I wrote a piece about prenatal care as I read the brief wrong, as it is already written I am posting it in case anyone is interested in the topic anyway.
How to improve the quality of prenatal care and facility-based delivery services in low income countries
A widely accepted ambition of programmes which are being distributed across the world is to improve child wellbeing. To do so a high level of quality must be maintained when implementing interventions in low income countries. One major area in need of focused attention is the quality and accessibility of prenatal care and facility-based delivery services (FBDS).
The impact of prenatal care and FBDS
Home births, as opposed to facility-based births, are prevalent in low income countries [1]. Home births are often preferred due to convenience, however unsanitary conditions and a lack of skilled care provided in many home birth settings leads to high mortality rates for both mothers and infants [2].
Evidence has shown that increased contact with prenatal care services results in women being 7.3 times more likely to deliver in a health facility than those who received no prenatal care [3]. Furthermore, a large investigation into the outcomes of children whose mothers received prenatal care found higher age-for-height at 24 months and improved schooling achievements compared to those who did not receive prenatal care [4]. Height-for-age is a metric which can be used to indicate children’s growth and nutritional status [5].
Therefore, increasing the quality and accessibility of prenatal care and FBDS to women in low income countries is crucial for promoting healthy childbirth.
Overcoming barriers to accessing prenatal care and facility-based delivery services
Improving the quality of prenatal care
In 2017 WHO found that 808 women died every day of childbirth related complications, almost all of these deaths were in low income countries and many could have been prevented with proper prenatal care and screening [6]. Due to this there is high demand for deployment of evidence-based interventions which take in to account the practical and contextual requirements of low-income countries.
A trial of provision of medical supply kits in ten clinics in Mozambique found an increase in healthy births in 2015 [7]. This shows that sometimes the barrier to good quality care is simply a lack of sufficient resources.
One often overlooked barrier to women accessing prenatal care is personal attitudes and cultural factors [8]. These social and psychological reasons for women not seeking prenatal care can often, although not always, be due to a lack of knowledge regarding the importance of screening during pregnancy and the health benefits of pregnancy medical care 8. Community outreach programmes which aim to educate young women before pregnancy of the importance of prenatal care could be used to increase knowledge and perceptions of seeking prenatal care.
Quality of community midwives in rural areas
In rural areas access to health facilities is limited meaning many mothers rely on community midwives. Investing in the development of rural medical centres may help improve mothers contact with prenatal care and increase FBDS, however research has shown that culturally appropriate changes which focus on improving the quality of current community midwives and related services would have better outcomes and be more cost effective [9].
By regulating midwives through ensuring a licensing system, quality can be monitored and controlled [10]. However, a lack of investment in quality midwifery education and poor working conditions mean this is hard to achieve and results in inadequate numbers of staff. To overcome this barrier there is a need for concentrated efforts to distribute educated professional training schemes into rural communities.
A lack of female empowerment has been reported as the most significant barrier to advancing as a midwife in low income countries [11]. By increasing women’s access to education, employment and increasing understanding of their rights, efforts to achieve gender equality can advance.
Removing user fees for facility-based delivery services
In many low-income countries lack of universal health care has led to many women from low income households unable to access skilled delivery care, this continues to increase socioeconomic inequalities, meaning the discrepancies in wellbeing, income and health between low- and high-income households is increasing.
Several Sub-Sahara African countries, including Ghana, Senegal, and Sierra Leone, have removed the fees associated with facility-based delivery services in the past two decades. The outcome of this policy change was a significant increase of facility-based deliveries for all mothers, independent of wealth or education [12].
Further investment in to providing fee free delivery services for mothers is vital for improving access to hygienic and safe delivery services.
Conclusions
Prenatal services and FBDS in low income countries are a vital resource for women in low income countries to have healthy births and for infants to have the best start to life as possible. These services, however, lack sufficient funding for suitable equipment and professionally trained midwives. Furthermore, access to these services is limited by a range of barriers such as rural locations, financial limitations, and personal attitudes. These barriers can be overcome by providing medical resources, implementing community outreach programmes to educate young women, regulating and training community midwives in rural areas, working to empower women from a young age, and to eliminate the fees associated with accessing FBDS.
[1] Montagu, D., Yamey, G., Visconti, A., Harding, A., & Yoong, J. (2011). Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data. PLoS ONE, 6(2), e17155. doi:10.1371/journal.pone.0017155
[2] ADDAI, I. (2000). Determinants of use of maternal-child health services in rural Ghana. Journal of Biosocial Science, 32(1), 1-15. doi:10.1017/s0021932000000018
[3] Guliani, H., Sepehri, A., & Serieux, J. (2012). What impact does contact with the prenatal care system have on women’s use of facility delivery? Evidence from low-income countries. Social Science & Medicine, 74(12), 1882-1890. doi:10.1016/j.socscimed.2012.02.008
[4] Liu, X., Behrman, J. R., Stein, A. D., Adair, L. S., Bhargava, S. K., Borja, J. B., … Sachdev, H. S. (2017). Prenatal care and child growth and schooling in four low- and medium-income countries. PLOS ONE, 12(2), e0171299. doi:10.1371/journal.pone.0171299
[5] DAPA Measurement Toolkit. (n.d.). Retrieved from https://dapa-toolkit.mrc.ac.uk/anthropometry/anthropometric-indices/growth
[6] WHO, UNICEF, UNFPA, & World Bank Group and the United Nations Population Division. (2019). Maternal mortality: Levels and trends 2000 to 2017. Retrieved from https://www.who.int/reproductivehealth/publications/maternal-mortality-2000-2017/en/
[7] Uneke, C. J., & Uro-Chukwu, H. C. (2018). Improving quality of antenatal care through provision of medical supply kits. The Lancet Global Health, 6(1), e4-e5. doi:10.1016/s2214-109x(17)30471-0
[8] Committee to Study Outreach for Prenatal Care, Division of Health Promotion and Disease Prevention, & Medicine, I. O. (1988). Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: National Academies Press.
[9] Glei, D. A., Goldman, N., & Rodrı́guez, G. (2003). Utilization of care during pregnancy in rural Guatemala: does obstetrical need matter? Social Science & Medicine, 57(12), 2447-2463. doi:10.1016/s0277-9536(03)00140-0
[10] Kwast, B. E., & Bentley, J. (1991). Introducing confident midwives: Midwifery education — action for safe motherhood. Midwifery, 7(1), 8-19. doi:10.1016/s0266-6138(05)80129-9
[11] UNFPA. (2007). Investing in midwives and others with midwifery skills to save the lives of mothers and newborns and improve their health. United Nations Population Fund.
[12] McKinnon, B., Harper, S., & Kaufman, J. S. (2015). Who benefits from removing user fees for facility-based delivery services? Evidence on socioeconomic differences from Ghana, Senegal and Sierra Leone. Social Science & Medicine, 135, 117-123. doi:10.1016/j.socscimed.2015.05.003
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