Health System Solutions

This section of the paper considers the main types of national health systems through which specific services can be delivered and characterizes specific features relating to maternity care, particularly delivery services. It aims to provide a backdrop for interpreting policies and policy shifts.

Preventing the bulk of maternal deaths requires curative care, i.e. using clinical services to treat conditions as they arise to prevent them from leading to death (WHO 1991). By the early 1990s these were identified and labelled essential obstetric care (WHO 1991). The main challenge for countries is to organise maternity health services so as to deliver these relevant preventive and curative interventions, particularly around the time of labour and delivery when most deaths occur. Most effective interventions require skilled, often specialized, personnel.

The features of maternity care services are largely determined by the characteristics of the national health systems within in which they are imbedded. National health systems comprise five main interacting components as shown in Figure 1: resources, organization, management, economic support, and, delivery of services (e.g. maternity care) (Roemer 1991). The components are in turn affected by a great multiplicity of social influences that can be grouped as economic, political and cultural.

(Roemer 1991) presents the national health systems of the world in a matrix based on the first two, the economic status of the country according to annual GNP (grouped as affluent and industrialized, developing and transitional, very poor, or resource (oil) rich) and its health policy orientation (grouped as entrepreneurial, welfare oriented, comprehensive, or socialist)². Examples of very poor countries with the above four health policy orientations respectively are Nepal, India, Sri Lanka, and China. During the 1980s, most very poor countries were categorized as having welfare-oriented health policies (Roemer 1991). In more recent years, very poor and transitional countries have been pressurized by the economic policies and structural adjustment programmes of the IMF and the World Bank to further reduce government expenditure and to rely more on private services and markets, thus moving more strongly to entrepreneurial and welfare-oriented health policies. In Zimbabwe for example, progressive erosion of the general standard of health services has been associated with a rising maternal mortality ratio (CSO 1995).

Figure 1. The five main interacting components of national health systems (taken from Roemer 1991)

Within the context of their national health systems, maternal health programmes need to find ways to decrease the gap between women and services so that both respond rapidly and appropriately to the obstetrical complications that cause death. Most countries appear to have developed a least minimal infrastructure for providing antenatal care, but a far bigger challenge is posed by delivery care services. We identify four basic models for organizing maternity care services. These can be described based on where women deliver and who delivers them (Figure 2) (Koblinsky et al. 1999). The differences in cost and constraints of the four models, in terms of type of staffing, training, up-grading of skills, type and number of health facilities, supervision, regulation, and fulfilment of mothers’ wishes, have not been quantified or described and thus are poorly understood) (Koblinsky et al 1999). Nevertheless the evidence unearthed suggests that where non-professionals (i.e. TBAs or relatives) carry out home deliveries, maternal mortality ratios are usually staggeringly high (often between 500-1000 per 100,000 - e.g. the Gambia) and never fall below 100 deaths per 100,000 women (e.g. rural China and Forteleza, Brazil). When a professional (midwife or doctor) linked up with a strong referral system carries out deliveries, maternal mortality ratios can be reduced to 50 per 100,000 or below, irrespective of whether births takes place at home, in health centres or maternity homes, or in hospitals. However, even where all births take place in a hospital (the fourth and arguably most advanced model), mortality is not necessarily reduced to fewer than 100 per 100,000 (e.g. Mexico City and Former Soviet Union) (Koblinsky et al . 1999).

Figure 2. Safe Motherhood Care: required features of service delivery models

EOC = essential obstetric care

A key feature of countries that have lowered maternal mortality to a level of < 100 per 100,000 appears to be that the large majority of births are delivered by professional skilled birth attendants. Where women are geographically isolated, strategies used to increase access to professional care include obligatory rural postings or incentives to health staff in rural areas, use of maternity waiting homes (homes located close to a referral facility where pregnant women can go near term)³ and delegation of life-saving skills to lower level staff.⁴

Where professionally trained birth attendants cannot conduct most deliveries, the appropriate organization of services is not clear. If referral services are accessible and functioning, prenatal screening based on poor obstetric history and identification of present medical problems or complications carried out by a trained nurse-midwife with women and their TBAs in the community, may contribute to reducing local, hospital-based maternal mortality [e.g. Nigeria (Brennan 1989) or Ethiopia (Poovan et al . 1990)]. TBAs and families can identify early signs of complications during labour and delivery and refer women successfully for treatment [e.g. Indonesia (Alisjahbana 1991) and Guatemala (Schieber 1991)]. In Forteleza Brazil (Koblinsky et al. 1999, Janowitz et al . 1985) such a TBA based system functioned, but with extraordinary inputs in terms of supervision, referral and free emergency care at the referral hospital. More commonly the necessary supervision and the required linkages to referral services are not available. In such instances, in Indonesia and the Gambia for example, trained TBAs alone, without the support of skilled back-up services, do not decrease the maternal mortality ratio (Alisjahbana 1991, Greenwood et al . 1987, Greenwood 1991). Rural China poses an intriguing exception in that it appears to achieve relatively low maternal mortality without a strong referral system or free tertiary level care (Koblinsky et al . 1999); much more effort is needed to understand how China is able to achieve such low mortality in its rural areas.