empowerment need to be recognized as key to bridge the gap on maternal and newborn health: the gap between those with highest and lowest coverage of effective interventions can be closed in a generation through intersectoral actions such as expanding educational programmes, improving living and working conditions, increasing access to clean water and adequate sanitation, empowerment women and girls including through the fulfillment and full and free exercise of their sexual and reproductive rights and progress towards universal health coverage. 13: young mothers (adolescents) also need to be mentioned: Effective interventions for improving survival and health of newborn babies form one component of integrated health services for reproductive, maternal, newborn and child and adolescent health. These interventions have been well documented across the life course and have been packaged for levels of service delivery. Many are delivered from common platforms for health care delivery; integrated planning and delivery can ensure efficient and effective health services for women, pregnant women and girls, mothers and children. 15: We welcome the essential role played by access to family planning and the right to control how many and the spacing of pregnancy in mother s and new-born s survival. Higher maternal mortality rate of mothers under 19 and under 15 should be highlighted: Very young mothers not only face more pregnancy-related problems but are also prone to obstructed labour, in particular for pregnant women and girls under 19 and even more under 15 for whom mortality rates increase. However to reflect this, on Figure 2 Figure 2: Packages of essential interventions for ending preventable newborn mortality, sexual health care needs to appear next to reproductive health care. Similarly, on Figure 2, there is a need to have male involvement in the chart as a cross cutting theme: from pre pregnancy to pregnancy period and the time around childbirth and the first day of life. This needs to come out strongly that the mothers require crucial support from their male counters to ensure their health and that of the new born. 17: we welcome the recognition of the important interventions before conception to prevent unsafe pregnancy. However, references should be made to the need for youth friendly family planning services and to maternal death due to unsafe abortions especially among girls under 19. Interventions should start well before conception. Every pregnancy should be wanted and, in this connection, intensified efforts are needed

6 to reach an estimated 222 million women in developing countries who would like to delay or stop childbearing but are not using any modern method of contraception.17 Investments in family planning including youth friendly services will also contribute significantly to an overall reduction in maternal and neonatal mortality. Reducing the number of unintended pregnancies could avert 60% of maternal deaths notably due to unsafe abortions and 57% of the child deaths. 18: we welcome the focus on young pregnant women and girls. However, we would recommend clearer language on ending early and forced marriage and involuntary sexual relations as age of maturity is not defined. Early and forced marriage and involuntary sexual relations should be ended as a priority. About 16 million adolescent girls between 15 and 19 years of age give birth each year, roughly 11% of all births worldwide. 19: Youth friendly Sexual and reproductive health services as well as comprehensive sexuality education are key to prevent unintended pregnancies among adolescents: Their needs are immense, and governments, civil society, communities and the international community must do much more to protect them and support their safe and healthy transition from childhood and adolescence to adulthood, including through prevention of early and forced marriage, sexual violence and through the provision of youth friendly sexual and reproductive health services and comprehensive sexuality education. Likewise: on 20: Providing care to women, girls and couples before and between pregnancies improves the chances of mothers and babies being healthy. Preconception care has, until recently, been a weak link in the continuum of care. In addition to family planning, it includes life-skills education, including comprehensive sexuality education; interventions to improve nutrition, prevent and manage harmful practices, such as smoking or alcohol use; 21: the link with other poverty related diseases and tropical neglected diseases need to also be highlighted: Antenatal care is an important channel for delivery of a set of interventions that have a direct impact on the health of the mother and the fetus. In lowincome countries, only an estimated 37% of women attend the recommended minimum four visits to antenatal clinics, and often the quality of care available is sub-optimal. An even lower proportion receives essential interventions such as screening for and treatment of anaemia and hypertension, Chagas disease, schistosomiasis and other neglected tropical diseases counselling and testing for HIV and syphilis, or diagnosis, prevention and treatment of malaria. 22: the role of all health providers in communities need to be stressed, including traditional birth attendants, village health teams, etc. Community health workers and other health support such as village health team, traditional birth attendants, etc.can play an important role in supporting families to adopt good home care practices, encouraging delivery in a health care facility when quality services are accessible, and ensuring timely referral of newborns showing signs of illness. 25: on neglected tropical diseases and vaccinations, plans have been agreed upon at international level that should be also mentioned: The plan also builds upon goals and targets included in other global actions plans, such as those for elimination of mother-tochild transmission of HIV and syphilis; control of malaria; improving maternal, infant and young child nutrition; reaching universal coverage of immunization; and the Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea including global vaccine plan and the WHO roadmap on NTDs 18 on neglected tropical diseases affecting pregnant women and girls and newborns. 2. Do you have any comments on the vision and global targets proposed in the ENAP? 18

7 Vision It would be useful to outline if (and if yes how) the goals are linked to the MDGs and the post-2015 agenda, e.g. regarding the time frames mentioned. The vision need to directly link and build on the achievement of MDG 4 and 5 and include Family planning and Sexual and reproductive health and rights for pregnant women, and girls, adolescents and youth upfront Global targets We welcome the link with Family planning 2020 initiative. However, the paper has already demonstrated the link between newborn health and maternal health, ante, and post maternal care and skilled birth attendance and access to family planning;, therefore, we believe this should be reflected in the global targets: To achieve an average global neonatal mortality rate of 7 deaths/1000 live births, all countries will have to reduce neonatal mortality by at least two-thirds from a baseline in 2012, which may be considered a continuation of Millennium Development Goal 4 and Millennium Development Goal 5 (especially indicators 5.2. Proportion of births attended by skilled health personnel; 5.3 Contraceptive prevalence rate; 5.5 Antenatal care coverage (at least one visit and at least four visits); 5.6 Unmet need for family planning) applied to the unfinished agenda for the reduction in the number of newborn deaths Linkages with other global and national plans should also mentioned other neglected tropical diseases : It also builds on and links with other global action plans, such as those on nutrition, vaccines, pneumonia, diarrhoea, and water and sanitation, elimination of mother-to-child transmission of HIV, syphilis and tetanus, TB and malaria and other neglected tropical diseases. Likewise in the indicators proposed in the annexes we would like to include: Under coverage and quality of care at national level: reference to MDG 5 indicators 5.3 Contraceptive prevalence rate; 5.5 Antenatal care coverage Unmet need for family planning Under Reproductive health care including preconception care and adolescent health care: Nutrition, immunisation, reduction in harmful practices (tobacco, alcohol), family planning, prevention of UNINTENDED pregnancy, prevention and treatment of STIs, improvements in environmental health, support for mental health, mitigation of interpersonal violence, life skill education including comprehensive sexuality education Under pregnancy care: on care for EVERY pregnant woman, prevention of neglected tropical diseases Under post natal care: Family planning: with indicators on contraception prevalence rate, access to family planning modern methods, information and services, decrease in unmet need for family planning Under routine care: family planning information, services - indicator unmet need for family planning and contraception prevalence rate Under policy and systems: Policy on payment for maternal and newborn

8 care services/free maternity, reproductive and sexual health and newborn services Under Human resources: availability of sexual and reproductive health services Under infrastructures: proportion of youth friendly services on sexual and reproductive health 3. The ENAP proposes three goals for coverage by 2020 and 2025, respectively. Please provide your comments on these objectives in the appropriate fields: Goal 1: Coverage and quality of care at birth Goal 2: Coverage and quality of care for newborns at risk Goal 3: Home visits and For 2020: participatory group Goals from the Family planning initiative should be reflected. Synergies support for women and with the Family planning initiative will be created to reach 120 million newborns women accessing modern family planning by In addition, focus on the work of participatory group should be mentioned: the participatory group should support in nutrition for ages 0-6 years old and also liaise with Early Childhood Education Centres to serve as forums for support groups for mothers For 2025: Goal should also be to reach universal access to modern family planning : Policies and programmes targeting universal access to modern family planning are in place and monitored and contraception prevalence rate increases 4. The ENAP proposes five strategic objectives as listed below. Please provide your comments on these objectives in the appropriate fields: As a general comment, while the importance of preventing unintended pregnancies is mentioned throughout the first part of the text, this aspect is not covered in the strategic objectives. Strategic objective 1: Interventions pre-birth are key as well to prevent unintended pregnancies Increase investment in and therefore decrease maternal and new born mortality. For this reason, care during labour, access to family planning and empowerment on sexual and reproductive childbirth, and the first rights through comprehensive sexuality education, culturally sensitive day and week of life. behavioural change campaign on girls and women rights including ending of harmful traditional practices are needed. In addition, special attention needs to be paid towards young pregnant women and girls especially below 19; finally nutrition of mothers greatly impacts the health of newborn: therefore actions should support preventing poverty related and neglected tropical diseases to the mother, increasing immunisation of the pregnant women and girls and improve their nutrition.

9 In addition, research on poverty related and neglected tropical diseases transmission from pregnant women and girls to newborns as well as diagnostics, vaccines, prevention, treatments are also needed. 35: Research on poverty related and neglected tropical diseases is also needed to develop new and improved, safe and effective, affordable and accessible health technologies including vaccines, diagnostics, and drugs. Often diagnostics tools to prevent, diagnose and treat these diseases are either still lacking or unsuitable to the conditions of individuals and communities in developing countries, for instance due to the length of the treatment or the need for advanced technology to conserve a drug or provide an appropriate diagnosis. Yet they have a great impact on mother and newborn health. Strategic objective 2: This objective should target more specifically adolescents from age 10 and Improve the quality of older. maternal and newborn 41: aspects linked to services towards youth or people living with HIV for care. instance need to be mentioned: For example, curricula in midwifery in some countries do not meet global standards, and students do not acquire the competences necessary to provide good-quality services with confidence. Absence of competences on youth friendly services, or on how to address youth but also how to preserve confidentiality also hinder access to family planning. Limitations in regulation and professional association capacity mean that midwifery personnel have little legal protection 42: infectious diseases (e.g., HIV, other neglected diseases), Add voluntary before screening: Prevention, voluntary screening and management of sexually transmitted infections Figure 5: adding under immunisation: diagnosis of neglected tropical diseases and prevention when possible 43: we welcome this paragraph and the attention to adolescent. This paragraph could include language on access to safe and legal abortion. Intervention before the pregnancy to prevent unintended pregnancy should be a priority for this target group, such as comprehensive sexuality education. Access to safe abortion for early and unintended pregnancy should also be supported. Special attention should be given to young adolescents from 10 years on. 44: there is a need not only for commodities but also new commodities adapted to the needs: mentions of this should be added such as New formulations of medicines may not have been registered and major supply chain bottlenecks exist. In many settings, essential commodities are frequently out of stock because of supply-chain deficiencies. Solutions for the specific needs (for instance heath stable medicines like Oxytocin) are often not available. In» Strategic objective 3: Community outreach is key to reach out to the most underserved youth Reach every woman and and women. Adapted and confidential services such as youth friendly every newborn to services are also crucial.

10 reduce inequities. Moreover, concerning neglected tropical diseases, there is also a need for funding and support to research and development to innovate on diagnostics, vaccines, prevention and treatment solutions adapted to the needs of the pregnant women and girls and newborns. 60 Add youth friendliness to list of aspects of the health system: Reaching every woman and every newborn requires investment in every aspect of the all health system, including leadership and governance, the work force, infrastructure, youth friendliness, commodities and supplies, service delivery, information systems, and financing Strategic objective 4: This concerns men and youth as well. Harness the power of Title: demonstrate the importance of key targets groups such as youth parents, families and and men: Harness the power of parents, pregnant women and girls, communities. men, families and communities 29 Add «pregnant women and girls» before parents: «harness the power of pregnant women and girls, parents,» to pay due respect to single mothers. Add Youth groups before women s groups to cover the positive impact of peer education approaches for increased sexual and reproductive health, the prevention of unwanted pregnancies and the referrals to health facilities in case of pregnancies. 71: Health outcomes, both positive and negative, are determined largely by decisions made within the household often largely made by men 72: Programmes that seek to strengthen health services through integration with community mobilization, education and empowerment of all community members in particular community leaders and men, in 73: Community-based activities can be broadly categorized into four areas, namely: (i) to develop capacities to stay healthy, make healthy decisions and respond to obstetric and neonatal emergencies; (ii) to increase awareness of the rights, needs and potential problems related to maternal, reproductive and newborn health; (iii) to strengthen social support networks between women, families and communities and with the health system; and (iv) to improve quality of care, access to modern family planning, health services and interactions with women and communities. Investment in each of these areas is necessary, particularly in settings where maternal and newborn mortality rates are high. Actions need to be taken in concert by multiple actors and, in this area, civil society can play a particular catalytic role through existing and strengthened coalitions and networks. 75 Line 1: Add and youth after women s Strategic objective 5:

11 Count every newborn - measurement, programme tracking and accountability. 91: Many countries have embraced maternal death surveillance and response as an effective means to identify deaths, investigate their determinants and take remedial action on preventable causes of death. Links with poverty related and neglected tropical disease should also be documented, as well as social determinants (age, gender, economic quintile, rural and urban status, etc.) to allow further research and better actions to prevent maternal and newborn deaths. Perinatal deaths should be considered as an important component of these initiatives. A meta-analysis of the impact associated with the introduction of perinatal audits in low- and middleincome countries demonstrated a 30% reduction in mortality when solutions identified from the audit process were linked to action.32 Auditing maternal and perinatal deaths and linking the results to a national process has the potential to strengthen capacity to avoid preventable causes of mortality. Nevertheless, legal protection mechanisms that would facilitate full enquiries are inadequate in many countries and therefore the full potential of the approach often remains untapped. 5. For each of the five strategic objectives a number of actions are being proposed. Please provide your comments on these actions proposed for each Strategic Objective in the appropriate fields: Proposed actions for Proposed actions should also include support to research and strategic objective 1: development of new and improved, safe and effective, affordable and Increase investment in accessible health technologies including vaccines, diagnostics, and drugs care during labour, on poverty related and neglected diseases as they have a great impact on childbirth, and the first mother and newborns. support research and development of new and day and week of life. improved, safe and effective, affordable and accessible health technologies including vaccines, diagnostics, and drugs on poverty related and neglected tropical diseases as well as on sexual and maternal health On sexual health and given the importance of intervention to prevent unintended pregnancies, sexual health should be mentioned: Develop or sharpen national plans for newborn health within the continuum of reproductive, sexual, maternal, newborn and child health in line with the principles, goal, targets and strategic objectives of the Every Newborn action plan. Proposed actions for strategic objective 2: Improve the quality of maternal and newborn care. The proposed actions should include ensuring access to youth friendly sexual and reproductive health services and comprehensive sexuality education in order to take up points from 43.Under 47: Ensuring access too youth friendly SRH services and Comprehensive sexuality education should also be a priority for the national plans. Under 50: new medicines for family planning, poverty related and neglected tropical diseases need to be developed as well. Medicines need to be appropriate for newborns, and pregnant women and girls and investments need to be made through public and private partnership to develop new and improve diagnosis, prevention and treatment for poverty and related and neglected tropical diseases (HIV & AIDs, Tuberculosis, Malaria, Chagas disease, Schistosomiasis, worms) as well as improve lifesaving commodities to adapt them to the needs of the pregnant women and girls and newborn (heat stable

12 oxytocin for instance). Investment also needs to be made by manufacturers to increase the availability of low-cost commodities that can be easily supplied and used in resource-poor settings. On summary this means: Adopt competence-based curricula including on prevention such as comprehensive sexuality education and put in place regulatory frameworks for midwifery and other health care personnel to be able to provide youth friendly services. Ensure that there are also dedicated youth friendly facilities, that all facilities providing maternal and newborn care are adequately staffed, have basic optimum infrastructure, allow for mother and baby to remain together, have a steady supply of life-saving key commodities and are able to provide uninterrupted services. And adding: support research and development for new and improve lifesaving commodities adapted to the needs Proposed actions for 61: Results of such analyses should be taken into consideration in strategic objective 3: the design of national newborn and maternal action plans. Reach every woman and 62: It is essential that health workers attitudes and behaviours every newborn to towards women, youth and newborns are respectful. reduce inequities. 64: Governments should adopt and enforce laws and policies on equity of access and quality of maternal, reproductive and newborn care, in both the public and private sectors. Policies should include: ensuring universal access by women and children to health care services, including reproductive and sexual services without enduring financial hardship; notification of maternal and perinatal deaths; context-specific approaches to HIV and infant feeding; ratification of the ILO s Maternity Protection Convention, 2000 (No. 183); and legislation to implement the International Code of Marketing of Breast-milk Substitutes. 65: They need to define a standard package of maternal, reproductive and sexual (including family planning) and newborn care for each level of health provision. 66 Line 3: Add including comprehensive sexuality education after health education Line 5: Add without parental or spousal consent after young adults. Line 6: Add and implement after introduce ; replace prevent by end ; delete or lower the number Line 7: Replace reduce rates of coerced sex by end sexual and gender based violence through effective laws. Line 8: Replace life-skills education by comprehensive sexuality education Line 9: Add comprehensive before sexuality education Line 10: Add educate boys that coerced sex is a human rights violation and a criminal offence after resist coerced sex. Line 11: Add: to provide information on sexual and reproductive health and rights, avoid unwanted pregnancies, provide safe and legal abortions, and before give pregnant Line 12: Add: and without parental and spousal consent after marital status 69: we welcome the mention of health and service delivery platform Summary box: add: Prepare and implement a development plan for the health workforce in order to increase motivation and retention of skilled

13 Proposed actions for strategic objective 4: Harness the power of parents, families and communities. personnel to develop youth friendly skills and thus broaden access to good-quality maternal and newborn care at community, primary and referral health care levels. add develop plan on prevention of unintended pregnancies such as comprehensive sexuality education programmes bullet 4: delete in some populations 81: In countries with a high burden of newborn mortality, the analysis of obstacles proposed under strategic objective 1 should also focus on factors that determine the demand for maternal, reproductive and newborn health services. 83 Line 2: Add and youth after women s Line 4: Add, boys after men Proposed actions for strategic objective 5: Count every newborn - measurement, programme tracking and accountability. 84 Line 2: Add individuals before families Summary box, bullet 1 Promote zero tolerance for preventable maternal and newborn deaths by changing social norms and expectations surrounding childbirth and newborn survival nand prioritising prevention measures such as preventing unintended pregnancies through access to family planning, and also giving a voice to parents affected by stillbirths or newborn deaths. bullet 2: add women before families 95. While routine systems are being strengthened, countries and development partners should invest in periodic household surveys in order to obtain data on mortality, intervention coverage and use of services. Population-based household surveys, including the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys have long collected data on indicators on family planning, antenatal care, and attendance at birth. Recently, more information on postnatal contacts for newborns have been incorporated into these two surveys and the number of countries with available data is steadily increasing. A list of proposed indicators that can be added to household surveys to measure newborn care practices and the content of postnatal care will be presented in the final action plan. Guidance and list of determinants should also be provided to help analyse the maternal and newborn deaths such as links with poverty related and neglected tropical disease, as well as social determinants (age, gender, economic quintile, rural and urban status, etc. Summary box: Track morbidity and disability outcomes, with links with poverty related and neglected tropical disease, as well as social determinants (age, gender, economic quintile, rural and urban status, etc. and especially once neonatal intensive care is being expanded) On research: Links to the Global Vaccines plan should be made. 99: Discovery research priorities highlighted the need to invest in science and technology to discover the causal pathways of preterm labour; new tocolytics to delay preterm birth; stable surfactant with easier mode of delivery; effective maternal vaccines to prevent neonatal sepsis; point of care diagnostics and new biological agents to better identify and treat neonatal sepsis; ways to better detect fetal

14 distress; new and improve diagnosis, prevention and treatment for poverty and related and neglected tropical diseases as well as improve lifesaving commodities to adapt them to the needs of the pregnant women and girls and newborn (heat stable oxytocin, uniject for instance); and to identify biomarkers for intrauterine growth retardation and antepartum stillbirths. On coordination: Public private partnerships play a key role in developing research and innovation notably on infectious, povertyrelated and neglected tropical diseases : 100: Putting the draft action plan in practice will need the participation of many stakeholders. These range from governments and policy makers, donor countries and global philanthropic institutions, and the United Nations and other multilateral organizations to civil society, health care workers and their professional associations, the business community, public private partnership on research and development, academic and research institutions. 6. The final plan of action will contain proposed roles and responsibilities of different stakeholders that will play a key role in the implementation of the ENAP. Based on the proposed actions called for in the action plan, please provide your suggestions on proposed roles and responsibilities of these different stakeholders in the appropriate fields: Governments and Parliamentary working groups for Every Newborn should be created policy-makers at nationally and regionally to ensure policies that sustain every new born national, regional and are implemented. global levels Support should be granted to innovative approach to develop new health solutions for PRNDS and sexual and maternal and new born health. Product Development Partnership (PDPs) are non-profit organisations that have emerged in the past 15 years to specifically address R&D for povertyrelated and neglected tropical neglected diseases. PDPs accounted for over 40 per cent of new global health products registered between 2000 and 2010 (Policy Cures 2012: 33) 19. Funding for PRND research and product development is critical. The field is indeed undermined by market failure (Policy Cures 2012: 9) 20. United Nations and other intergovernmental organizations 19 Policy Cures Saving Lives and Creating Impact: EU investment in poverty-related and neglected diseases. Available at: online.org/fileadmin/user_upload_en/pdf/gh_r_d_eu/new/saving_lives_and_creating_impact_dsw- PC_New_Report.pdf 20 Policy Cures Saving Lives and Creating Impact: EU investment in poverty-related and neglected diseases. Available at: online.org/fileadmin/user_upload_en/pdf/gh_r_d_eu/new/saving_lives_and_creating_impact_dsw- PC_New_Report.pdf

15 Donors and foundations Private sector Non-governmental organizations (NGOs) Ensure that the policies at the work place favour women s pre and postnatal care, invest in adolescents of ages 10 plus education, livelihoods and health care. In addition, private sector through pharmaceutical research and their partnership with public institutions has a key role to play in researching and developing new and improve diagnosis, prevention and treatment for poverty and related and neglected diseases as well as improve lifesaving commodities to adapt them to the needs of the pregnant women and girls and newborn (heat stable oxytocin uniject for instance). Communities parent groups and/or Youth groups should also be mentioned as key fora to improve knowledge, provide information, referral to youth in general and young pregnant women and girls in particular. Academics and research institutions The part on research priorities ( 96-99) should include something on vaccinations for new-borns and children (Global Vaccine Action Plan Health professionals and their associations

16 7. Please provide any general comment on the draft Every Newborn: An Action Plan to End Preventable Deaths (ENAP) here, in the following field: We welcome the focus on girls and adolescents. However, the ENAP should be more sensitive to the special needs of young people, especially girls for whom pregnancies are a special danger and who thus should be in a position to prevent and end unintended pregnancies. Moreover, adolescent nutrition is the key to stop the vicious circle of growth failure, transmitted across generations through the mother: small adults are more likely to have low-weight babies and children, especially girls, born with a low birth weight are more likely to have growth failure during childhood and to become small adults. This should not only be done in separate paragraphs but it should be streamlined throughout the publication. Need for youth friendly facilities and skills among health workers should be highlighted. Accessing age appropriate reproductive health information through comprehensive sexuality education is core to preventing unintended pregnancies to this age group. Therefore emphasis should be put on integration of sexual and reproductive health and rights and health education in national curricula through joint work of Ministries of Education and Health and other stakeholders, such as civil society organisations. In addition, from our experience in the field notably on very young adolescent, the age bracket of the adolescents of 10 year old plus needs to be emphasized throughout the publication. The ENAP also recognised the need for linkages between maternal and newborn health with reproductive health and access to family planning; this should also be reflected in the indicators. Moreover, this approach can only be sustainable through a holistic and human rights based approach. Access to family planning is empowering men, women and girls, to choose when, and how frequently they want to have children. Failure to exert this fundamental right to choose is linked to gender bias, deeply rooted in cultural and social context. Therefore, awareness raising campaigns and behavioural changes programmes on gender equality, involvement of men and boys, changing legal and traditional environment to end traditional harmful practices such as early and forced marriages, and sexual violence are key to reducing maternal and new-born mortality. Research also needs to be mentioned while defining strategies to improve maternal and newborn health. Poverty related and neglected tropical diseases (PRNDs) affect millions of pregnant women and girls and newborns, especially in the low and middle income countries where these diseases are endemic. Several of these present risks for the pregnancy and can be transmitted to the newborn. Solutions to diagnose, prevent and treat PRNDs are often still lacking or unsuitable to the conditions of individuals and communities (length of treatment, preservation, climate resistant drugs, etc.). Similarly some of the lifesaving commodities in maternal health such as oxytocin are not adapted to context or needs such as heat in low and middle income countries. Unfortunately as these solutions are needed mainly in low and middle income countries, the market fails to provide incentive to private research solely. Therefore, there is a crucial need for more funding to public and private partnership on research and development for health solutions on PRNDS and reproductive health.