The fifth Millennium Development Goal (MDG5) aims at improving maternal health. Globally, the maternal mortality ratio (MMR) declined from 400 to 260 per 100000 live births between 1990 and 2008. During the same period, MMR in sub-Saharan Africa decreased from 870 to 640. The decreased in MMR has been attributed to increase in the proportion of deliveries attended by skilled health personnel. Global improvements maternal health and health service provision indicators mask inequalities both between and within countries. In Namibia, there are significant inequities in births attended by skilled providers that favour those that are economically better off. The objective of this study was to identify the drivers of wealth-related inequalities in child delivery by skilled health providers.
Namibia Demographic and Health Survey data of 2006-07 are analysed for the causes of inequities in skilled birth attendance using a decomposable health concentration index and the framework of the Commission on Social Determinants of Health.
About 80.3% of the deliveries were attended by skilled health providers. Skilled birth attendance in the richest quintile is about 70% more than that of the poorest quintile. The rate of skilled attendance among educated women is almost twice that of women with no education. Furthermore, women in urban areas access the services of trained birth attendant 30% more than those in rural areas. Use of skilled birth attendants is over 90% in Erongo, Hardap, Karas and Khomas Regions, while the lowest (about 60-70%) is seen in Kavango, Kunene and Ohangwena. The concentration curve and concentration index show statistically significant wealth-related inequalities in delivery by skilled providers that are to the advantage of women from economically better off households (C = 0.0979; P < 0.001).
Delivery by skilled health provider by various maternal and household characteristics was 21 percentage points higher in urban than rural areas; 39 percentage points higher among those in richest wealth quintile than the poorest; 47 percentage points higher among mothers with higher level of education than those with no education; 5 percentage points higher among female headed households than those headed by men; 20 percentage points higher among people with health insurance cover than those without; and 31 percentage points higher in Karas region than Kavango region.
Inequalities in wealth and education of the mother are seen to be the main drivers of inequities in the percentage of births attended by skilled health personnel. This clearly implies that addressing inequalities in access to child delivery services should not be confined to the health system and that a concerted multi-sectoral action is needed in line with the principles of the Primary health Care.
In Tanzania, maternal mortality ratio remains unacceptably high at 578/100,000 live births. Despite a high coverage of antenatal care (96%), only 44% of deliveries take place within the formal health services. Still, "Ensure skilled attendant at birth" is acknowledged as one of the most effective interventions to reduce maternal deaths. Exploring the potential of community-based interventions in increasing the utilization of obstetric care, the study aimed at developing, testing and assessing a community-based safe motherhood intervention in Mtwara rural District of Tanzania.
This community-based intervention was designed as a pre-post comparison study, covering 4 villages with a total population of 8300. Intervention activities were implemented by 50 trained safe motherhood promoters (SMPs). Their tasks focused on promoting early and complete antenatal care visits and delivery with a skilled attendant. Data on all 512 deliveries taking place from October 2004 to November 2006 were collected by the SMPs and cross-checked with health service records. In addition 242 respondents were interviewed with respect to knowledge on safe motherhood issues and their perception of the SMP's performance. Skilled delivery attendance was our primary outcome; secondary outcomes included antenatal care attendance and knowledge on Safe Motherhood issues.
Deliveries with skilled attendant significantly increased from 34.1% to 51.4% (ρ < 0.05). Early ANC booking (4 to 16 weeks) rose significantly from 18.7% at baseline to 37.7% in 2005 and 56.9% (ρ < 0.001) at final assessment. After two years 44 (88%) of the SMPs were still active, 79% of pregnant women were visited. Further benefits included the enhancement of male involvement in safe motherhood issues.
The study has demonstrated the effectiveness of community-based safe motherhood intervention in promoting the utilization of obstetric care and a skilled attendant at delivery. This improvement is attributed to the SMPs' home visits and the close collaboration with existing community structures as well as health services.
Reduction of maternal mortality is a global priority particularly in developing countries including Ethiopia where maternal mortality ratio is one of the highest in the world. The key to reducing maternal mortality ratio and improving maternal health is increasing attendance by skilled health personnel throughout pregnancy and delivery. However, delivery service is significantly lower in Amhara Regional State, Ethiopia. Therefore, this study aimed to assess factors affecting institutional delivery service utilization among mothers who gave birth in the last 12 months in Sekela District, Amhara Region, Ethiopia.
Community-based cross-sectional study was conducted among mothers with birth in the last 12 months during August, 2010. Multistage sampling technique was used to select 371 participants. A pre tested and structured questionnaire was used to collect data. Bivariate and multivariate data analysis was performed using SPSS version 16.0 software.
The study indicated that 12.1% of the mothers delivered in health facilities. Of 87.9% mothers who gave birth at home, 80.0% of them were assisted by family members and relatives. The common reasons for home delivery were closer attention from family members and relatives (60.9%), home delivery is usual practice (57.7%), unexpected labour (33.4%), not being sick or no problem at the time of delivery (21.6%) and family influence (14.4%). Being urban resident (AOR [95% CI] = 4.6 [1.91, 10.9]), ANC visit during last pregnancy (AOR [95% CI] = 4.26 [1.1, 16.4]), maternal education level (AOR [95%CI] =11.98 [3.36, 41.4]) and knowledge of mothers on pregnancy and delivery services (AOR [95% CI] = 2.97[1.1, 8.6]) had significant associations with institutional delivery service utilization.
Very low institutional delivery service utilization was observed in the study area. Majority of the births at home were assisted by family members and relatives. ANC visit and lack of knowledge on pregnancy and delivery services were found to be associated with delivery service utilization. Strategies with focus on increasing ANC uptake and building knowledge of the mothers and their partners would help to increase utilization of the service. Training and assigning skilled attendants at Health Posta level to provide skilled home delivery would improve utilization of the service.
Institutional delivery service utilization; Preferred place of delivery; Sekela District
A crucial question in the aim to attain MDG5 is whether it can be achieved faster with the scaling up of multi-purpose health workers operating in the community or with the scaling up of professional skilled birth attendants working in health facilities. Most advisers concerned with maternal mortality reduction concur to promote births in facilities with professional attendants as the ultimate strategy. The evidence, however, is scarce on what it takes to progress in this path, and on the 'interim solutions' for situations where the majority of women still deliver at home. These questions are particularly relevant as we have reached the twentieth anniversary of the safe motherhood initiative without much progress made.
In this paper we review the current situation of human resources for maternal health as well as the problems that they face. We propose seven key areas of work that must be addressed when planning for scaling up human resources for maternal health in light of MDG5, and finally we indicate some advances recently made in selected countries and the lessons learned from these experiences. Whilst the focus of this paper is on maternal health, it is acknowledged that the interventions to reduce maternal mortality will also contribute to significantly reducing newborn mortality.
Addressing each of the seven key areas of work – recommended by the first International Forum on 'Midwifery in the Community', Tunis, December 2006 – is essential for the success of any MDG5 programme.
We hypothesize that a great deal of the stagnation of maternal health programmes has been the result of confusion and careless choices in scaling up between a limited number of truly skilled birth attendants and large quantities of multi-purpose workers with short training, fewer skills, limited authority and no career pathways. We conclude from the lessons learnt that no significant progress in maternal mortality reduction can be achieved without a strong political decision to empower midwives and others with midwifery skills, and a substantial strengthening of health systems with a focus on quality of care rather than on numbers, to give them the means to respond to the challenge.
Availability of a Skilled Birth Attendant (SBA) during childbirth is a key indicator for MDG5 and a strategy for reducing maternal and neonatal mortality in Africa. There is limited information on how SBAs and their functions are defined. The aim of this study was to map the cadres of health providers considered SBAs in Sub Saharan Africa (SSA); to describe which signal functions of Essential Obstetric Care (EmOC) they perform and assess whether they are legislated to perform these functions.
Methods and Findings
Key personnel in the Ministries of Health, teaching institutions, referral, regional and district hospitals completed structured questionnaires in nine SSA countries in 2009–2011. A total of 21 different cadres of health care providers (HCP) were reported to be SBA. Type and number of EmOC signal functions reported to be provided, varied substantially between cadres and countries. Parenteral antibiotics, uterotonic drugs and anticonvulsants were provided by most SBAs. Removal of retained products of conception and assisted vaginal delivery were the least provided signal functions. Except for the cadres of obstetricians, medical doctors and registered nurse-midwives, there was lack of clarity regarding signal functions reported to be performed and whether they were legislated to perform these. This was particularly for manual removal of placenta, removal of retained products and assisted vaginal delivery. In some countries, cadres not considered SBA performed deliveries and provided EmOC signal functions. In other settings, cadres reported to be SBA were able to but not legislated to perform key EmOC signal functions.
Comparison of cadres of HCPs reported to be SBA across countries is difficult because of lack of standardization in names, training, and functions performed. There is a need for countries to develop clear guidelines defining who is a SBA and which EmOC signal functions each cadre of HCP is expected to provide.
Recent efforts to reduce maternal mortality in developing countries have focused primarily on two long-term aims: training and deploying skilled birth attendants and upgrading emergency obstetric care facilities. Given the future population-level benefits, strengthening of health systems makes excellent strategic sense but it does not address the immediate safe-delivery needs of the estimated 45 million women who are likely to deliver at home, without a skilled birth attendant. There are currently 28 countries from four major regions in which fewer than half of all births are attended by skilled birth attendants. Sixty-nine percent of maternal deaths in these four regions can be attributed to these 28 countries, despite the fact that these countries only constitute 34% of the total population in these regions. Trends documenting the change in the proportion of births accompanied by a skilled attendant in these 28 countries over the last 15-20 years offer no indication that adequate change is imminent. To rapidly reduce maternal mortality in regions where births in the home without skilled birth attendants are common, governments and community-based organizations could implement a cost-effective, complementary strategy involving health workers who are likely to be present when births in the home take place. Training community-based birth attendants in primary and secondary prevention technologies (e.g. misoprostol, family planning, measurement of blood loss, and postpartum care) will increase the chance that women in the lowest economic quintiles will also benefit from global safe motherhood efforts.
Cross-sectional studies; Delivery; Maternal health services; Maternal mortality; Misoprostol; Postpartum haemorrhage; Skilled birth attendants; Traditional birth attendants
The fifth Millennium Development Goal calls for a reduction of maternal mortality ratio by 75% between 1990 and 2015. A key indicator to measure this goal is the proportion of births attended by skilled health personnel. The maternal mortality ratio of Ethiopia is 676 deaths per 100,000 live births. Skilled birth attendance is correlated with lower maternal mortality rates globally and in Sub-Saharan Africa. However, the proportion of births with a skilled attendant is only 10% in Ethiopia. Therefore identifying the determinants of skilled attendance for delivery is a priority area to give policy recommendations.
A community based nested case control study was conducted from October 2009 – August 2011 at the University of Gondar health and demographic surveillance systems site located at Dabat district, Northwest Ethiopia. Data were obtained from the infant mortality prospective follow up study conducted to identify the determinants of infant survival. A pretested and structured questionnaire via interview was used to collect data on the different variables. Logistic regression analysis was used to identify the determinants of skilled birth attendance. Strength of the association was assessed using odds ratio with 95% CI.
A total of 1065 mothers (213 cases and 852 controls) were included in the analysis. Among the cases, 166 (77.9%) were from urban areas. More than half (54%) of the cases have secondary and above level of education. Secondary and above level of education [AOR (95%CI) = 2.8 (1.29, 3.68)] and urban residence [AOR (95%CI) = 8.8 (5.32, 14.46)] were associated with skilled attendance for delivery. Similarly, women who had ANC during their pregnancy four or more times [AOR (95%CI) = 2.8 (1.56, 4.98)] and who own TV [AOR (95%CI) = 2.5 (1.32, 4.76)] were more likely to deliver with the assistance of a skilled attendant.
Women’s education, place of residence, frequency of antenatal care visit and ever use of family planning were found to be determinants of skilled birth attendance. Encouraging women to complete at least secondary education and to have antenatal care frequently are important to increase skilled attendance during delivery.
Determinant; Skilled birth attendance; Ethiopia
Bangladesh is distinct among developing countries in achieving a low maternal mortality ratio (MMR) of 322 per 100,000 livebirths despite the very low use of skilled care at delivery (13% nationally). This variation has also been observed in Matlab, a rural area in Bangladesh, where longitudinal data on maternal mortality are available since the mid-1970s. The current study investigated the possible causes of the maternal mortality decline in Matlab. The study analyzed 769 maternal deaths and 215,779 pregnancy records from the Health and Demographic Surveillance System (HDSS) and other sources of safe motherhood data in the ICDDR,B and government service areas in Matlab during 1976-2005. The major interventions that took place in both the areas since the early 1980s were the family-planning programme plus safe menstrual regulation services and safe motherhood interventions (midwives for normal delivery in the ICDDR,B service area from the late 1980s and equal access to comprehensive emergency obstetric care [EmOC] in public facilities for women from both the areas). National programmes for social development and empowerment of women through education and microcredit programmes were implemented in both the areas. The quantitative findings were supplemented by a qualitative study by interviewing local community care providers for their change in practices for maternal healthcare over time. After the introduction of the safe motherhood programme, reduction in maternal mortality was higher in the ICDDR,B service area (68.6%) than in the government service area (50.4%) during 1986-1989 and 2001-2005. Reduction in the number of maternal deaths due to the fertility decline was higher in the government service area (30%) than in the ICDDR,B service area (23%) during 1979-2005. In each area, there has been substantial reduction in abortion-related mortality—86.7% and 78.3%—in the ICDDR,B and government service areas respectively. Education of women was a strong predictor of the maternal mortality decline in both the areas. Possible explanations for the maternal mortality decline in Matlab are: better access to comprehensive EmOC services, reduction in the total fertility rate, and improved education of women. To achieve the Millenium Development Goal 5 targets, policies that bring further improved comprehensive EmOC, strengthened family-planning services, and expanded education of females are essential.
Causes of death; Delivery; Health services; Health facilities; Healthcare; Maternal health; Maternal mortality; Obstetric care; Risk factors; Bangladesh
Reducing maternal morbidity and mortality is a global priority which is particularly relevant to developing countries like Ethiopia. One of the key strategies for reducing maternal morbidity and mortality is increasing institutional delivery service utilization of mothers under the care of skilled birth attendants. The aim of this study was to determine the level of institutional delivery service utilization and associated factors.
A community-based cross-sectional survey was conducted from April 1–20, 2011, among mothers who gave birth 12 months before the study began in Munesa Woreda, Arsi Zone, Oromia Region, Southeast Ethiopia. A stratified cluster sampling was used to select a sample of 855 participants.
Out of all deliveries, only 12.3% took place at health facilities. Women who were urban residents (AOR = 2.27, 95%CI: 1.17, 4.40), women of age at interview less than 20 years (AOR = 6.06, 95%CI: 1.54, 23.78), women with first pregnancy (AOR = 2.41, 95%CI: 1.17, 4.97) and, women who had ANC visit during the last pregnancy (AOR = 4.18, 95%CI: 2.54, 6.89) were more likely to deliver at health institutions. Secondary and above level of mother`s and husband`s education had also a significant effect on health institution delivery with AOR = 4.31 (95%CI: 1.62, 11.46) and AOR = 2.77 (95%CI: 1.07, 7.19) respectively.
Institutional delivery service utilization was found to be low in the study area. Secondary and above level of mother`s and husband`s education, urban residence and ANC visit were amongst the main factors that had an influence on health institution delivery. Increasing the awareness of mothers and their partners about the benefits of institutional delivery services are recommended.
South Africa’s maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country’s Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, “patient-oriented” barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services.
A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers.
Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care.
To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these “patient-oriented” barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.
Maternal health is one of the major worldwide health challenges. Currently, the unacceptably high levels of maternal mortality are a common subject in global health and development discussions. Although some countries have made remarkable progress, half of the maternal deaths in the world still take place in Sub-Saharan Africa where little or no progress has been made. There is no single simple, straightforward intervention that will significantly decrease maternal mortality alone; however, there is a consensus on the importance of a strong health system, skilled delivery attendants, and women's rights for maternal health. Our objective was to describe and determine different factors associated with the maternal mortality ratio in Sub-Saharan countries.
An ecological multi-group study compared variables between many countries in Sub-Saharan Africa using data collected between 1997 and 2006. The dependent variable was the maternal mortality ratio, and Health care system-related, educational and economic indicators were the independent variables. Information sources included the WHO, World Bank, UNICEF and UNDP.
Maternal mortality ratio values in Sub-Saharan Africa were demonstrated to be high and vary enormously among countries. A relationship between the maternal mortality ratio and some educational, sanitary and economic factors was observed. There was an inverse and significant correlation of the maternal mortality ratio with prenatal care coverage, births assisted by skilled health personnel, access to an improved water source, adult literacy rate, primary female enrolment rate, education index, the Gross National Income per capita and the per-capita government expenditure on health.
Education and an effective and efficient health system, especially during pregnancy and delivery, are strongly related to maternal death. Also, macro-economic factors are related and could be influencing the others.
Developing countries are currently struggling to achieve the Millennium Development Goal Five of reducing maternal mortality by three quarters between 1990 and 2015. Many health systems are facing acute shortages of health workers needed to provide improved prenatal care, skilled birth attendance and emergency obstetric services – interventions crucial to reducing maternal death. The World Health Organization estimates a current deficit of almost 2.4 million doctors, nurses and midwives. Complicating matters further, health workforces are typically concentrated in large cities, while maternal mortality is generally higher in rural areas. Additionally, health care systems are faced with shortages of specialists such as anaesthesiologists, surgeons and obstetricians; a maldistribution of health care infrastructure; and imbalances between the public and private health care sectors. Increasingly, policy-makers have been turning to human resource strategies to cope with staff shortages. These include enhancement of existing work roles; substitution of one type of worker for another; delegation of functions up or down the traditional role ladder; innovation in designing new jobs;transfer or relocation of particular roles or services from one health care sector to another. Innovations have been funded through state investment, public-private partnerships and collaborations with nongovernmental organizations and quasi-governmental organizations such as the World Bank. This paper focuses on how two large health systems in India – Gujarat and Tamil Nadu – have successfully applied human resources strategies in uniquely different contexts to the challenges of achieving Millennium Development Goal Five.
The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249–584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda.
Using census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18–50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordinates were used to calculate the path distances between each village and its designated health center and district hospital. Bivariate and multivariate logistic regressions were used to identify factors associated with delivery in health facilities.
Analysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of health facility deliveries in recent years. Delivering a penultimate baby at a health facility (OR = 4.681 [3.204 - 6.839]), possessing health insurance (OR = 3.812 [1.795 - 8.097]), managing household finances (OR = 1.897 [1.046 - 3.439]), attending more antenatal care visits (OR = 1.567 [1.163 - 2.112]), delivering more recently (OR = 1.438 [1.120 - 1.847] annually), and living closer to a health center (OR = 0.909 [0.846 - 0.976] per km) were independently associated with facility delivery.
The strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health center. Recent structural interventions in Rwanda, including the rapid scale-up of community-financed health insurance, likely contributed to the dramatic improvement in the health facility delivery rate observed in our study.
Maternal health; Service delivery; Health financing; Health systems; Sub-Saharan Africa
A measure of the proportion of deliveries assisted by skilled attendants is one of the indicators of progress towards achieving Millennium Development Goal (MDG) 5, which aims at improving maternal health. This study aimed at establishing delivery practices and associated factors among mothers seeking child welfare services at selected health facilities in Nyandarua South district, Kenya to determine whether mothers were receiving appropriate delivery care.
A hospital-based cross-sectional survey among women who had recently delivered while in the study area was carried out between August and October 2009. Binary Logistic regression was used to identify factors that predicted mothers' delivery practice.
Among the 409 mothers who participated in the study, 1170 deliveries were reported. Of all the deliveries reported, 51.8% were attended by unskilled birth attendants. Among the deliveries attended by unskilled birth attendants, 38.6% (452/1170) were by neighbors and/or relatives. Traditional Birth Attendants attended 1.5% (17/1170) of the deliveries while in 11.7% (137/1170) of the deliveries were self administered. Mothers who had unskilled birth attendance were more likely to have <3 years of education (Adjusted Odds ratio [AOR] 19.2, 95% confidence interval [CI] 1.7 - 212.8) and with more than three deliveries in a life time (AOR 3.8, 95% CI 2.3 - 6.4). Mothers with perceived similarity in delivery attendance among skilled and unskilled delivery attendants were associated with unsafe delivery practice (AOR 1.9, 95% CI 1.1 - 3.4). Mother's with lower knowledge score on safe delivery (%) were more likely to have unskilled delivery attendance (AOR 36.5, 95% CI 4.3 - 309.3).
Among the mothers interviewed, utilization of skilled delivery attendance services was still low with a high number of deliveries being attended by unqualified lay persons. There is need to implement cost effective and sustainable measures to improve the quality of maternal health services with an aim of promoting safe delivery and hence reducing maternal mortality.
Delivery by a skilled birth attendant (SBA) in a hospital is advocated to improve maternal health; however, hospital expenses for delivery care services are a concern for women and their families, particularly for women who pay out-of-pocket. Although health insurance is now implemented in Lao PDR, it is not universal throughout the country. The objectives of this study are to estimate the total health care expenses for vaginal delivery and caesarean section, to determine the association between health insurance and family income with health care expenditure and assess the effect of health insurance from the perspectives of the women and the skilled birth attendants (SBAs) in Lao PDR.
A cross-sectional study was carried out in two provincial hospitals in Lao PDR, from June to October 2010. Face to face interviews of 581 women who gave birth in hospital and 27 SBAs was carried out. Both medical and non-medical expenses were considered. A linear regression model was used to assess influencing factors on health care expenditure and trends of medical and non-medical expenditure by monthly family income stratified by mode of delivery were assessed.
Of 581 women, 25% had health care insurance. Health care expenses for delivery care services were significantly higher for caesarean section (270 USD) than for vaginal delivery (59 USD). After adjusting for the effect of hospital, family income was significantly associated with all types of expenditure in caesarean section, while it was associated with non-medical and total expenditures in vaginal delivery. Both delivering women and health providers thought that health insurance increased the utilisation of delivery care.
Substantially higher delivery care expenses were incurred for caesarean section compared to vaginal delivery. Three-fourths of the women who were not insured needed to be responsible for their own health care payment. Women who had higher family incomes were able to pay for more non-medical care expenses. The effect of health insurance on service utilization was noted by women and SBAs. To achieve the goal of utilizing delivery care in the hospitals, coverage of health insurance needs to be expanded.
Maternal mortality in childbirth has been, until recently, a neglected tragedy in most developing countries. Rates of maternal deaths range from 300 to 700/100 000 live births, from 50 to 100 times greater in developing than in developed countries. The major direct obstetric causes include illegal abortions, hemorrhage, sepsis, obstructed labour, ruptured uterus, and pregnancy-induced hypertension. During the past decade, increased recognition of this problem has led to the “Safe Motherhood Initiative” by the World Health Organization in 1987, which has been integrated into the goal of “Health for All by the Year 2000.” The training of traditional birth attendants (who attend from 40% to 60% of births in developing countries) is seen as one of the most important ways to improve obstetric care in remote rural villages.
family medicine; maternal mortality; obstetrics; World Health Organization
In many developing countries, the maternal mortality ratio remains high with huge poor-rich inequalities. Programmes aimed at improving maternal health and preventing maternal mortality often fail to reach poor women. Vouchers in health and Health Equity Funds (HEFs) constitute a financial mechanism to improve access to priority health services for the poor. We assess their effectiveness in improving access to skilled birth attendants for poor women in three rural health districts in Cambodia and draw lessons for further improvement and scaling-up.
Data on utilisation of voucher and HEF schemes and on deliveries in public health facilities between 2006 and 2008 were extracted from the available database, reports and the routine health information system. Qualitative data were collected through focus group discussions and key informant interviews. We examined the trend of facility deliveries between 2006 and 2008 in the three health districts and compared this with the situation in other rural districts without voucher and HEF schemes. An operational analysis of the voucher scheme was carried out to assess its effectiveness at different stages of operation.
Facility deliveries increased sharply from 16.3% of the expected number of births in 2006 to 44.9% in 2008 after the introduction of voucher and HEF schemes, not only for voucher and HEF beneficiaries, but also for self-paid deliveries. The increase was much more substantial than in comparable districts lacking voucher and HEF schemes. In 2008, voucher and HEF beneficiaries accounted for 40.6% of the expected number of births among the poor. We also outline several limitations of the voucher scheme.
Vouchers plus HEFs, if carefully designed and implemented, have a strong potential for reducing financial barriers and hence improving access to skilled birth attendants for poor women. To achieve their full potential, vouchers and HEFs require other interventions to ensure the supply of sufficient quality maternity services and to address other non-financial barriers to demand. If these conditions are met, voucher and HEF schemes can be further scaled up under close monitoring and evaluation.
Maternal mortality remains high in developing countries and data to monitor indicators of progress in maternal care is needed. We examined the status of maternal care before and after health care worker (HCW) training in WHO recommended Focused Antenatal Care.
An initial cross-sectional survey was conducted in 2002 in Asembo and Gem in western Kenya among a representative sample of women with a recent birth. HCW training was performed in 2003 in Asembo, and a repeat survey was conducted in 2005 in both areas.
Antenatal clinic (ANC) attendance was similar in both areas (86%) in 2005 and not significantly different from 2002 (90%). There was no difference in place of delivery between the areas or over time. However, in 2005, more women in Asembo were delivered by a skilled assistant compared to Gem (30% vs.23%, P = 0.04), and this proportion increased compared to 2002 (17.6% and 16.1%, respectively). Provision of iron (82.4%), folic acid (72.0%), sulfadoxine-pyrimethamine (61.7%), and anthelminths (12.7%) had increased in Asembo compared to 2002 (2002: 53.3%, 52.8%, 20.3%, and 4.6%, respectively), and was significantly higher than in Gem in 2005 (Gem 2005: 69.7%, 47.8%, 19.8%, and 4.1%, respectively) (P < 0.05 for all). Offering of tests for sexually transmitted diseases and providing information related to maternal health was overall low (<20%) and did not differ by area. In 2005, more women rated the quality of the antenatal service in Asembo as very satisfactory compared to Gem (17% vs. 6.5%, P < 0.05).
We observed improvements in some ANC services in the area where HCWs were trained. However, since our evaluation was carried out 2 years after three-day training, we consider any significant, sustained improvement to be remarkable.
Bangladesh is on its way to achieving the MDG 5 target of reducing the maternal mortality ratio by three-quarters between 1990 and 2015, but the annual rate of decline needs to triple. Although the use of skilled birth attendants has improved over the past 15 years, it remains less than 20% as of 2007 and is especially low among poor, uneducated rural women. Increasing the numbers of skilled birth attendants, deploying them in teams in facilities, and improving access to them through messages on antenatal care to women, have the potential to increase such use. The use of caesarean sections is increasing although not among poor, uneducated rural women. Strengthening appropriate quality emergency obstetric care in rural areas remains the major challenge. Strengthening other supportive services, including family planning and delayed first birth, menstrual regulation, and education of women, are also important for achieving MDG 5.
Maternal health; Maternal mortality; Obstetric care; Quality of care; Bangladesh
To improve access to skilled attendance at delivery and thereby reduce maternal mortality, the Government of Ghana introduced a policy exempting all women attending health facilities from paying delivery care fees.
To examine the effect of the exemption policy on delivery-related maternal mortality.
Maternal deaths in 9 and 12 hospitals in the Central Region (CR) and the Volta Region (VR) respectively were analysed. The study covered a period of 11 and 12 months before and after the introduction of the policy between 2004 and 2006. Maternal deaths were identified by screening registers and clinical notes of all deaths in women aged 15–49 years in all units of the hospitals. These deaths were further screened for those related to delivery. The total births in the study period were also obtained in order to calculate maternal mortality ratios (MMR).
A total of 1220 (78.8%) clinical notes of 1549 registered female deaths were retrieved. A total of 334 (21.6%) maternal deaths were identified. The delivery-related MMR decreased from 445 to 381 per 100,000 total births in the CR and from 648 to 391 per 100,000 total births in the VR following the implementation of the policy. The changes in the 2 regions were not statistically significant (p=0.458) and (p=0.052) respectively. No significant changes in mean age of delivery-related deaths, duration of admission and causes of deaths before and after the policy in both regions.
The delivery-related institutional maternal mortality did not appear to have been significantly affected after about one year of implementation of the policy.
Exemption policy; maternal death; institutional maternal deaths; Central Region; Volta Region; Ghana
Health institutions need to contribute their quota towards the achievement of the Millennium Development Goal (MDG) with respect to maternal health. In order to do so, current data on maternal mortality is essential for careproviders and policy makers to appreciate the burden of the problem and understand how best to distribute resources. This study presents the magnitude and distribution of causes of maternal deaths at the beginning of the 21st century in a Nigerian referral hospital and derives recommendations to reduce its frequency.
A retrospective descriptive analysis of all cases of maternal deaths at Olabisi Onabanjo University Teaching Hospital, Sagamu, Southwest Nigeria between 1 January 2000 to 30 June 2005.
There were 75 maternal deaths, 2509 live births and 2728 deliveries during the study period. Sixty-three (84.0%) of the deaths were direct maternal deaths while 12 (16.0%) were indirect maternal deaths. Major causes of deaths were hypertensive disorders in pregnancy (28.0%), haemorrhage (21.3%) and sepsis (20.0%). Overall, eclampsia was the leading cause of deaths singly accounting for 24.0% of all maternal deaths. Abortion and HIV-related mortality accounted for 1.3% and 4.0% of maternal deaths, respectively. The maternal mortality ratio of 2989.2 per 100,000 live births was significantly higher than that reported for 1988–1997 in the same institution. Up to 67/794 (8.4%) patients referred from other facilities died compared to 8/1934 (0.4%) booked patients (OR: 22.1; 95% CI: 10.2–50.1). Maternal death was more likely to follow operative deliveries than non-operative deliveries (27/545 vs 22/2161; OR: 5.07; 95% CI: 2.77–9.31).
At the middle of the first decade of the new millennium, a large number of pregnant women receiving care in this centre continue to die from preventable causes of maternal death. Adoption of evidence-based protocol for the management of eclampsia and improvement in the quality of obstetric care for unbooked emergencies would go a long way to significantly reduce the frequency of maternal deaths in this institution.
Maternal mortality in Sub-Saharan Africa remains a challenge with estimates exceeding 1,000 maternal deaths per 100,000 live births in some countries. Successful prevention of maternal deaths hinges on adequate and quality emergency obstetric care. In addition to skilled personnel, there is need for a supportive environment in terms of essential drugs and supplies, equipment, and a referral system. Many household surveys report a reasonably high proportion of women delivering in health facilities. However, the quality and adequacy of facilities and personnel are often not assessed. The three delay model; 1) delay in making the decision to seek care; 2) delay in reaching an appropriate obstetric facility; and 3) delay in receiving appropriate care once at the facility guided this project. This paper examines aspects of the third delay by assessing quality of emergency obstetric care in terms of staffing, skills equipment and supplies.
We used data from a survey of 25 maternity health facilities within or near two slums in Nairobi that were mentioned by women in a household survey as places that they delivered. Ethical clearance was obtained from the Kenya Medical Research Institute. Permission was also sought from the Ministry of Health and the Medical Officer of Health. Data collection included interviews with the staff in-charge of maternity wards using structured questionnaires. We collected information on staffing levels, obstetric procedures performed, availability of equipment and supplies, referral system and health management information system.
Out of the 25 health facilities, only two met the criteria for comprehensive emergency obstetric care (both located outside the two slums) while the others provided less than basic emergency obstetric care. Lack of obstetric skills, equipment, and supplies hamper many facilities from providing lifesaving emergency obstetric procedures. Accurate estimation of burden of morbidity and mortality was a challenge due to poor and incomplete medical records.
The quality of emergency obstetric care services in Nairobi slums is poor and needs improvement. Specific areas that require attention include supervision, regulation of maternity facilities; and ensuring that basic equipment, supplies, and trained personnel are available in order to handle obstetric complications in both public and private facilities.
Access to appropriate health care including skilled birth attendance at delivery and timely referrals to emergency obstetric care services can greatly reduce maternal deaths and disabilities, yet women in sub-Saharan Africa continue to face limited access to skilled delivery services. This study relies on qualitative data collected from residents of two slums in Nairobi, Kenya in 2006 to investigate views surrounding barriers to the uptake of formal obstetric services. Data indicate that slum dwellers prefer formal to informal obstetric services. However, their efforts to utilize formal emergency obstetric care services are constrained by various factors including ineffective health decision making at the family level, inadequate transport facilities to formal care facilities and insecurity at night, high cost of health services, and inhospitable formal service providers and poorly equipped health facilities in the slums. As a result, a majority of slum dwellers opt for delivery services offered by traditional birth attendants (TBAs) who lack essential skills and equipment, thereby increasing the risk of death and disability. Based on these findings, we maintain that urban poor women face barriers to access of formal obstetric services at family, community, and health facility levels, and efforts to reduce maternal morbidity and mortality among the urban poor must tackle the barriers, which operate at these different levels to hinder women's access to formal obstetric care services. We recommend continuous community education on symptoms of complications related to pregnancy and timely referral. A focus on training of health personnel on “public relations” could also restore confidence in the health-care system with this populace. Further, we recommend improving the health facilities in the slums, improving the services provided by TBAs through capacity building as well as involving TBAs in referral processes to make access to services timely. Measures can also be put in place to enhance security in the slums at night.
Urban poor; Nairobi; Slums; Formal Emergency Obstetric Care (EmOC); Barriers; Qualitative data
Maternal mortality is a global burden, with more than 500,000 women dying each year due to pregnancy and childbirth-related complications. Birth-preparedness and complication readiness is a comprehensive strategy to improve the use of skilled providers at birth, the key intervention to decrease maternal mortality. Birth-preparedness and complication readiness include many elements, including: (a) knowledge of danger signs; (b) plan for where to give birth; (c) plan for a birth attendant; (d) plan for transportation; and (e) plan for saving money. The 2003 Burkina Faso Demographic and Health Survey indicated that only 38.5% of women gave birth with the assistance of a skilled provider. The Maternal and Neonatal Health Program of JHPIEGO implemented a district-based model service-delivery system in Koupéla, Burkina Faso, during 2001–2004, to increase the use of skilled providers during pregnancy and childbirth. In 2004, a cross-sectional survey with a random sample of respondents was conducted to measure the impact of birth-preparedness and complication readiness on the use of skilled providers at birth. Of the 180 women who had given birth within 12 months of the survey, 46.1% had a plan for transportation, and 83.3% had a plan to save money. Women with these plans were more likely to give birth with the assistance of a skilled provider (p=0.07 and p=0.03 respectively). Controlling for education, parity, average distance to health facility, and the number of antenatal care visits, planning to save money was associated with giving birth with the assistance of a skilled provider (p=0.05). Qualitative interviews with women who had given birth within 12 months of the survey (n=30) support these findings. Most women saved money for delivery, but had less concrete plans for transportation. These findings highlight how birth-preparedness and complication readiness may be useful in increasing the use of skilled providers at birth, especially for women with a plan for saving money during pregnancy.
Maternal health; Birth-preparedness; Delivery; Childbirth; Burkina Faso; West Africa
There is increasing attention, globally and in countries, to monitoring and addressing the health systems and human resources inputs, processes and outputs that impede or facilitate progress towards achieving the Millennium Development Goals for maternal and child health. We reviewed the situation of human resources for health (HRH) in 68 low- and middle-income countries that together account for over 95% of all maternal and child deaths.
We collected and analysed cross-nationally comparable data on HRH availability, distribution, roles and functions from new and existing sources, and information from country reviews of HRH interventions that are associated with positive impacts on health services delivery and population health outcomes.
Findings from 68 countries demonstrate availability of doctors, nurses and midwives is positively correlated with coverage of skilled birth attendance. Most (78%) of the target countries face acute shortages of highly skilled health personnel, and large variations persist within and across countries in workforce distribution, skills mix and skills utilization. Too few countries appropriately plan for, authorize and support nurses, midwives and community health workers to deliver essential maternal, newborn and child health-care interventions that could save lives.
Despite certain limitations of the data and findings, we identify some key areas where governments, international partners and other stakeholders can target efforts to ensure a sufficient, equitably distributed and efficiently utilized health workforce to achieve MDGs 4 and 5.