Removing barriers to maternal health services

In the previous step we saw that many women do not access maternal health services when they need them, whether the pregnancy is complicated or uncomplicated. Here we consider some of the barriers that women may face in relation to accessing services, and current strategies to remove these barriers and increase demand for services.

What are the barriers?

Barriers to accessing maternal health services can take a variety of forms, such as:

• Geographic, including long travel distances, lack of transportation from remote areas, and difficult terrain
• Financial, whereby care may not be affordable, notably surgical care
• Social, for example community preferences, cultural norms and traditional attitudes that restrict women’s movement
• Individual, including lack of knowledge about the benefits of care, lack of information on services, pregnancy complications and childbirth, an experience of poor quality care or uneventful past deliveries
• Nature of labour, in that it can start at an unpredictable time and women may have difficulty moving.

Current strategies

Current strategies to increase access to these services include:

• Maternity waiting homes and ambulance services
• Reducing or removing user fees, cash transfers
• Birth preparedness and complication readiness
• Information, Education, and Communication (ICE) campaigns
• Respectful care
• Participatory learning and action cycles with women’s groups.

More information on some of these strategies is outlined under the following headings.

Maternity waiting homes

A maternity waiting home is a facility that is within easy reach of a hospital or health centre which provides emergency obstetric care. Women arrive in late pregnancy and wait for labour to start there. This strategy can address geographical barriers to access, and represents a very popular method in some countries. However, evidence on their effectiveness in improving maternal outcomes and on their sustainability remains of poor quality.

Reducing or removing user fees

User fees are payments made at the point of service by a patient. It was previously argued by the World Bank (1987)¹ that user fees would have a range of benefits, including improving efficiency and equity through increased health revenues, increasing quality and coverage by reducing unnecessary demand, and would shift focus towards primary healthcare services. However, it has since been claimed² that user fees do not offer these benefits, but instead place a higher burden on the poor and increase or sustain health inequalities. In relation to maternal health, reduction or removal of user fees would mean that women no longer pay directly to health facilities for delivery and emergency obstetric care. Some countries have opted to remove user fees through the introduction of insurance schemes or government subsidies.

This strategy can address the financial barriers to skilled birth attendance and emergency obstetric care; caesarean sections can be very expensive and impoverish women and their families. Skilled birth attendance generally increases after removal of user fees, but attributing such a change to the policy is often challenging. The quality of implementation is critical.

Birth preparedness and complication readiness (BP/CR)

BP/CR is the process of planning for birth and anticipating the actions needed in case of an emergency. It is implemented during antenatal consultations with providers and/or as part of health promotion activities at home and in the community.

BP/CR addresses the barrier relating to the nature of labour, with a focus on improving knowledge. There is good evidence that health promotion activities at home and in the community improve neonatal survival, although the evidence is less clear for maternal survival.³

Respectful care

Respectful care means ensuring that women receive the “highest attainable standard of health, which includes the right to dignified, respectful health care throughout pregnancy and childbirth, as well as the right to be free from violence and discrimination.”⁴

A perceived lack of quality care represents an individual barrier, and there is evidence to suggest⁵ that women can ‘vote with their feet’ if they perceive poor quality of care in facilities. Research is underway to find the best approach to ensure respectful care. This concept is discussed further in Steps 3.12 and 3.13.

Women’s groups

Women’s groups are a community mobilisation technique in which women come together to collectively decide on priority actions. Decisions made in these groups can address all types of barriers.

Research has shown that under certain circumstances women’s groups are associated with a reduction of neonatal mortality.⁶ This may also be the case for maternal mortality, but the evidence is less strong.