Three Ways to Improve Maternal Health: Reflections from South Asia

Three Ways to Improve Maternal Health: Reflections from South Asia

 {Photo credit: Emily Phillips/MSH Afghanistan}A postnatal woman with her newborn and mother-in-law.Photo credit: Emily Phillips/MSH Afghanistan

Last month I represented Management Sciences for Health (MSH) at Oxfam India’s South Asia Consultation on Maternal Health in Kathmandu, Nepal. The purpose of the meeting was to discuss significant maternal health programming experiences in Afghanistan, Bangladesh, India, Nepal, Pakistan, and Sri Lanka, and to suggest strategic directions for Oxfam India’s future maternal health programming. More than 30 representatives from governments, national and international universities, and nongovernmental organizations attended.

Three elements of improving maternal health outcomes stood out in my mind from discussions at the meeting:

1. Systematic use of data for collecting, reporting, analyzing, and decision making

First, it is critical to accurately count and report maternal deaths. It is equally important to use this information to support decision-making processes aimed at improving maternal outcomes. Sri Lanka is the perfect example. Since the 1950’s, maternal deaths have been recorded by health facilities. In 1970, the Government initiated a nationwide maternal death surveillance system and began using all this information (at health facility, local, and national levels) to identify gaps in health service delivery, to analyze their causes, and to allocate resources to remedy this situation.  

For example, if the data showed that the majority of women in a subnational area of the country were dying from postpartum hemorrhage, the government focused on the prevention and treatment of this condition during future training and supervision activities of its health providers, and on providing them the needed supplies, drugs and equipment. This systematic process of data collection, analysis, and decision making takes place annually and has been instrumental in decreasing Sri Lanka’s maternal mortality ratio to its current (and very low) 33 deaths per 100,000 live births.

The World Bank’s forthcoming Global Financing Facility (GFF) will provide more than $4 Billion to more than 60 low- and middle-income countries to reduce disease and death during adolescence, maternity, neonatal period, and childhood. Informed by the Sri Lankan and similar experiences, the GFF is prioritizing the strengthening of birth and death registration systems as one of its core program strategies.

2. Task shifting

Task shifting improves obstetric outcomes. In Afghanistan, the limited number of female health providers has been a significant obstacle to improving the coverage of maternal and reproductive health services. In response, with the support of international donors, the Ghazanfar Institute of Health Sciences and the Afghan Government established a community midwifery training school in each of 14 provinces. MSH provided technical assistance to these local organizations through its US Agency for International Development (USAID)-funded Leadership, Management and Governance (LMG) project.

Different from professional midwifery training, which takes three to five years, community midwives are trained for 18 months using a hands-on curriculum approved by the Government. They are officially accredited by the Government to perform antenatal care, delivery, identify some obstetric emergencies, and refer other emergencies for higher level care. The government and schools select students from areas in need of skilled midwives and students are expected to return to these localities after graduations.

Studies by Dr. Linda Bartlett, Associate Scientist at the Johns Hopkins Bloomberg School of Public Health, show that in provinces benefitting from these schools, approximately 90 percent of graduates worked in their assigned places and they contributed to a 39 percent increase in antenatal care and a 63 percent increase in delivery by a skilled attendant.

Bartlett and I presented on the epidemiology, programming, and challenges and opportunities surrounding maternal health care in Afghanistan at the Nepal meeting.

3. Respectful maternal care

Third, when women feel disrespected by health care providers, they are less likely to seek care. A direct way to ensure respectful and non-discriminatory care, and therefore increase women’s use of services, is to influence the behavior of the organization that hires and fires them.

The governments of Sri Lanka and the Indian State of Tamil Nadu provide good examples of leaders who clearly set high expectations for respectful and non-discriminatory care. To communicate these expectations, both governments issued a Charter of Patient Rights, which was widely disseminated to health providers  and the population and also posted at health facilities. Some facilities also developed simple, yet highly effective, mechanisms such as a phone hotline that patients could use  to report health providers’ inappropriate behavior.

But the most important element of this response (and unfortunately, the least likely to be consistently implemented) was the employer’s quick, fair, and transparent response to reports of poor behavior. Employers’ quick responses, communicated to both the employee and the client, reaffirmed their commitment to patients’ rights and set precedent for future responses to clients’ concerns.

In cases when this response was delayed or non-existent, some patients took matters into their hands and reported inappropriate behavior to the press. In many cases, the resulting scandal elicited the desired reaction from the employer.

Supporting better maternal care

Systematic use of data, task shifting, and respectful maternal care are three ways that civil society, governments (as employers of health providers), and the international development community can support better maternal care. They are also consistent with USAID's maternal health vision, Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action Evidence for Strategic Approaches (PDF).

MSH applies these best practices in our maternal care programming, which spans the lifecycle from preconception through pregnancy, postpartum, and preconception -- again, with an emphasis on integrated, respectful services and continuum of care -- starting at the community level.

We’ll share more about our comprehensive approach to maternal care on this blog and in the March 2015 issue of the Global Health Impact Newsletter (subscribe).

More on MSH's work in Asia