Tracking progress towards safe motherhood: meeting the benchmark yet missing the goal? An appeal for better use of health-system output indicators with evidence from Zambia and Sri Lanka

Effects of a community-level intervention on maternal health care utilization in a resource-poor setting of Northern Ghana

BACKGROUND

This study aimed to assess the effects of health education and community-level participatory interventions at the community level and the use of community maternal health promoters on the utilization of maternal health care services in poor rural settings of northern Ghana.

METHODS

A randomized controlled survey design was conducted from June 2019 to July 2020 in two rural districts of northern Ghana. A multistage cluster sampling technique was used to select the participants. Data were collected from a repeated cross-sectional household survey. Descriptive analysis, bivariate and covariates adjusted simple logistic regression analyses were performed using STATA version 16 statistical software.

RESULTS

At post-intervention, the two groups differed significantly in terms of ANC (p = 0.001), skilled delivery (SD) (p = 0.003), and PNC (p < 0.0001). Women who received health education on obstetric danger signs had improved knowledge by 50% at the end of the study. Women who received the health education intervention (HEI) on practices related to ANC and skilled delivery had increased odds to utilize ANC (AOR = 4.18; 95% CI = 2.48-7.04) and SD (AOR = 3.90; 95% CI = 1.83-8.29) services. Institutional delivery and PNC attendance for at least four times significantly increased from 88.5 to 97.5% (p < 0.0001), and 77.3-96.7% (p < 0.0001) respectively at postintervention. Women who had received the HEI were significantly more likely to have good knowledge about obstetric danger signs (AOR = 10.17; 95% CI = 6.59-15.69), and BPCR (AOR = 2.10; 95% CI = 1.36-3.24). Women who had obtained tertiary education were significantly more likely to make at least four visits to ANC (AOR = 2.38; 95% CI = 0.09-1.67).

CONCLUSIONS

This study suggests that the use of health education and participatory sessions led by community-based facilitators could be a potentially effective intervention to improve the knowledge of women about obstetric danger signs and encourage the uptake of maternity care services in resource-poor settings of Ghana.

Using clinical cascades to measure health facilities' obstetric emergency readiness: testing the cascade model using cross-sectional facility data in East Africa

OBJECTIVES

Globally, hundreds of women die daily from preventable pregnancy-related causes, with the greatest burden in sub-Saharan Africa. Five key emergencies-bleeding, infections, high blood pressure, delivery complications and unsafe abortions-account for nearly 75% of these obstetric deaths. Skilled clinicians with strategic supplies could prevent most deaths. In this study, we (1) measured facility readiness to manage common obstetric emergencies using the clinical cascades and signal function tracers; (2) compared these readiness estimates by facility characteristics; and (3) measured cascading drop-offs in resources.

DESIGN

A facility-based cross-sectional analysis of resources for common obstetric emergencies.

SETTING

Data were collected in 2016 from 23 hospitals (10 designated comprehensive emergency obstetric care (CEmOC) facilities) in Migori County, western Kenya, and Busoga Region, eastern Uganda, in the Preterm Birth Initiative study in East Africa. Baseline data were used to estimate a facility's readiness to manage common obstetric emergencies using signal function tracers and the clinical cascade model. We compared emergency readiness using the proportion of facilities with tracers (signal functions) and the proportion with resources for identifying and treating the emergency (cascade stages 1 and 2).

RESULTS

The signal functions overestimated practical emergency readiness by 23 percentage points across five emergencies. Only 42% of CEmOC-designated facilities could perform basic emergency obstetric care. Across the three stages of care (identify, treat and monitor-modify) for five emergencies, there was a 28% pooled mean drop-off in readiness. Across emergencies, the largest drop-off occurred in the treatment stage. Patterns of drop-off remained largely consistent across facility characteristics.

CONCLUSIONS

Accurate measurement of obstetric emergency readiness is a prerequisite for strengthening facilities' capacity to manage common emergencies. The cascades offer stepwise, emergency-specific readiness estimates designed to guide targeted maternal survival policies and programmes.

TRIAL REGISTRATION NUMBER

NCT03112018.

A systematic review of the profile and density of the maternal and child health workforce in China

BACKGROUND

To track progress in maternal and child health (MCH), understanding the health workforce is important. This study seeks to systematically review evidence on the profile and density of MCH workers in China.

METHODS

We searched 6 English and 2 Chinese databases for studies published between 1 October 1949 and 20 July 2020. We included studies that reported on the level of education or the certification status of all the MCH workers in one or more health facilities and studies reporting the density of MCH workers per 100 000 population or per 1000 births. MCH workers were defined as those who provided MCH services in mainland China and had been trained formally or informally.

RESULTS

Meta-analysis of 35 studies found that only two-thirds of obstetricians and paediatricians (67%, 95% CI: 59.6-74.3%) had a bachelor or higher degree. This proportion was lower in primary-level facilities (28% (1.5-53.9%)). For nurses involved in MCH care the proportions with a bachelor or higher degree were lower (20.0% (12.0-30.0%) in any health facility and 1% (0.0-5.0%) in primary care facilities). Based on 18 studies, the average density of MCH doctors and nurses was 11.8 (95% CI: 7.5-16.2) and 11.4 (7.6-15.2) per 100 000 population, respectively. The average density of obstetricians was 9.0 (7.9-10.2) per 1000 births and that of obstetric nurses 16.0 (14.8-17.2) per 1000 births. The density of MCH workers is much higher than what has been recommended internationally (three doctors and 20 midwives per 3600 births).

CONCLUSIONS

Our review suggests that the high density of MCH workers in China is achieved through a mix of workers with high and low educational profiles. Many workers labelled as "obstetricians" or "paediatrician" have lower qualifications than expected. China compensates for these low educational levels through task-shifting, in-service training and supervision.

Place of birth for unintended pregnancies in six former Soviet Union countries

OBJECTIVE

This paper aims at exploring the association between unintended pregnancies and place of birth in six Former Soviet Union (FSU) countries.

MATERIAL AND METHODS

A secondary analysis of the latest cross-sectional Demographic and Health Surveys of six FSU countries from 2005 through 2012 was conducted. Prevalence of institutional births and unintended pregnancies was estimated by country and for the pooled population. Odds ratio (OR) and 95% confidence interval (CI) were calculated to measure the country and pooled association between pregnancy intention and institutional birth.

RESULTS

Institutional births occurred in 90.4% of the overall study population and ranged from 78.2% in Tajikistan to 99.7% in Ukraine Demographic and Health Survey. Around one out of 10 pregnancies resulted unintended. In the pooled analysis, unintended pregnancies were significantly associated with giving births outside health facility (aOR1.2; 95% CI 1.0-1.6).

CONCLUSION

Based on the study findings we suggest that increase awareness of benefit of skilled delivery care is needed among women with poor access to family planning.

Does knowledge of pregnancy complications influence health facility delivery? Analysis of 2014 Bangladesh Demographic and Health Survey

Introduction

Only thirty-seven percent (37%) of deliveries occur in health facilities in Bangladesh despite the enormous benefits of health facility delivery. We investigated women’s recall of receiving counseling on pregnancy complications and how it affects health facility delivery in Bangladesh.

Materials and methods

Data from the 2014 Bangladesh Demographic and Health Survey was used for the study. After calculating the proportion of women who were informed about pregnancy complications during their last Antenatal Care (ANC) and the number of them who delivered in health facilities, Binary Logistic Regression was utilized in investigating chances of giving birth in health facilities among women who recalled they were told about pregnancy complications and those who were not told. The models were considered significant at 95%.

Results

A little above half of the women who were told about pregnancy complications during ANC delivered in health facilities (53.3%) and 43.6% of those who were not told delivered in health facilities. The findings revealed that women who were told about pregnancy complications during ANC were more likely to deliver at the health facility compared to those who were not told [COR = 1.56, CI = 1.31–1.87], and this persisted after controlling for the effect of covariates [AOR = 1.44, CI = 1.21–1.71].

Conclusion

This study has stressed the importance of telling women about pregnancy complications during ANC by revealing that telling women about pregnancy complications during ANC is likely to result in health facility delivery. Health workers should intensify health education on pregnancy complications during ANC and motivate women to deliver in health facilities.

Clinical cascades as a novel way to assess physical readiness of facilities for the care of small and sick neonates in Kenya and Uganda

BACKGROUND

Globally, there were 2.7 million neonatal deaths in 2015. Significant mortality reduction could be achieved by improving care in low- and middle-income countries (LMIC), where the majority of deaths occur. Determining the physical readiness of facilities to identify and manage complications is an essential component of strategies to reduce neonatal mortality.

METHODS

We developed clinical cascades for 6 common neonatal conditions then utilized these to assess 23 health facilities in Kenya and Uganda at 2 time-points in 2016 and 2017. We calculated changes in resource availability over time by facility using McNemar's test. We estimated mean readiness and loss of readiness for the 6 conditions and 3 stages of care (identification, treatment, monitoring-modifying treatment). We estimated overall mean readiness and readiness loss across all conditions and stages. Finally, we compared readiness of facilities with a newborn special care unit (NSCU) to those without using the two-sample test of proportions.

RESULTS

The cascade model estimated mean readiness of 26.3-26.6% across the 3 stages for all conditions. Mean readiness ranged from 11.6% (respiratory distress-apnea) to 47.8% (essential newborn care) across both time-points. The model estimated overall mean readiness loss of 30.4-31.9%. There was mild to moderate variability in the timing of readiness loss, with the majority occurring in the identification stage. Overall mean readiness was higher among facilities with a NSCU (36.8%) compared to those without (20.0%).

CONCLUSION

The cascade model provides a novel approach to quantitatively assess physical readiness for neonatal care. Among 23 facilities in Kenya and Uganda, we identified a consistent pattern of 30-32% readiness loss across cascades and stages. This aggregate measure could be used to monitor and compare readiness at the facility-, health system-, or national-level. Estimates of readiness and loss of readiness may help guide strategies to improve care, prioritize resources, and promote neonatal survival in LMICs.

Health facility or home delivery? Factors influencing the choice of delivery place among mothers living in rural communities of Eritrea

BACKGROUND

In Eritrea, despite high antenatal care (ANC) use, utilization of health facilities for child birth is still low and with marked variations between urban and rural areas. Understanding the reasons behind the poor use of these services in a rural setting is important to design targeted strategies and address the challenge contextually. This study aimed to determine factors that influence women's choice of delivery place in selected rural communities in Eritrea.

METHODS

A cross-sectional survey of 309 women aged 15-49 years with a delivery in the last 1-2 years prior to the survey was conducted in a randomly selected villages of Hadish Adi, Serea, Genseba, Kelay Bealtat, Dirko, Mai Leham, Kudo Abour, Adi Koho, and Leayten. Data were collected using an interviewer administered questionnaire. Chi-square tests were used to explore association between variables. Using odds ratios with 95% confidence intervals with p < 0.05 taken as statically significant association, bivariate and multivariate logistic regression analysis were used to identify factors that affect the choice of delivery place.

RESULTS

Overall, 75.4% of the respondents delivered their last child at home while 24.6% delivered in health facility. Women whose husband's had no formal education were less likely [AOR = 0.02; 95% CI 0.01-0.54] to deliver in health facility. Women who had joint decision-making with husbands on delivery place [AOR = 5.42; 95% CI 1.78-16.49] and women whose husbands choose health facility delivery [AOR = 2.32; 95% CI 1.24-5.11] were more likely to have health facility delivery. Respondents who had medium wealth status [AOR = 3.78; 95% CI 1.38-10.37] have access to health facility within 2 km distance [AOR = 14.67; 95% CI 2.30-93.45] and women with traditional means of transport [AOR = 9.78; 95% CI 1.23-77.26] were also more likely to deliver in health facility. Women who read newspaper daily or infrequently had three [AOR = 3.77; 95% CI 1.12-4.04] and almost three times [AOR = 2.95; 95% CI 1.01-8.59] higher odds of delivering in health facility. Similarly, women who have knowledge about complications during delivery [AOR = 4.39; 95% CI 1.63-11.83], good perception on the quality of care they received [AOR = 9.52; 95% CI 1.91-47.50], had previous facility delivery [AOR = 2.69; 95% CI 0.94-7.68], have negative experiences of delivery outcomes in her community [AOR = 1.31; 95% CI 1.00-4.96], and women who perceive home delivery as life threatening [AOR = 1.84; 95% CI 1.46-3.38] were more likely to deliver in health facility.

CONCLUSION

To increase health facility delivery, raising women's awareness on the benefits of delivering in health facility, male involvement in the use of maternal health services, increasing women decision-making power, addressing common barriers of lack of transport, and compensations for transport expenses to alleviate the cost of transport are recommended. Efforts to shorten distance to reach health facility and health education focusing on the potential threats of delivering at home at the individual and community level can have substantial contribution to increase health facility delivery in rural communities of Eritrea.

Where women go to deliver: understanding the changing landscape of childbirth in Africa and Asia

Growing evidence from a number of countries in Asia and Africa documents a large shift towards facility deliveries in the past decade. These increases have not led to the improvements in health outcomes that were predicted by health policy researchers in the past. In light of this unexpected evidence, we have assessed data from multiple sources, including nationally representative data from 43 countries in Asia and Africa, to understand the size and range of changing delivery location in Asia and Africa. We have reviewed the policies, programs and financing experiences in multiple countries to understand the drivers of changing practices, and the consequences for maternal and neonatal health and the health systems serving women and newborns. And finally, we have considered what implications changes in delivery location will have for maternal and neonatal care strategies as we move forward into the next stage of global action. As a result of our analysis we make four major policy recommendations. (1) An expansion of investment in mid-level facilities for delivery services and a shift away from low-volume rural delivery facilities. (2) Assured access for rural women through funding for transport infrastructure, travel vouchers, targeted subsidies for services and residence support before and after delivery. (3) Increased specialization of maternity facilities and dedicated maternity wards within larger institutions. And (4) a renewed focus on quality improvements at all levels of delivery facilities, in both private and public settings.

Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness

Background

Globally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model.

Objective-method

We compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial.

Findings

Although most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%.

Significance

Comparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade’s intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted.

Measuring facility capability to provide routine and emergency childbirth care to mothers and newborns: An appeal to adjust for delivery caseload of facilities

Background

Measurement of Emergency Obstetric Care capability is common, and measurement of newborn and overall routine childbirth care has begun in recent years. These assessments of facility capabilities can be used to identify geographic inequalities in access to functional health services and to monitor improvements over time. This paper develops an approach for monitoring the childbirth environment that accounts for the delivery caseload of the facility.

Methods

We used data from the Kenya Service Provision Assessment to examine facility capability to provide quality childbirth care, including infrastructure, routine maternal and newborn care, and emergency obstetric and newborn care. A facility was considered capable of providing a function if necessary tracer items were present and, for emergency functions, if the function had been performed in the previous three months. We weighted facility capability by delivery caseload, and compared results with those generated using traditional “survey weights”.

Results

Of the 403 facilities providing childbirth care, the proportion meeting criteria for capability were: 13% for general infrastructure, 6% for basic emergency obstetric care, 3% for basic emergency newborn care, 13% and 11% for routine maternal and newborn care, respectively. When the new caseload weights accounting for delivery volume were applied, capability improved and the proportions of deliveries occurring in a facility meeting capability criteria were: 51% for general infrastructure, 46% for basic emergency obstetric care, 12% for basic emergency newborn care, 36% and 18% for routine maternal and newborn care, respectively. This is because most of the caseload was in hospitals, which generally had better capability. Despite these findings, fewer than 2% of deliveries occurred in a facility capable of providing all functions.

Conclusion

Reporting on the percentage of facilities capable of providing certain functions misrepresents the capacity to provide care at the national level. Delivery caseload weights allow adjustment for patient volume, and shift the denominator of measurement from facilities to individual deliveries, leading to a better representation of the context in which facility births take place. These methods could lead to more standardized national datasets, enhancing their ability to inform policy at a national and international level.

The 'Dream Team' for sexual, reproductive, maternal, newborn and adolescent health: an adjusted service target model to estimate the ideal mix of health care professionals to cover population need

BACKGROUND

A competent, enabled and efficiently deployed health workforce is crucial to the achievement of the health-related sustainable development goals (SDGs). Methods for workforce planning have tended to focus on 'one size fits all' benchmarks, but because populations vary in terms of their demography (e.g. fertility rates) and epidemiology (e.g. HIV prevalence), the level of need for sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) workers also varies, as does the ideal composition of the workforce. In this paper, we aim to provide proof of concept for a new method of workforce planning which takes into account these variations, and allocates tasks to SRMNAH workers according to their competencies, so countries can assess not only the needed size of the SRMNAH workforce, but also its ideal composition (the 'Dream Team').

METHODS

An adjusted service target model was developed, to estimate (i) the amount of health worker time needed to deliver essential SRMNAH care, and (ii) how many workers from different cadres would be required to meet this need if tasks were allocated according to competencies. The model was applied to six low- and middle-income countries, which varied in terms of current levels of need for health workers, geographical location and stage of economic development: Azerbaijan, Malawi, Myanmar, Peru, Uzbekistan and Zambia.

RESULTS

Countries with high rates of fertility and/or HIV need more SRMNAH workers (e.g. Malawi and Zambia each need 44 per 10,000 women of reproductive age, compared with 20-27 in the other four countries). All six countries need between 1.7 and 1.9 midwives per 175 births, i.e. more than the established 1 per 175 births benchmark.

CONCLUSIONS

There is a need to move beyond universal benchmarks for SRMNAH workforce planning, by taking into account demography and epidemiology. The number and range of workers needed varies according to context. Allocation of tasks according to health worker competencies represents an efficient way to allocate resources and maximise quality of care, and therefore will be useful for countries working towards SDG targets. Midwives/nurse-midwives who are educated according to established global standards can meet 90% or more of the need, if they are part of a wider team operating within an enabled environment.

Quality maternity care for every woman, everywhere: a call to action

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.

Assessing the midwifery workforce demand: Utilising Birthrate Plus in China

OBJECTIVE

To assess the ability of the Birthrate Plus Workforce Planning Methodology (BR+) to forecast midwifery workforce demand in Chinese settings.

DESIGN

A retrospective analysis of medical records.

SETTING

ten hospitals in Beijing District.

METHODS

Hospitals were selected using stratified sampling methods. The client category and midwife hours in each hospital were analysed over 1 month in consecutive three years (2013, 2014, and 2015).

FINDINGS

Client category allocation varied between different hospital levels; Clients in higher category tended to need longer midwife hours; Mean birthrate of the ten hospitals was 154.30 (SD=40.700). Seven out of the ten hospitals were in need of more midwives.

CONCLUSIONS

Birthrate Plus was proved to be effective and efficient in Chinese settings; Gaps between available and needed midwives were large and prevalent in Chinese hospitals.

Measuring maternal, foetal and neonatal mortality: Challenges and solutions

Levels and causes of mortality in mothers and babies are intrinsically linked, occurring at the same time and often to the same mother-baby dyad, although mortality rates are substantially higher in babies. Measuring levels, trends and causes of maternal, neonatal and foetal mortality are important for understanding priority areas for interventions and tracking the success of interventions at the global, national, regional and local level. However, there are many measurement challenges. This paper provides an overview of the definitions and indicators for measuring mortality in pregnant and post-partum women (maternal and pregnancy-related mortality) and their babies (foetal and neonatal mortality). We then discuss current issues in the measurement of the levels and causes of maternal, foetal and neonatal mortality, and present options for improving measurement of these outcomes. Finally, we illustrate some important uses of mortality data, including for the development of models to estimate mortality rates at the global and national level and for audits.

The availability of emergency obstetric care in the context of the JSY cash transfer programme in Madhya Pradesh, India

Background

Since 2005, India has implemented a national cash transfer programme, the Janani Suraksha Yojana (JSY), which provides women a cash transfer upon giving birth in an existing public facility. This has resulted in a steep rise in facility births across the country. The early years of the programme saw efforts being made to strengthen the ability of facilities to provide obstetric care. Given that the JSY has been able to draw millions of women into facilities to give birth (there have been more than 50 million beneficiaries thus far), it is important to study the ability of these facilities to provide emergency obstetric care (EmOC), as the functionality of these facilities is critical to improved maternal and neonatal outcomes. We studied the availability and level of provision of EmOC signal functions in public facilities implementing the JSY programme in three districts of Madhya Pradesh (MP) state, central India. These are measured against the World Health Report (WHR) 2005benchmarks. As a comparison, we also study the functionality and contribution of private sector facilities to the provision of EmOC in these districts.

Methods

A cross-sectional survey of all healthcare facilities offering intrapartum care was conducted between February 2012 and April 2013. The EmOC signal functions performed in each facility were recorded, as were human resource data and birth numbers for each facility.

Results

A total of 152 facilities were surveyed of which 118 were JSY programme facilities. Eighty-six percent of childbirths occurred at programme facilities, two thirds of which occurred at facilities that did not meet standards for the provision basic emergency obstetric care. Of the 29 facilities that could perform caesareans, none could perform all the basic EmOC functions. Programme facilities provided few EmOC signal functions apart from parenteral antibiotic or oxytocic administration. Complicated EmOC provision was found predominantly in non-programme (private) facilities; only one of six facilities able to provide such care was in the public sector and therefore in the JSY programme. Only 13 % of all qualified obstetricians practiced at programme facilities.

Conclusions

Given the high proportion of births in public facilities in the state, the JSY programme has an opportunity to contribute to the reduction in maternal and perinatal mortality However, for the programme to have a greater impact on outcomes; EmOC provision must be significantly improved.. While private, non-programme facilities have better human resources and perform caesareans, most women in the state give birth under the JSY programme in the public sector. A demand-side programme such as the JSY will only be effective alongside an adequate supply side (i.e., a facility able to provide EmOC).

Signal functions for measuring the ability of health facilities to provide abortion services: an illustrative analysis using a health facility census in Zambia

Background

Annually, around 44 million abortions are induced worldwide. Safe termination of pregnancy (TOP) services can reduce maternal mortality, but induced abortion is illegal or severely restricted in many countries. All abortions, particularly unsafe induced abortions, may require post-abortion care (PAC) services to treat complications and prevent future unwanted pregnancy. We used a signal-function approach to look at abortion care services and illustrated its utility with secondary data from Zambia.

Methods

We refined signal functions for basic and comprehensive TOP and PAC services, including family planning (FP), and assessed functions currently being collected via multi-country facility surveys. We then used the 2005 Zambian Health Facility Census to estimate the proportion of 1369 health facilities that could provide TOP and PAC services under three scenarios. We linked facility and population data, and calculated the proportion of the Zambian population within reach of such services.

Results

Relevant signal functions are already collected in five facility assessment tools. In Zambia, 30 % of facilities could potentially offer basic TOP services, 3.7 % comprehensive TOP services, 2.6 % basic PAC services, and 0.3 % comprehensive PAC services (four facilities). Capability was highest in hospitals, except for FP functions. Nearly two-thirds of Zambians lived within 15 km of a facility theoretically capable of providing basic TOP, and one-third within 15 km of comprehensive TOP services. However, requiring three doctors for non-emergency TOP, as per Zambian law, reduced potential access to TOP services to 30 % of the population. One-quarter lived within 15 km of basic PAC and 13 % of comprehensive PAC services. In a scenario not requiring FP functions, one-half and one-third of the population were within reach of basic and comprehensive PAC respectively. There were huge urban-rural disparities in access to abortion care services. Comprehensive PAC services were virtually unavailable to the rural population.

Conclusions

Secondary data from facility assessments can highlight gaps in abortion service provision and coverage, but it is necessary to consider TOP and PAC separately. This approach, especially when combined with population data using geographic coordinates, can also be used to model the impact of various policy scenarios on access, such as requiring three medical doctors for non-emergency TOP. Data collection instruments could be improved with minor modifications and used for multi-country comparisons.

A scoping review of geographic information systems in maternal health

Background

Geographic information systems (GIS) are increasingly recognized tools in maternal health.

Objectives

To evaluate the use of GIS in maternal health and to identify knowledge gaps and opportunities.

Search strategy

Keywords broadly related to maternal health and GIS were used to search for academic articles and gray literature.

Selection criteria

Reviewed articles focused on maternal health, with GIS used as part of the methods.

Data collection and analysis

Peer reviewed articles (n = 40) and gray literature sources (n = 30) were reviewed.

Main results

Two main themes emerged: modeling access to maternal services and identifying risks associated with maternal outcomes. Knowledge gaps included a need to rethink spatial access to maternal care in low- and middle-income settings, and a need for more explicit use of GIS to account for the geographical variation in the effect of risk factors on adverse maternal outcomes. Limited evidence existed to suggest that use of GIS had influenced maternal health policy. Instead, application of GIS to maternal health was largely influenced by policy priorities in global maternal health.

Conclusions

Investigation of the role of GIS in contributing to future policy directions is warranted, particularly for elucidating determinants of global maternal health.

Context matters: Successes and challenges of intrapartum care scale-up in four districts of Afghanistan

Reducing preventable maternal mortality and achieving Sustainable Development Goal targets for 2030 will require increased investment in improving access to quality health services in fragile and conflict-affected states. This study explores the conditions that affect availability and utilisation of intrapartum care services in four districts of Afghanistan where mortality studies were conducted in 2002 and 2011. Information on changes in each district was collected through interviews with community members; service providers; and district, provincial and national officials. This information was then triangulated with programme and policy documentation to identify factors that affect the coverage of safe delivery and emergency obstetric care services. Comparison of barriers to maternal health service coverage across the four districts highlights the complexities of national health policy planning and resource allocation in Afghanistan, and provides examples of the types of challenges that must be addressed to extend the reach of life-saving maternal health interventions to women in fragile and conflict-affected states. Findings suggest that improvements in service coverage must be measured at a sub-national level, and context-specific service delivery models may be needed to effectively scale up intrapartum care services in extremely remote or insecure settings.

Using the unmet obstetric needs indicator to map inequities in life-saving obstetric interventions at the local health care system in Kenya

BACKGROUND

Developing countries with high maternal mortality need to invest in indicators that not only provide information about how many women are dying, but also where, and what can be done to prevent these deaths. The unmet Obstetric Needs (UONs) concept provides this information. This concept was applied at district level in Kenya to assess how many women had UONs and where the women with unmet needs were located.

METHODS

A facility based retrospective study was conducted in 2010 in Malindi District, Kenya. Data on pregnant women who underwent a major obstetric intervention (MOI) or died in facilities that provide comprehensive Emergency Obstetric Care (EmOC) services in 2008 and 2009 were collected. The difference between the number of women who experienced life threatening obstetric complications and those who received care was quantified. The main outcome measures in the study were the magnitude of UONs and their geographical distribution.

RESULTS

566 women in 2008 and 724 in 2009 underwent MOI. Of these, 185 (32.7%) in 2008 and 204 (28.1%) in 2009 were for Absolute Maternal Indications (AMI). The most common MOI was caesarean section (90%), commonly indicated by Cephalopelvic Disproportion (CPD)-narrow pelvis (27.6% in 2008; 26.1% in 2009). Based on a reference rate of 1.4%, the overall MOI for AMI rate was 1.25% in 2008 and 1.3% in 2009. In absolute terms, 22 (11%) women in 2008 and 12 (6%) in 2009, who required a life saving intervention failed to get it. Deficits in terms of unmet needs were identified in rural areas only while urban areas had rates higher than the reference rate (0.8% vs. 2.2% in 2008; 0.8% vs. 2.1% in 2009).

CONCLUSIONS

The findings, if used as a proxy to maternal mortality, suggest that rural women face higher risks of dying during pregnancy and childbirth. This indicates the need to improve priority setting towards ensuring equity in access to life saving interventions for pregnant women in underserved areas.

"Not too far to walk": the influence of distance on place of delivery in a western Kenya health demographic surveillance system

Background

Maternal health service coverage in Kenya remains low, especially in rural areas where 63% of women deliver at home, mainly because health facilities are too far away and/or they lack transport. The objectives of the present study were to (1) determine the association between the place of delivery and the distance of a household from the nearest health facility and (2) study the demographic characteristics of households with a delivery within a demographic surveillance system (DSS).

Methods

Census sampling was conducted for 13,333 households in the Webuye health and demographic surveillance system area in 2008–2009. Information was collected on deliveries that had occurred during the previous 12 months. Digital coordinates of households and sentinel locations such as health facilities were collected. Data were analyzed using STATA version 11. The Euclidean distance from households to health facilities was calculated using WinGRASS version 6.4. Hotspot analysis was conducted in ArcGIS to detect clustering of delivery facilities. Unadjusted and adjusted odds ratios were estimated using logistic regression models. P-values less than 0.05 were considered significant.

Results

Of the 13,333 households in the study area, 3255 (24%) reported a birth, with 77% of deliveries being at home. The percentage of home deliveries increased from 30% to 80% of women living within 2km from a health facility. Beyond 2km, distance had no effect on place of delivery (OR 1.29, CI 1.06–1.57, p = 0.011). Heads of households where women delivered at home were less likely to be employed (OR 0.598, CI 0.43–0.82, p = 0.002), and were less likely to have secondary education (OR 0.50, CI 0.41–0.61, p < 0.0001). Hotspot analysis showed households having facility deliveries were clustered around facilities offering comprehensive emergency obstetric care services.

Conclusion

Households where the nearest facility was offering emergency obstetric care were more likely to have a facility delivery, but only if the facility was within 2km of the home. Beyond the 2-km threshold, households were equally as likely to have home and facility deliveries. There is need for further research on other factors that affect the choice of place of delivery, and their relationships with maternal mortality.

Distance to care, facility delivery and early neonatal mortality in Malawi and Zambia

Background

Globally, approximately 3 million babies die annually within their first month. Access to adequate care at birth is needed to reduce newborn as well as maternal deaths. We explore the influence of distance to delivery care and of level of care on early neonatal mortality in rural Zambia and Malawi, the influence of distance (and level of care) on facility delivery, and the influence of facility delivery on early neonatal mortality.

Methods and Findings

National Health Facility Censuses were used to classify the level of obstetric care for 1131 Zambian and 446 Malawian delivery facilities. Straight-line distances to facilities were calculated for 3771 newborns in the 2007 Zambia DHS and 8842 newborns in the 2004 Malawi DHS. There was no association between distance to care and early neonatal mortality in Malawi (OR 0.97, 95%CI 0.58–1.60), while in Zambia, further distance (per 10 km) was associated with lower mortality (OR 0.55, 95%CI 0.35–0.87). The level of care provided in the closest facility showed no association with early neonatal mortality in either Malawi (OR 1.02, 95%CI 0.90–1.16) or Zambia (OR 1.02, 95%CI 0.82–1.26). In both countries, distance to care was strongly associated with facility use for delivery (Malawi: OR 0.35 per 10km, 95%CI 0.26–0.46). All results are adjusted for available confounders. Early neonatal mortality did not differ by frequency of facility delivery in the community.

Conclusions

While better geographic access and higher level of care were associated with more frequent facility delivery, there was no association with lower early neonatal mortality. This could be due to low quality of care for newborns at health facilities, but differential underreporting of early neonatal deaths in the DHS is an alternative explanation. Improved data sources are needed to monitor progress in the provision of obstetric and newborn care and its impact on mortality.

The impact of targeted subsidies for facility-based delivery on access to care and equity - evidence from a population-based study in rural Burkina Faso

We conducted the first population-based impact assessment of a financing policy introduced in Burkina Faso in 2007 on women's access to delivery services. The policy offers an 80 per cent subsidy for facility-based delivery. We collected information on delivery in five repeated cross-sectional surveys carried out from 2006 to 2010 on a representative sample of 1050 households in rural Nouna Health District. Over the 5 years, the proportion of facility-based deliveries increased from 49 to 84 per cent (P<0.001). The utilization gap across socio-economic quintiles, however, remained unchanged. The amount received for all services associated with births decreased by 67 per cent (P<0.001), but women continued to pay on average 1423 CFA (\[euro]1=655 CFA), about 500 CFA more than the set tariff of 900 CFA. Our findings indicate the operational effectiveness of the policy in increasing the use of facility-based delivery services for women. The potential to reduce maternal mortality substantially has not yet been assessed by health outcome measures of neonatal and maternal mortality.

Improving maternal and perinatal outcomes in the hypertensive disorders of pregnancy: a vision of a community-focused approach

The hypertensive disorders of pregnancy (HDP; pre-existing hypertension, gestational hypertension, and pre-eclampsia) remain important causes of maternal morbidity and mortality, especially in low- and middle-income countries. The paper summarizes the current state of evidence around possible technologies to support community-based improvements in maternal and perinatal outcomes for women with pre-eclampsia. Through the testing and, where proven, introduction of these technologies, we believe that HDP-related progress toward achieving Millennium Development Goal 5 can best be accelerated. The evidence and discussion are presented under the following headings: (1) prediction; (2) prevention; (3) diagnosis; (4) risk stratification; (5) decision aids; (6) treatment; (7) geographic information systems; (8) communication; and (9) community and patient education.

Models of care that have reduced maternal mortality and morbidity in Sri Lanka

Sri Lanka, a non-industrialized country with limited resources, has been able to achieve a maternal mortality ratio that is markedly lower than the ratios of similar countries. Many factors have contributed to Sri Lanka's success story. A political commitment to the cause and implementation of clear policies through well-structured and organized community-based and institutional healthcare services--expanded to cover the whole country and provided free of charge--have been the foundation of maternal and child health (MCH) services in the country. The healthcare programs have been well accepted and utilized by the people as the literacy rate is more than 90% for both men and women. Public health midwives form the backbone of MCH services and provide frontline reproductive health care. More than 98% of deliveries occur in hospitals and are attended by midwives. Furthermore, 85% of women in Sri Lanka deliver in facilities served by specialist obstetricians/gynecologists. The Sri Lanka College of Obstetricians and Gynecologists plays a leading role by assisting the Family Health Bureau in making policies and guidelines, training staff, and acting as team leaders for maternity care services. This was evident after the tsunami in December 2004. National maternal mortality reviews, monitoring and evaluation of MCH activities, and relatively high contraceptive prevalence rates have also contributed to the success in Sri Lanka, which could serve as a model for other countries.

Reducing maternal mortality: better monitoring, indicators and benchmarks needed to improve emergency obstetric care. Research summary for policymakers

Several limitations of emergency obstetric care (EmOC) indicators and benchmarks are analysed in this short paper, which synthesises recent research on this topic. A comparison between Sri Lanka and Zambia is used to highlight the inconsistencies and shortcomings in current methods of monitoring EmOC. Recommendations are made to improve the usefulness and accuracy of EmOC indicators and benchmarks in the future.

New signal functions to measure the ability of health facilities to provide routine and emergency newborn care

Based upon an expert survey and consensus method, Sabine Gabrysch and colleagues recommend new signal functions to monitor and track facilities' provision of routine and emergency newborn care.

Emergency obstetric care availability: a critical assessment of the current indicator

Monitoring progress in reducing maternal and perinatal mortality requires suitable indicators. The density of emergency obstetric care (EmOC) facilities has been proposed as a potentially useful indicator, but different UN documents make inconsistent recommendations, and its current formulation is not associated with maternal mortality. We compiled recently published indicator benchmarks and distinguished three sources of inconsistency: (i) use of different denominator metrics (per birth and per population), (ii) different assumptions on need for EmOC and for EmOC facilities and (iii) failure to specify facility capacity (birth load). The UN guidelines and handbook require fewer EmOC facilities than the World Health Report 2005 and do not specify capacity for deliveries or staffing levels. We recommend (i) always using births as the denominator for EmOC facility density, (ii) clearly stating assumptions on the proportion of deliveries needing basic and comprehensive emergency obstetric care and the desired proportion of deliveries in EmOC facilities and (iii) specifying facility capacity and staffing and adapting benchmarks for settings with different population density to ensure geographical accessibility.

Availability and distribution of, and geographic access to emergency obstetric care in Zambia

OBJECTIVE

To assess the availability and coverage of emergency obstetric care (EmOC) services in Zambia.

METHODS

Reported provision of EmOC signal functions in the Zambian Health Facility Census and additional criteria on staffing, opening hours, and referral capacity were used to classify all Zambian health facilities as providing comprehensive EmOC, basic EmOC, or more limited care. Geographic accessibility of EmOC services was estimated by linking health facility data with data from the Zambian population census.

RESULTS

Few Zambian health facilities provided all basic EmOC signal functions and had qualified health professionals available on a 24-hour basis. Of the 1131 Zambian delivery facilities, 135 (12%) were classified as providing EmOC. Zambia nearly met the UN EmOC density benchmarks nationally, but EmOC facilities and health professionals were unevenly distributed between provinces. Geographic access to EmOC services in rural areas was low; in most provinces, less than 25% of the population lived within 15 km of an EmOC facility.

CONCLUSION

A national Health Facility Census with geographic information is a valuable tool for assessing service availability and coverage at national and subnational levels. Simultaneously assessing health worker density and geographic access adds crucial information.