Elsevier

The Lancet

Volume 388, Issue 10056, 29 October–4 November 2016, Pages 2193-2208
The Lancet

Series
The scale, scope, coverage, and capability of childbirth care

https://doi.org/10.1016/S0140-6736(16)31528-8Get rights and content

Summary

All women should have access to high quality maternity services—but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

Introduction

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

  • 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

  • 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

  • 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)

  • 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

  • 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

  • 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).

Section snippets

Where do births take place, and with whom?

As well as increases in skilled birth attendant coverage, some countries have increased facility deliveries at astonishing rates (appendix). The intersection between where births take place and with whom captures the endpoint of the paths women take in a given context (figure 1). A provider's designation (eg, midwife or obstetrician) should indicate skills, while a facility's designated level (eg, hospital, health centre, or health post) should signal its capability to provide certain elements

Are staff skilled?

Skilled staff are essential to provide high quality intrapartum care to each woman and newborn, are a determinant of facility capability, and a requirement for adequate home-based childbirth care (figure 1). Skills include the ability to communicate in a caring, respectful manner, plus the knowledge and technical skills to give appropriate, well-timed care.8, 9 Unfortunately, in many settings women receive neither; systematic reviews8, 9, 10, 11, 12, 13 show substantial disrespect and abuse,

What capability do facilities have?

To give high-quality intrapartum care, skilled staff require an enabling environment, and facilities that receive women at any time of day. Specialist back-up care should be part of the plan, via transfer to another facility if needed. Figure 1 designates facilities as capable of providing comprehensive or basic EmOC, or routine care only. Routine care is included for completeness because facilities should at a minimum be able to manage some complications, stabilise women, and guarantee

What does it take to access care?

Access to health services remains a challenge for women in many countries; in 2013, met need for skilled birth attendant delivery worldwide was 74%.1 A 2015 systematic review31 of met need for EmOC, an indicator that signposts women's use of facilities for complications (assuming 15% of all pregnancies will require such care), estimated that the percentage of women with complications who actually attended EmOC facilities was 21% in low-income settings and 32% in middle-income settings. Economic

Discussion

The MDG5 indicators of skilled birth attendant and antenatal care coverage are insufficient to characterise the maternal health-care systems of countries, or indicate the likelihood of achieving good outcomes. Unless other aspects linked to quality and timeliness, ensuring of respectful care and other elements of coverage are addressed, achievements towards improving maternal health could be overestimated. Policy makers need information to contextualise their countries along a number of

Conclusion

A powerful body of data is available to examine current configurations of childbirth care, and to begin to evaluate whether maternal services meet the needs of women. In view of the enormous range of contexts, we cannot recommend one configuration of care. These decisions need to be made locally and nationally. However, we can reiterate that facility deliveries only make sense if they can provide safe routine services, as well as basic EmOC and referral capability to guarantee women with

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