The Kambia Appeal

By: Erin Lieber

Each year, childbirth and near term complications take the lives of roughly 529,000 women, with the most deaths taking place in sub-Saharan Africa (Blum et al. 2006). Most developing countries have adopted a multi-pronged approach in an effort to reduce maternal mortality. The strategy stems from the “Safe Motherhood” (SM) campaign and concentrates on family planning, antenatal care, including proactive education and reassurance, skilled assistance at delivery and access to emergency obstetric care for complicated and high risk labor. “Safe Motherhood” was introduced in the 1980’s and research shows that the success and execution of each of these aspects significantly varies. While coverage for antenatal care is estimated at 70-90%, coverage of skilled assistance at delivery, defined as a trained health professional such as a midwife, nurse or doctor, is only 30-40%. There are many barriers that contribute to the challenge and low coverage of skilled assistance at delivery such as inadequacies of local health systems, patient perceptions of quality causing women to bypass their local centers, as well as financial constraints of accessing a skilled birth attendant.

A significant factor in health system demand constraints includes low quality of local facilities and patients choosing higher level care although further away geographically. Research shows that more than 40% of women who chose to deliver in a poor rural area of Tanzania, bypassed their nearest health facility, choosing to deliver at the government hospital or mission facility (Kruk et al. 2009). Although there are often health centers close to the patients home, the perceptions of quality of those centers is low. Tanzania, for example, has invested in designated village level primary care facilities, often called dispensaries, to be the main point of care for uncomplicated births, an effort that led to 90% of the population living within 10km of a health center (National Bureau of Statistics, Tanzania and Macro International 1997). Despite effective proximity, research cites poor quality as a concern in dispensaries in both delivery of care and the degree of skilled labor. A recent study in Tanzania even found that providers in rural areas tend to be less skilled than those in urban areas (Leonard and Masatu 2007).

Financial constraints also contribute to low coverage of skilled workers, as highly trained clinicians such as doctors or midwives require higher compensation, which generates the need for various fees that may discourage woman from using these services. This, in turn, decreases funding for skilled care at delivery, and the overall number of workers with specific obstetric skill sets decrease as well.

There are many initiatives working on solutions to improve maternal health in low-resource countries and they are emphasizing the skilled care approach in their strategies. Some ways to improve the coverage of skilled care include increasing the number of skilled birth attendants and quality care in the dispensaries closest to the women’s home. An organized referral system should also be in place so that higher risk and complicated births are taken to the next closest higher level facility in an efficient manner. This sort of organization will provide quality data to plan for investments in each both types of facilities, so that confidence is restored in the local facilities and woman do not bypass the first facility unless referred. Education and awareness on the quality of first level dispensaries is extremely important within the community so that women are comfortable not only with prenatal and preventive obstetric care but also with giving birth at these facilities. A strong commitment to strengthen local health centers will give donors the confidence to invest more in increasing the coverage of skilled birth attendants and quality care in an effort to reduce maternal mortality in developing countries.