The huge majority of the annual 6.3 million perinatal deaths and half a million maternal deaths take place in developing countries and are avoidable. However, most of the interventions aiming at reducing perinatal and maternal deaths need a health care system offering appropriate antenatal care and quality delivery care, including basic and comprehensive emergency obstetric care facilities. To promote the uptake of quality care, there are two possible approaches: influencing the demand and/or the supply of care. Five lessons emerged from experiences. First, it is difficult to obtain robust evidence of the effects of a particular intervention in a context, where they are always associated with other interventions. Second, the interventions tend to have relatively modest short-term impacts, when they address only part of the health system. Third, the long-term effects of an intervention on the whole health system are uncertain. Fourth, because newborn health is intimately linked with maternal health, it is of paramount importance to organise the continuum of care between mother and newborn. Finally, the transfer of experiences is delicate, and an intervention package that has proved to have a positive effect in one setting may have very different effects in other settings. L’accès aux services de santé maternelle et périnatale: leçons tirées d’exemples réussies et moins réussies de l’amélioration de l’accès à un accouchement et à des soins sûrs pour le nouveau-né L’immense majorité des 6,3 millions de décès périnataux et du demi-million de décès maternels surviennent dans les pays en développement et sont évitables. Cependant, la plupart des interventions visant à réduire la mortalité périnatale et maternelle ont besoin d’un système de soins de santé offrant des prestations de soins prénataux appropriés et de qualité, y compris des services complets de soins obstétriques d’urgence de base. Afin de promouvoir l’adoption de soins de qualité, il y a deux approches possibles: influencer la demande et/ou l’offre de soins. Cinq leçons ont été dégagées de certaines expériences. D’abord, il est difficile d’obtenir des preuves solides des effets d’une intervention particulière dans un contexte où ils sont toujours associés à d’autres interventions. Deuxièmement, les interventions ont tendance à avoir des impactes relativement modestes à court terme quand elles ne visent qu’une partie du système de santé. Troisièmement, les effets à long terme d’une intervention sur l’ensemble du système de santé sont incertains. Quatrièmement, comme la santé du nouveau-né est intimement liée à celle de la mère, il est d’une importance primordiale d’organiser la continuité des soins entre la mère et le nouveau-né. Enfin, le transfert d’expériences est délicat et une trousse d’intervention qui s’est avérée positive dans un contexte peut avoir des effets très différents dans d’autres contextes. Punto de vista Acceso a servicios maternos y perinatales: lecciones de ejemplos exitosos y menos exitosos en la mejora del acceso a un parto seguro y cuidados neonatales La gran mayoría de las 6.3 millones de muertes perinatales y el medio millón de muertes maternas suceden en países en vías de desarrollo y son inevitables. Sin embargo, la mayoría de las intervenciones que buscan reducir las muertes maternas y perinatales requieren de un sistema sanitario que ofrezca unos cuidados prenatales apropiados y unos cuidados de calidad durante el parto, incluyendo el acceso a instalaciones obstétricas básicas y de emergencia. A la hora de promover la mejora del servicio hay dos posibilidades: influenciar la demanda y/o la oferta de cuidados. Se obtuvieron cinco lecciones como resultado de las diferentes experiencias. Primero, es difícil obtener una evidencia robusta de los efectos que tiene una intervención en particular dentro de un contexto en el cual siempre hay otras intervenciones asociadas. Segundo, las intervenciones tienden a tener impactos con ventanas de tiempo relativamente cortas cuando solo han sido dirigidas hacia una parte del sistema sanitario. Tercero, los efectos a largo plazo de una intervención, sobre todo en el sistema de salud, son inciertos. Cuarto, puesto que la salud neonatal estáíntimamente ligada a la salud materna, es muy importante ligar los cuidados continuos de la madre y del neonato. Finalmente, la transferencia de experiencias es delicada y un tipo de intervención que ha tenido un efecto positivo en un lugar puede tener efectos muy diferentes en otro. Every year worldwide there are over 6.3 million perinatal deaths and between 343 000 and half a million maternal deaths (Stanton et al. 2006; WHO 2006; Hill et al. 2007; Hogan et al. 2010). In particular, 98% of perinatal deaths and 99% of maternal deaths take place in developing countries and are avoidable. Early neonatal deaths (in the first week of life) and fresh stillbirths (occurring during delivery) have similar obstetric origins. That makes perinatal mortality an indicator of the availability and quality of obstetric and paediatric care and of maternal health and nutrition (WHO 2006; Fauveau 2007). The medical causes of perinatal and maternal deaths are known and effective treatments exist. Evidence-based effective and cost-effective interventions for reducing the burden of stillbirths (Darmstadt et al. 2009; Haws et al. 2009; Menezes et al. 2009; Yakoob et al. 2009), of neonatal deaths (Darmstadt et al. 2005) and of maternal deaths (Campbell & Graham 2006) have recently been reviewed. Most of the interventions need a health care system offering appropriate antenatal care and quality delivery care, including basic and comprehensive emergency obstetric care facilities. The challenge in low-income countries is to deliver both high coverage and high-quality care, and thus to reduce financial and geographical barriers to access to maternal and perinatal health services. Improving access to maternal and newborn quality care does not guarantee a positive effect on maternal and newborn health outcomes but is reasonably considered as a contributing action to this goal, along with education and socioeconomic development. Bhutta et al. (2009) categorised 5 interventions with a high level of confidence (according to the strength and quality of evidence) for wide-scale delivery and nine additional interventions with some evidence of impact (Table 1). However, some of the evidence-based interventions are already included in the ‘antenatal care’ package – screening and treatment of syphilis, the diagnosis and treatment of reproductive tract infections, immunisation with tetanus toxoid, malaria prophylaxis in endemic areas and nutritional support (Darmstadt et al. 2005). Regarding delivery, interventions that save the newborn life are included in the intrapartum care package, including identification and management of malpresentation and prolonged labour, the use of resuscitation techniques for asphyxiated infants, proper management of neonatal sepsis and other infections, skin-to-skin Kangaroo Care for pre-term infants and immediate and exclusive breastfeeding for all children (Anonymous 1999). Evidence-based interventions for maternal health consist of a long list of unfinished actions (Campbell & Graham 2006). A shorter list of essential interventions for maternity care in low-resource countries was recently defined by FIGO (2009). In short, the principle is to offer quality pre-natal, intra-partum and post-partum care by skilled health personnel at the first level (basic essential obstetric care), backed up by an effective and affordable referral system including hospital for delivering timely comprehensive essential obstetric and perinatal care. However, even if there is a relatively strong consensus on effective interventions in the international organisation spheres and among academic staff, this is not necessarily the case in countries. Indeed, there is still a huge number of clinical staff who are not informed on or not convinced by the evidence, or who do not comply with evidence-based interventions for various reasons (Khalil et al. 2005; Harvey et al. 2007; Richard et al. 2008a; Waiswa et al. 2008; Karolinski et al. 2009; Mfinanga et al. 2009; Stanton et al. 2009; Turner & Short 2009). If the appropriate interventions regarding the reduction of maternal and perinatal mortality, as well as the types of strategies in which they should be included, are relatively well-defined today, their implementation remains a challenge. To promote the uptake of appropriate care (i.e. effective and delivered with quality), there are two possible approaches: influencing the demand and/or the supply of care (Figure 1). In this article, demand-side interventions are defined as those that operate at the individual, household or community level (Ensor & Cooper 2004). Supply-side interventions are those that influence the health service actors, be they individual health personnel, health institutions or ministries of health. Possible interventions influencing the demand or the supply side for reducing maternal and perinatal mortality. There are necessarily interactions between supply- and demand-side interventions. For example, maternity waiting homes are considered as ‘supply’, because they improve access to maternal health care. However, they will achieve their objective only if they attract women living in remote areas (demand creation). There is a link between barriers to seek care (financial, geographical, perception of staff, poor attitude and low perceived quality of care) and the extent and the quality of supply (distribution and qualification of staff, basic and continuing training, outreach services, capacity to reach all the communities, capacity to adapt to the local culture). Both are important – a high coverage of poor pregnancy and delivery care is not necessarily better than an excellent but barely accessible health service. However, quality of care should be first developed, because it would not be ethical to improve access to known bad health services. In 2001–2005, Family Care International (FCI) implemented a complex intervention, called the Skilled Care Initiative (SCI), in Ouargaye, a poor district located in south-eastern Burkina Faso (Family Care International 2005). SCI consisted of two main interventions: improving the availability and quality of maternity care at referral, mid- and lower-level facilities; and promoting service utilisation through behaviour change communication, counselling and community mobilisation. A quasi-experimental design was used to assess the extent to which the SCI was associated with increased institutional births and maternal and perinatal mortality reduction in the intervention district (Ouargaye) versus the comparison district (Diapaga) (Graham et al. 2008). In 2004–2005, after a phase of supply improvement, SCI extensively developed the community mobilisation in Ouargaye. Community mobilisation aimed at increasing the use of quality delivery care through four axes: (i) advocacy and awareness raising; (ii) social marketing; (iii) behavioural change communication and (iv) community capacity strengthening. The evaluation showed that the main significant difference between Ouargaye and Diapaga districts was the scope and intensity of the community-based interventions implemented in Ouargaye. There was a temporal association relationship before and after the implementation of the demand-driven interventions with a 30% increase in institutional births in the intervention district compared to 10% increase in comparison district (Figure 2) (Hounton et al. 2009). Trends of institutional births in Ouargaye and Diapaga, Burkina Faso, 2001–2005. Source: Hounton et al. 2009. At the end of the 20th century, there was a renewed interest in poverty and equity in health. In 1990, Demographic and Health Surveys included an indicator of the households’ wealth, and these data were progressively used by researchers to show the association of poverty with health coverage and outcomes. The World Bank health, nutrition and population strategy, adopted in 1997, focussed on improving the health of the world’s poor (Gwatkin 2000). The first publications in relation to wealth and access to obstetric care showed the enormous size of the poor–rich gap in many countries (Kunst & Houweling 2001). This gap is more important for antenatal care and professional delivery care than for the treatment for acute respiratory infection (ARI), diarrhoeal diseases or immunisation (Houweling et al. 2007). In the poorest countries, most of the women living in rural areas have little access to caesarean sections. In 16 countries of sub-Saharan Africa, caesarean section rates in rural poorer women do not reach 1% (and in 10 of these countries rates are lower than 0.5%) (Ronsmans et al. 2006).With the familial technique developed in 2004, it is possible to explore the relationship between maternal mortality and poverty and to examine the poor–rich gap (Graham et al. 2004). The first results point to the magnitude of the gradient between the poorest quintile (e.g. in Peru, 800 maternal deaths per 100 000 live births) and the richest quintile (130 per 100 000). Part of this is explained by the lack of access to antenatal and delivery care (Ronsmans & Graham 2006). Financial barriers are increasingly seen as one of the main barriers to access to emergency obstetric and perinatal care (Richard et al. 2008a,b). In response, quite a few initiatives have emerged at local or national level in Asia, Africa and Latin America. Case studies of experiences such as cost sharing mechanisms in Burkina Faso (Ouédraogo et al. 2008), obstetric risk insurance in Mauritania (Renaudin et al. 2007), focussed community health insurance in Guinea (Ndiaye et al. 2008), fee exemption strategies in Ghana (Witter et al. 2007), Senegal (Witter et al. 2008) and Bolivia (Pooley et al. 2008), vouchers and health equity funds in Cambodia (Por et al. 2008) and conditional cash assistance in India (Devadasan et al. 2008) have all shown some degree of success in improving access to maternal and perinatal care. But again, all these strategies need supply-side efforts to increase quality and organisation of care to work. The principle of a voucher scheme is to give selected persons (e.g. poor women) a voucher that entitles them to specified free services. In the case of safe motherhood, vouchers cover, for instance, antenatal care to delivery and post-partum for women and In a voucher scheme was implemented in in districts of with a Health scheme and a supply-side The was to promote access to were to in at the community level or at the hospital level through poor or support from the for the cost of and other during were to be the voucher management women were by local health and staff at their through The voucher for for delivery and for care. The voucher entitles the (i) for antenatal care, delivery and care at the health (ii) referral from the health to referral hospital in case of and (iii) free antenatal care, delivery and care at the health (Por et al. 2008). the results in of In the and the scheme were – only of the births – and of still place at In the voucher scheme and of The of institutional increased up to the of women from to In the voucher scheme of and the the coverage of institutional increased up to (and was to This is a in than However, it is considered that of the population is for a the of was of the number of poor The that most of the women who from the used a for delivery for the first in by of Source: et al. 1990, the districts of have 000 living in rural health services to services in most districts and are by and by the for In the of and a to and population health services in the The of of health system and and of by the health The support to the district health service & 2006). This a quasi-experimental design with data on and population and health services before and after the of services in the health system. a of the effect of a supply-side from health that were better better and with more skilled In the case of referral to the district care was by the to the in case of from immediate and free of to the district For the before the rates of obstetric interventions for were for than at In district of the districts where the number of is the of the district rates of obstetric intervention were for than for and the maternal mortality was in than in per 100 000 births that obstetric interventions were effective in & 2004). the after the implementation of the the of for for at it increased in the population to the the per cost of health care was for the than the population because health services are by staff of professional and because and are more and used in et al. 2007). However, at a cost of for the of reproductive health services coverage of 99% for the package, of for institutional delivery, at a of for caesarean and with a possible effect of a maternal mortality this still a for A scheme or for to increase the of health services for a defined of through the financial of health health institutions or on a of and thus the that health will to financial success on the selected – and will – the system & 2009). In a of have been including of health to achieve including This was in districts in and up from et al. 2006; et al. The institutional for the has four of and (i) health staff who deliver the (ii) the (iii) the or district in of in with the health the health and to the (iv) the (in of quality and et al. 2006). The health is through a of (e.g. number of number of number of women to of tetanus et al. 2007). are from the health that are for the of services to a fee for a list of services, by a quality et al. has been a increase in institutional over et al. 2008). to coverage has been increased from of births in to in mortality has been over this from per live births in to in and in de la de la & International 2008; de la & International 2009). mortality has been on a from per births in to in to in and to in should be that the have been through a of including in the management of a increase in community health insurance and to In on health care has was to other of the health care system delivery such quality mechanisms including of the health of the and of the various and continuing from the to health is thus difficult to the effect of a financial from the associated of of the case studies was an they were as a intervention at the the Skilled Care Initiative or the obstetric risk insurance in or a intervention was implemented in a where other interventions were already in place a few voucher scheme in all interventions in the have and supply-side Indeed, it is difficult to a demand-side intervention when the supply side is not it would be in a supply-side intervention community would not be very and would health personnel would their The is that there is The of an intervention on the and the intensity of the it the on exemption for delivery care in Ghana a modest impact on access to care, with an increase in and a increase in the et al. 2007). for this modest increase in utilisation be the that even for the delivery fee the reduction in cost for was not to from to and from to et al. 2008). The other was the poor quality of care both before and after the exemption et al. 2007). The the impact of a intervention on the whole health system. change in the health and and to extent a to improve access to care has a or a positive effect on other of the health system. For example, the to in Africa access to services but at the of some services, including antenatal care et al. 2001). is the to for caesarean section the effect of increasing the for a for the staff or the hospital to the of and/or (Ouédraogo et al. 2008; et al. 2008). In the impact of the health system should be The is the importance of an to perinatal newborn health is intimately linked with maternal health. health staff should all and for the and and not only for one of evidence-based of care have been defined at different of clinical care at hospital and outreach services and and community care et al. 2007). are not and are all known by the health personnel and by their ministries of health. However, their implementation is not The is the transfer of experiences. intervention package that proved to have a positive effect in one setting may have very different effects in other settings. For example, conditional cash have been a success in Latin et al. et al. 2006; et al. but are in a different in India where results are The scheme to have to increased institutional but with different effects to the because of in the in some of the funds (Devadasan et al. 2008). barriers to access to maternal and perinatal services is a of This has to be on a strategy, on an appropriate between demand-side and supply-side interventions implemented on the long with to be to the The for of the on interventions perinatal mortality.
No takes yet. Share an insight, caveat, or question.
Brouwere et al. (2010) studied this question.
Synapse has enriched 3 closely related papers on similar clinical questions. Consider them for comparative context: