Strategies to improve maternal health

OONA CAMPBELL: I’m Oona Campbell. I’m an epidemiologist who’s worked on maternal health for the last 30 years, and in this step, I’m going to talk about what strategic approaches are available to improve maternal health. So what should we do? In this step, I’m going to focus on how we think about organising health services to provide such care, and I’m going to focus on delivering care rather than, say, antenatal or postnatal care. And here we can think about care for women that are experiencing emergencies or care that addresses all women.

An early strategy developed in the 1990s was the emergency obstetric care strategy, and this assumed that most births were uncomplicated, so it could happen at home safely, and that one needed to primarily worry about care for the 15% of births that might be complicated. The strategies involved trying to prevent complications in the home and trying to treat a limited number of complications in the home. But the main feature of this strategy was to refer women when they began to experience complications and to avoid the three delays. This slide shows a schematic of the emergency strategy, where most women are at home delivering and they stay there if nothing goes wrong.

But when things go wrong, we have the first emergency transport pathway where women go to a facility capable of providing basic emergency obstetric care, or they might go to a facility capable of providing comprehensive emergency obstetric care. And these are, roughly speaking, the equivalent of a health centre and health post respectively. In order for the emergency care strategy to work, we have to avoid the three delays. The first was the delay in deciding to seek care, the second is the delay in identifying and reaching an appropriate health facility, and the third is the delay in getting appropriate treatment once you arrive at the health facility. If you can do this, you then prevent maternal death.

So how do we avoid the three delays? Well, one way is when women are in the antenatal period to get them to prepare for the eventuality of having a complication. So that’s telling them to think about where they might go if they experience a complication and potentially save money to seek such care. It’s also about telling them what are maternal and newborn danger signs so that they can move more quickly, and also to tell them where they can find emergency transport and communication schemes.

In the actual case that women do experience emergencies, the kinds of things that help are when we have effective emergency transport, where there aren’t huge financial barriers so that when there’s user fee removals, but also using community finance for transportation and emergency treatment– and also trying to shift tasks so that the providers at the very lowest levels can actually manage complications. The second strategy is a different one, and this one focuses on all births, ensuring that all births take place with a skilled attendant, and this is mostly in health facilities.

Here, the focus is on all births, but also to ensure that there’s an enabling environment, facilities that can function and provide key elements of routine care and at least basic emergency care, if needed, but also facilities that can refer women to higher level facilities where they can get emergency care. There’s a great deal of interest as to whether women should all be in a health facility that can provide the most comprehensive emergency care, versus places that might be able to just provide some of the emergency care needed, but that can refer women, and also interest in ensuring that there’s routine care for newborns and the need to provide resuscitation and care for small and sick babies.

So this best bet strategy focuses on monitoring the woman and baby during labour and for 24 hours postpartum. The focus is on safety and primary prevention and respectful care. There is a focus also on early detection and basic management problems, and then treatment that can be provided at that level or referral elsewhere for an emergency. In this schematic, we look at the skilled birth attendant strategies. So in the first one, we see that women can actually go to be somewhere close to a health facility ahead of labour, and these places are often called maternity waiting homes.

But they need not be a formal structure– so it could be that you go to stay with a relative close to a hospital, if you live far away. Or you can seek to choose to deliver in a health facility that can provide routine care or/and comprehensive emergency obstetric care. For example, in the UK, most women would go to deliver– when they’re in routine labour without a complication– would go to a hospital where they might be cared for by a midwife, but where they could get comprehensive care and feeding. And there, the movement to get this comprehensive care is within the health facility.

In the second example, women go to a lower level facility that might be a birthing home or health centre, and there they could get routine care– but again, if complications happened, they could get basic emergency care in that health facility. But equally, they could be transported from a basic emergency obstetric care facility to a comprehensive facility. Something which happens is, in some settings, is that women go to health facilities that are not able to provide even the most basic emergency obstetric care. That sort of strategy that I think works very well, but in that case, again, you would be referring to women with complications to a hospital where they could get comprehensive care.

And a final approach is for the health provider to go and do a home birth– and that does happen successfully in some settings. It’s not very common. But again, the health provider, the midwife, or the doctor would then travel with the woman to a hospital, if emergency care was needed. The issues with a safe birth attendant strategy are first of all, is the care actually respectful and evidence-based, and does it safeguard normality? Or is there over-medicalization and over-intervention. Are the providers really skilled? So are they midwives and obstetricians in name only, or do they have the skills to both do normal childbirth, uncomplicated childbirth, and manage complications?

Do facilities have the right drugs, supplies, and equipment to provide the care needed? So even the most skilled providers can’t do very much in the absence of the right equipment and drugs. Are staffing levels sufficient and are staff their all the time? And does referral work from one level to the other– if you need to move from, for example, a health centre to a hospital? And our costs affordable or catastrophic? So does the need for emergency care, or even normal childbirth care, tip people into poverty? From my perspective, there’s clear merit in the second approach, which aims to ensure that all women are looked after, whether their births are uncomplicated or complicated.

But it’s also important to recognise that both of these strategies require other strategies and support to improve the coverage and quality of care. Some of these are within the health system, so we need strategies to help train, deploy, numerate, and motivate the human resources and task shift downwards so that people who live close to the community actually have the skills to provide good quality care. But we also need strategies around financing care, ensuring quality, and health information systems, so we can have data to monitor and evaluate our systems, and also leadership and governance. But we also need to think about the demand side– how do we ensure that we have community participation, women’s education, and also inter-sectional approaches?

For example, it’s almost impossible to imagine care which is of high quality and provides women with dignity if you don’t have water and sanitation within health facilities. And this is an example of an inter-sectional programme. Control of that doesn’t just happen within the service. So something that starts out with a very simple premise, which is how do we provide good delivery care, we can immediately see how this is embedded in a very complex web and context, and these are some of the things you’ll be learning about in subsequent steps.