Abstract
BACKGROUND: Between 2000 and 2017/2018, Morocco reduced its maternal mortality ratio by 68% and its neonatal mortality rate by 52%-a higher improvement than other North African countries. We conducted the Exemplars in Maternal and Neonatal Health study to systematically and comprehensively research factors associated with this rapid reduction in mortality over the past two decades. METHODS: The study was conducted from September 2020 to December 2021 using mixed methods, including: literature, database and document reviews, quantitative analyses of national data sets and qualitative key-informant interviews at national and district levels. Analyses were based on a conceptual framework of drivers of health and survival of mothers and neonates. RESULTS: A favourable political and economic environment, and a high political commitment encouraged prioritisation of maternal and neonatal health (MNH) by aligning evidence-based policy and technical approaches. Five main factors accounted for Morocco's success: (1) continuous increases in antenatal care and institutional delivery and reductions socioeconomically-based inequalities in MNH service usage; (2) health-system strengthening by expanding the network of health facilities, with increased uptake of facility birthing, scale-up of the production of midwives, reductions in financial barriers and, later in the process, attention to improving the quality of care; (3) improved underlying health status of women and changes in reproductive patterns; (4) a supportive policy and infrastructure environment; and 5) increased education and autonomy of women. CONCLUSION: Our study provides evidence that supportive changes in Morocco's policy environment for maternal health, backed by greater political will and increased resources, significantly contributed to the dramatic progress in reducing maternal and neonatal mortality. While these efforts were successful in improving MNH in Morocco, several implementation challenges still require special attention and renewed political attention is needed.