The untold story: how the health care systems in developing countries contribute to maternal mortality

Abstract

This article attempts to put together evidence from maternal mortality studies in developing countries of how an inadequate health care system characterized by misplaced priorities contributes to high maternal mortality rates. Inaccessibility of essential health information to the women most affected, and the physical as well as economic and sociocultural distance separating health services from the vast majority of women, are only part of the problem. Even when the woman reaches a health facility, there are a number of obstacles to her receiving adequate and appropriate care. These are a result of failures in the health services delivery system: the lack of minimal life-saving equipment at the first referral level; the lack of equipment, personnel, and know-how even in referral hospitals; and worst of all, faulty patient management. Prevention of maternal deaths requires fundamental changes not only in resource allocation, but in the very structures of health services delivery. These will have to be fought for as part of a wider struggle for equity and social justice.

PIP: Examination is made of the "avoidable factors" in maternal mortality based on the standards realistic under prevailing country conditions: patient factors or inaccessible health services and failures in the health services delivery system. Patient factors are defined as those actions by the patient that are faulty: delayed arrival or nonarrival at a health facility, failure to seek legal abortion or interference with pregnancy, nonuse of prenatal care, and transportation problems. Problems that jeopardize survival chances are also quality of care issues of "doing too little, too late." Conditions in the health services delivery system which exacerbate a woman's condition are shortage of trained personnel, lack of equipment and supplies, and poor patient management. Prevention and control of maternal mortality is dependent on structural factors and women's resources such as their time, money, information they have, and their authority over decision making. Action must be taken by health activists to make fundamental changes in both the structure and delivery of health services. There must be a call for reallocation of national resources to the health sector of which a significant proportion should be directed to the health care of women and, specifically, maternal mortality. 5% of gross national product is the usual expenditure for health by most developing countries, and 50% is devoted to primary health care and a very small amount to maternal and child health. Women's health regardless of maternal status needs attention, but not at the expense of maternal health care. Community level resources need enhancement, so that women have access close to their homes. Proper resource allocation also means equipping the 1st referral levels with necessary supplies, equipment, and personnel. 5% of maternal mortality would be reduced with the availability of 8 surgical functions identified by WHO for health facilities serving populations of 100,000. Training nurse practitioners and midwives is a viable option for complicated deliveries. Innovations such as "waiting shelter" for high risk women in need of transport are creative and use scarce resources to best advantage. Health services must be socially accountable with careful record keeping and public accessibility of records. The deprived section of society should be empowered and participate in the changes.