Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions

Abstract

Background: Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth.

Methods: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care.

Results: Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships.

Conclusions: Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery.

Figure 1

Labour and birth packages by level of care. * Ongoing process to define newborn care interventions by level of care. Comprehensive emergency obstetric care image source: Karen Kasmauski/MCSP. Basic emergency obstetric care image source: K. Holt/Jhpiego. Home/community level image source: K. Kasmauski/Jhpiego.

Figure 2

Very major or significant health system bottlenecks for labour and birth. NMR: Neonatal Mortality Rate *Cameroon, Kenya, Malawi, Uganda, Bangladesh, Nepal, Vietnam. **Democratic Republic of Congo, Nigeria, Afghanistan, India, Pakistan. See additional file 2 for more details. Part A: Grading according to very major or significant health system bottlenecks for skilled birth attendance as reported by twelve countries combined. Part B: Grading according to very major or significant health system bottlenecks for basic emergency obstetric care (BEmOC) as reported by twelve countries combined. Part C: Grading according to very major or significant health system bottlenecks for comprehensive emergency obstetric care (CEmOC) as reported by twelve countries combined.

Figure 3

Individual country grading of health system bottlenecks for labour and birth. Part A: Heat map showing individual country grading of health system bottlenecks for skilled birth attendance (SBA) and table showing total number of countries grading significant or major bottleneck for calculating priority building blocks. Part B: Heat map showing individual country grading of health system bottlenecks for basic emergency obstetric care (BEmOC) and table showing total number of countries grading significant or major bottleneck for calculating priority building blocks. Part C: Heat map showing individual country grading of health system bottlenecks for comprehensive emergency obstetric care (CEmOC) and table showing total number of countries grading significant or major bottleneck for calculating priority building blocks. DRC: Democratic Republic of the Congo.

Figure 4

Health system strengthening for improving maternal and newborn health service delivery in Tamil Nadu, India. GIS: geographical information systems. FRUs: first referral units. CEmOC: comprehensive emergency obstetric care. CHCs: community health centres. PHCs: primary health centres. MCH: maternal and child health.

Figure 5

Malaysia's approach to improving the quality of maternal and newborn health. CEMD: Confidential Enquiry into Maternal Deaths

Figure 6

Key messages and key action points for quality essential care during labour and birth. SBA: skilled birth attendant. BEmOC: basic emergency obstetric care. CEmOC: comprehensive emergency obstetric care.