Improving Birth Outcomes Meeting the Challenge in the Developing World (2003) / Chapter Skim
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5. Improving Birth Outcomes Within Health Care Systems
5. Improving Birth Outcomes Within Health Care Systems
Pages 163-202
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PART 111 Improving Health Care Systems
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In order for these interventions to have the maximum impact on birth outcomes in large populations, however, they must be implemented within an effective health care system. As discussed in Chapters 2 and 3, the key requirements for reducing maternal, fetal, and neonatal mortality are skilled birth attendance and, for complicated deliveries, access to the appropriate level of essential obstetric and neonatal care (WorId Health Organization, 1999; Li et al., 1996~.
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Such trials are also complex owing to their multiple components and the involvement of several levels of government (Sorensen et al., 1998) Clearly the evidence base for improving birth outcomes within the health care systems of diverse countries would be strengthened by conducting RCTs of interventions in the systems in question.
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Skilled birth attendants can provide clean and safe deliveries and immediate postpartum care in homes or clinics. Postnatal
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Local services can easily be tailored to meet community needs and local participation in decisions on the delivery of health services increases the use of services, improves patient satisfaction and knowledge, and strengthens health care capacity. Since the risks for adverse birth outcomes are so high at the time of labor and delivery and the immediate postpartum period, the quality of care at that time becomes the major focus.
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169 ° ~ ~ E ~ o c, ~ ° - ~ ° ~ E ~ o E 3 -° ~ ~ ~ =, ~ ~ ' ° x by ~ O ~ O (L)
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It also involves transportation and communication capacity for referrals. Provider and community attitudes that can be major barriers to the use of skilled birth attendants and other health care services need to be overcome (Mathur et al., 1979; The Prevention of Maternal Mortality Network, 1992~.
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WITHIN HEALTH CARE SYSTEMS 171 rages where they are known and respected, professional care providers begin their work as strangers to a village. Partnerships with TBAs can facilitate the transition of a new midwife, who will need to show understanding and respect for local birth traditions that are not harmful (Koblinsky et al., 1999; Sibley et al., 2002~.
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and Rivera, 2002~. Model 3: Hospital/clinic birth with basic essential care Deliveries attended by skilled, experienced birth attendants can be furtner supported when they take place in hospitals or clinics that provide basic essential obstetric and neonatal care.
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As a result, health care providers and families became increasingly concerned with safety measures that improve childbirth outcomes. Even women at low risk began to choose a hospital birth (see Box 5-3~.
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In Jamaica and Sri Lanka, developing countries in which physicians attend about 15 percent of deliveries the approximate percentage of all births that involve potentially life-threatening complications (World Health Organization, 1994) maternal mortality has been considerably reduced (Graham et al., 2001~.
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These delays in recognizing the problem; deciding to seek care; getting to a facility that can provide it; and receiving appropriate treatment confront every medical emergency. Several determinants of the use of referral care may need to be addressed to increase referrals for complicated births, such as the ability of pregnant women and their families to recognize symptoms of complications (The Prevention of Maternal Mortality Network, 1992; Bloom et al., 1999~; distance to the referral facility (The Prevention of Maternal Mortality Network, 1992)
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, and in Kenya with a hospital emergency vehicle and radio contact with several health centers (Macintyre and Hotchkiss, 1999~. Transportation is needed for skilled birth attendants to deliver care to isolated populations.
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BUILDING CAPACITY FOR REPRODUCTIVE HEALTH CARE Access to quality reproductive health services is key to improving birth outcomes (Pittrof et al., 2002~. In developing countries, this involves building health care capacity in the form of facilities, equipment, supplies, andmost important personnel.
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Skilled birth attendants whether midwives, physicians, or nurses
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After receiving training in clean delivery practices and the recognition of complications, TBAs in the Gambia were initially found to have had a positive effect on maternal health, yet three years later, the maternal mortality ratio remained near 700 per 100,000 births (Greenwood et al., 1990~. Training of TBAs once thought to be an affordable way to reduce mortality during childbirth is no longer considered an effective investment of limited funding resources.
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are well positioned to collaborate on the establishment or expansion of surveillance and evaluation of birth outcomes. Government alliances with private health care providers whether forprofit or not-for-profit best serve the public interest when private providers offer a full range of priority services (e.g.
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Projects with direct and indirect effects on maternal health including family planning, primary health care, nutrition, training, and disease control represent about 12 percent of bilateral financing. Several private foundations support reproductive health programs; in recent years, the Bill and Melinda Gates Foundation has provided significant funding for maternal and child health.
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In Senegal, Zambia, and elsewhere, decentralization has improved delivery of general reproductive health services, but not those for more sensitive areas such as abortion, adolescent care, and HIV/AIDS prevention (Wilson, 2000; Population Council, 1998~. Sector-wide approaches focus on all components of health services, including maternal and neonatal health.
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The definition of key health problems is itself a process, which begins with the collection and analysis of data on health outcomes (in this case, adverse birth outcomes such as maternal, neonatal, or fetal mortality) in the community and comparison with standard populations.
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provides the foundation for identifying, prioritizing, and evaluating interventions to improve birth outcomes. Evaluation of services provides the basis for determining costeffectiveness and establishes benchmarks for continuing improvement.
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For example, in Argentina, Ecuador, Iran, Mozambique, Thailand, and Zimbabwe traveling registrars issue birth certificates. However, in several developing countries particularly those with the highest neonatal and fetal mortality rates few births are registered.
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For example, even the most widely accepted maternal mortality statistics the revised WHO/UNICEF/UNFPA estimates based on 1995 levels (WorId Health Organization, United Nations Children's Fund, United Nations Fund for Population Activities, 2001) which estimate 515,000 deaths per year worIdwide must estimate the total number of maternal deaths, because country data do not include mortality associated with indirect causes or related to abortions or ectopic pregnancies occurring earlier in gestation.
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workers collect data on pregnancies, live births, late fetal deaths, neonatal, and infant deaths from families and traditional birth attendants and assign a cause of death based on verbal autopsy. A retrospective population-based survey, performed every 6 months, indicates that 98 percent of births and childhood deaths are recorded.
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Cost of services Ideally, the budgeting and planning of reproductive health servicesand indeed, of health care in general in a particular setting would reflect the most cost-effective means of meeting significant population needs. However, despite wide recognition of the need for quality, cost-effective maternal and neonatal health care, little comparable "cost per outcome" information exists to aid in identifying priority services.
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Spread across entire populations of developing countries, a comprehensive package of maternal services that could avert 20 to 80 percent of maternal and neonatal deaths would cost an estimated US$1 to $4 per capita (Gelband et al., 2001~. Cost-effectiveness Since commitments of money, time, and intellectual effort to one health priority inevitably deplete resources for other health priorities, the choice among interventions needs to be based on sound evidence.
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In recent years, comparisons based on the DALY have improved countries' ability to assess health priorities, measure progress in health care delivery, and estimate the impact of conditions that, while they cause relatively few deaths, result in significant disability. DALYs have been calculated for five major causes of maternal mortality and morbidity (hemorrhage, puerperal infection, eclampsia, obstructed labor, and abortion)
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For health systems and maternal and child health programs, surveillance of maternal, fetal, and neonatal mortality provides the foundation for identifying, selecting, and evaluating interventions to improve birth outcomes. Fetal, early neonatal, and late neonatal, as well as maternal deaths must each be clearly defined to address the distinct causes of mortality for each of these populations.
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These include a skilled attendant at every birth; access to essential obstetric and neonatal services for every complicated delivery; and preconceptional, antenatal, and postpartum care that is affordable and effective. Additional maternal and neonatal health services can be added to an effective basic program according to the priorities and resources of countries.
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Adverse birth outcomes cannot be eliminated, even in countries with large health budgets. However, experience in virtually all industrialized countries and in many developing nations as well indicates that maternal, fetal, and neonatal deaths can be reduced considerably.
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1993. Traditional birth attendants and maternal mortality in Ghana.
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I The impact of trained traditional birth attendants on the outcome of pregnancy.
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1997. Characteristics of traditional birth attendants and their beliefs and practices in the Offot Clan, Nigeria.
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1979. The impact of training traditional birth attendants on the utilisation of maternal health services.
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1999. International maternal mortality reduction: outcome of traditional birth attendant education and intervention in Angola.
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:1091-1110. The Prevention of Maternal Mortality Network.
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2001. Maternal Mortality in 1995: Estimates Developed by VDHO, UNICEF, UNFPA.
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