The Millennium Development Goal (MDG) to reduce maternal mortality did not recommend specific configurations of maternal health-care services, but aimed implicitly, as reflected in its tracking indicators, to ensure high coverage of skilled birth attendant at delivery and antenatal care. Underlying these choices were assumptions that high coverage of skilled birth attendant and antenatal care would put women and their babies in contact with professionals who could manage uneventful pregnancy, labour, and birth, and either prevent, detect and treat, or appropriately refer complications. Additionally, antenatal care sessions provide an opportunity to arrange appropriate childbirth care.
The end of the MDG era showed progress: from 1990 to 2013, global coverage of births occurring with skilled birth attendants increased from 57% to 74%, one or more antenatal visits from 65% to 83%, and four or more antenatal care visits from 37% to 64%.1, 2 However some countries continue to have high maternal mortality ratios, despite high coverage of skilled birth attendants and antenatal care. Such sustained maternal mortality could arise because such indicators track contacts with care and not the content of care; a quality gap might remain despite increases in coverage.3, 4 Furthermore, features beyond skilled birth attendant and antenatal care coverage are likely to be influential. For example, a high population density and short travel times should facilitate access to emergency obstetric care (EmOC), and women's health profiles and life circumstances might also drive health outcomes.
Comparative tracking of maternal health-care provision across different countries has been minimal, apart from the two aforementioned MDG indicators, with only a few indicators and benchmarks used (appendix). In the new era of Sustainable Development Goal (SDG) targets, the shortcomings of use of unidimensional and limited metrics to characterise complex services should be redressed. In this Series paper, we focus on intrapartum care. In the appendix, we briefly describe the status of family planning, abortion, antenatal, and postnatal services. The continuum of care is important, but we chiefly address childbirth services because they are more complex to provide, and because good intrapartum and immediate postpartum care reduce maternal, fetal, and neonatal deaths, and promote health, wellbeing, and enhance child development.5
A useful starting point for this Series paper is to lay out pathways that could theoretically lead individual women to receive adequate intrapartum care with skilled birth attendants (figure 1). Informed by this framework, we present a multifaceted characterisation of the main configurations of childbirth services currently used by women in low-income and middle-income countries (LMICs), with some data presented on high-income countries (HICs) for comparison. We begin with the prevailing patterns of where, and with whom, deliveries take place. We then detail the levels of facilities, and facility and staff capabilities, and touch on other aspects of quality, followed by a section on strategies to link women to such intrapartum services. Financing innovations, also essential for improvements to access and quality, are addressed by Koblinsky and colleagues.6 Finally, we discuss whether current models of service delivery are likely to be fit-for-purpose, and indicate the scope for future change. We make recommendations for data collection for improved planning, provision, and tracking.
Key messages
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Facility and skilled birth attendant deliveries are increasing; this investment should yield multiple benefits, reduce maternal and perinatal mortality, and improve maternal and neonatal wellbeing
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Progress is not as great as expected; phrases such as skilled birth attendant and emergency obstetric care can mask poor quality care; we need to ensure skilled providers for routine and emergency childbirth care, along with timely access to such care
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National health plans need to ensure women, especially the most remote or vulnerable, can reach intrapartum services in a timely way: this requirement will entail understanding of the current use of routine and emergency transport, and patterns of relocation (before the start of labour) to stay near the planned childbirth locale (maternity waiting homes)
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It is unethical to encourage women to give birth in places with low facility capability, no referral mechanism, with unskilled providers, or where content of care is not evidence-based: this failing should be remedied as a matter of priority; childbirth should only be promoted in facilities that can guarantee at least a basic emergency obstetric care standard
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Low-income and middle-income countries could promote births in comprehensive emergency obstetric care facilities, as most high-income countries have done; however, such models can be associated with unnecessary intervention and high costs; to support normal birth, provision of alongside midwifery-led units can be a good choice for many women, such units have the additional advantage that they eliminate the need for inter-facility emergency transfer, although they do not address bottlenecks around initial access
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The current indicator of skilled birth attendant coverage is a unidimensional and limited metric with which to characterise complex services; a more diverse range of indicators is needed to capture the nature and content of care being provided; these data are readily available
Our exploration of childbirth services presents evidence from 50 countries. We drew on academic literature, particularly reviews, and, for a subset of 29 LMICs, we conducted our own analyses (methods detailed in the appendix).