By: Margaret Kruk & Nana A.Y. Twum-Danso; Originally posted on Impatient Optimists
Maternal mortality is declining globally but remains persistently high in sub-Saharan Africa: the region contributes 56 percent of all maternal deaths each year. This has been attributed to the low number of women delivering with a skilled birth attendant, which results in many women dying at home or arriving at health facilities too late to be saved. To increase the number of women who have access to skilled providers during childbirth, low-income countries have worked to bring childbirth services to primary care facilities that are close to home. Typically these community clinics are meant to be staffed with nurses and midwives trained to provide basic obstetric care, although in practice, skilled providers are difficult to attract and retain in rural areas. In this model, the vast majority of women are expected to deliver at these community clinics, while women with high-risk pregnancies or those who develop complications in labor are referred to hospitals.
The problem with this approach is that it is based on myths about what women expect from the health system and how they actually use health care. These are the myths we want to debunk.
Evolving evidence and new research question this model. In 2012, in the Pwani Region of Tanzania, 40 percent of women who lived within walking distance of free primary care clinics bypassed those health clinics to deliver at the next level up, at a hospital or health center. First time mothers and women living near a low-quality facility were more likely to bypass. The wealthiest women were more likely to bypass but many poor women did the same.
The women who bypassed went to substantial effort to avoid the local clinic. They traveled nearly four times further and paid nearly twice as much as women delivering in the local clinic. But arguably they got what they paid for: better quality of care. Data from Demographic and Health Surveys from other countries in sub-Saharan Africa and other regions confirm that large proportions of women are choosing hospitals instead of lower level clinics.
The other myth about this model is that these facilities provide skilled delivery care.
There is compelling evidence from multiple studies in sub-Saharan Africa and South Asia, that many of the facilities that currently provide delivery services do not have providers that are sufficiently trained or adequately equipped to provide skilled care that meets the basic standards of obstetric care. Other data from stated preference studies, commonly used in marketing but rarely in public health, show that women greatly value quality of care for delivery in deciding where to deliver. This includes both technical components such as medicines and life-saving equipment and strong provider interpersonal skills such as respectful and attentive treatment.
In rural Africa and other sparsely populated regions of the world with limited resources, is it possible to build a high quality primary care system that meets basic obstetric and early newborn care standards? These countries spend less than $100 per capita on health—many much less than that. It is difficult to see how thousands of clinics could be upgraded to provide quality services for pregnant women and newborns. Even if money were available, health workers are not. Many skilled nurse-midwives do not want to live in rural areas, doctors even less so, with the result that many facilities are staffed with auxiliary workers. Changing this dynamic has proven very difficult. Finally, even assuming that new equipment and health workers can improve clinical care, research confirms the difficulty of sustaining quality in facilities with low delivery volumes (e.g. 2 to 10 deliveries per month) when providers do not have a chance to maintain their skills.
How can these data help us rethink service delivery?
Rather than tasking primary care clinics with all of obstetric and early newborn care, they could serve to support the continuum of home-community-facility care, tailored to local needs and preferences. In rural settings where high quality services are difficult to sustain in clinics, women might instead deliver at well-equipped high volume facilities: health centers and hospitals.
To ensure that distance to such facilities does not become a barrier to utilization, we would have to invest in models for locally appropriate transport and communication systems and in maternity homes that can serve multiple purposes for reproductive, maternal and newborn health. The private sector has much to contribute here.
This would leave primary care clinics in the community close to home to focus efforts on the content and quality of care during the antenatal and postnatal periods of pregnancy, and to provide other outpatient preventive and curative care as is done in most high and middle-income countries.
If we want the best health outcomes for mothers and babies, perhaps it’s time to listen to women and reform the health system to best meet their needs – identifying innovative solutions to enable them to access quality facility services.