Barriers to accessing adequate maternal care in Central and Eastern European countries: A systematic literature review

https://doi.org/10.1016/j.socscimed.2017.01.049Get rights and content

Highlights

  • Skilled professionals, up-to-date care and equipment are lacking in CEE.

  • Distance and travel costs to facility is a barrier mostly in remote areas.

  • Care is often expert-centered with poor attitude towards patients.

  • Women are lacking information, autonomy and trust of medical doctors.

  • Major barrier is the inability to pay the high (in)formal payments.

Abstract

Maternal health outcomes in Central and Eastern Europe (CEE) compare unfavorable with those in Western Europe, despite macro-indicators that suggest well-designed maternal care systems. However, macro-indicators at the system level only capture capacity, funding and utilization of care and not the actual allocation of financial and human resources, the quality of care and access to it. It is these latter which are problematic in the CEE region. In this study service-related indicators of access to maternal care in CEE are examined. These include availability, appropriateness, affordability, approachability and acceptability of maternal care.

This study uses a qualitative systematic literature review, analyzing information of peer-reviewed articles published since 2004. Other inclusion criteria included language, setting and publication purpose. The included articles were analyzed using a framework analysis technique and quality was assessed using standardized evaluation checklists.

Results indicate improvements in maternal care. However, availability of care is limited by outdated equipment and training curricula, and the lack of professionals and pharmaceuticals. Geographical distance to healthcare institutions, inappropriate communication of providers and waiting times are the main approachability barriers. Some mothers are unaware of the importance of care or are discouraged to utilize healthcare services because of cultural aspects. Finally, a major barrier in accessing maternal care in the CEE is the inability to pay for it.

Our findings indicate that major gaps in evidence exist and that more representative and better quality data should be collected. Governments in CEE countries need to establish a reliable system for measuring and monitoring a suitable set of indicators, as well as deal with the general social and economic problem of informality. Medical curricula in the CEE region need to be overhauled and there should be a focus on improving the allocation of medical staff and institutions as well as protecting vulnerable population groups to ensure universal access to care.

Introduction

The maternal mortality ratio (MMR) in the WHO European Region compares favorably with that in other parts of the world, such as South-East Asia and Africa (18 versus 190 and 500 maternal deaths per 100,000 live births respectively, estimates for 2013) (WHO, 2014). This aggregated indicator however masks substantial disparities across the European countries and hides the relatively high rates in Central and Eastern European (CEE) countries (UN, 2011, UNFPA, 2009). In Albania, Armenia and Georgia, the MMR estimates for 2013 amount to 30–40 maternal deaths per 100,000 live births (WHO, 2014). Within the European Union (EU), the MMR in countries such as Hungary, Latvia and Romania is about 2–4 times higher than the EU average (estimated to be 8 maternal deaths per 100.000 live births in 2013) (WHO, 2014). A higher MMR not only indicates the more frequent occurrence of a tragic event but also suggests shortcomings in the maternal care system (Bouvier-Colle et al., 2012, Wildman et al., 2004, Maruthappu et al., 2015).

Despite the higher maternal mortality in much of the CEE region compared with Western Europe, many macro-indicators of maternal health care are similar and seem to suggest that maternal care systems in CEE countries are well-resourced. Macro-level indicators provide a broad picture of health through aggregate measures that are useful in monitoring health trends and inequalities (Masseria et al., 2007). CEE countries score well on macro-indicators such as coverage of prenatal care (more than 95% of the pregnant women having at least one visit to a prenatal care provider), presence of a skilled attendant at birth (virtually always) and adequate availability of emergency obstetric care (on average 4 facilities per 500,000 inhabitants) (UN, 2011, UNFPA, 2009). CEE countries also spend more on health care than many low-income countries elsewhere in the world. The contradiction between the relatively high MMR and seemingly favorable health system indicators in the CEE region is not surprising since the above indicators only enumerate capacity, funding and utilization of maternal care, but provide no information on the quality of care and the barriers to access, which have been identified as major problems in CEE countries (UNFPA, 2009).

Another drawback of the macro-indicators in the CEE region concerns misreported or underreported data (Wilmoth et al., 2012, UNFPA, 2009). Owing to this, the real situation in the CEE maternal care systems cannot be fully understood if only macro-indicators are taken into account. The use of micro-level indicators of service quality and access is needed in addition to macro-level indicators for a comprehensive assessment of healthcare provision, not only in the CEE region but also worldwide (Kelley and Hurst, 2006, WHO, 2006, WHO, 2011).

This study analyzes the barriers to accessing adequate maternal care in CEE countries. For this purpose, it systematically reviews the empirical evidence on this topic from 2004 to 2016. Following the framework of Levesque et al. (2013), we distinguish five aspects of access:

  • -

    availability, which reflects the geographical location, distribution and number of healthcare service points, opening hours, services or providers that the patients can choose from;

  • -

    appropriateness, which refers to the technical and professional aspects of care and their adequacy, i.e. what services are provided and how they are provided;

  • -

    affordability, which refers to patient payments, including various types of out-of-pocket payments, but also indirect payments that make care less affordable and limit access to services;

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    approachability, which reflects the awareness of service availability, transparency and information regarding available treatments and services;

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    acceptability, which refers to cultural, traditional and informational aspects that determine whether institutionalized care is accepted by individuals, as well as whether and how often the care being available, accessible and affordable will be demanded.

We systematically searched for empirical studies on maternal care in CEE countries that cover at least one of the above aspects of access. The countries selected for this review are the countries of the WHO European region located in CEE, but excluding the Central Asian countries because of their specific organization and outcomes in maternal care. Thus, the review includes Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Georgia, Hungary, Latvia, Lithuania, Kosovo, Macedonia, Moldova, Montenegro, Poland, Russian Federation, Serbia, Slovakia, Slovenia and Ukraine. The five aspects of access are used as themes according to which we extracted and classified relevant information from the publications included in the review. Thus, the study provides evidence to understand the shortcomings in CEE maternal care systems and in particular the barriers to access that exist in this region. This topic has not been addressed in a systematic literature review before. It also identifies gaps in our knowledge on maternity care in the CEE region. Finally, the review might help in defining access-related indicators for the assessment of maternal care provision not only in CEE countries but also in other parts of the world.

Section snippets

Methods

This study applied the method of a qualitative systematic literature review to outline the evidence on access to maternal care in CEE countries. By identifying and synthesizing the available evidence based on the framework outlined above, this study design allowed us to gain in-depth insights into the complex problem of accessing adequate maternal care in CEE countries and to outline research gaps in the field.

For the selection of relevant publications, a systematic approach was followed. The

Results

The literature search in May 2014 yielded an initial list of 357 articles in PubMed that provided 29 relevant articles after the first screening of title and abstract. After the second screening based on the full text, 15 articles were retained. The search in the other databases also provided some relevant publications: EBSCO HOST - CINAHL plus (7 out of 57 articles), Global Health database (9 out of 63 articles), Popline database (2 out of 12 articles), EMBASE (10 out of 174 articles).

Discussion and conclusions

The evidence obtained through our systematic literature review on barriers to accessing adequate maternal care services in CEE countries indicates a variety of access-related problems. These include problems with reaching the healthcare facility due to distance, poor and derogative attitudes of providers of maternal care and waiting times. Furthermore, there is a lack of evidence-based care and in some instances, outdated equipment and lack of pharmaceuticals. In some CEE countries, access is

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