Barriers to the implementation of effective maternal health care in the developing world: views from the frontline
Keywords: third delay; crowdsourcing
developing countries
maternity

Background
Over the past few decades, the scientific community has tested interventions which, when implemented successfully, have resulted in significant reductions in maternal mortality and morbidity. Unfortunately, these have not been consistently used in regions with the highest maternal mortality and morbidity rates. The ‘three delays’ model has been used to explain delays in women accessing emergency obstetric care as the result of barriers to: I) decision-making, II) accessing services and III) receipt of appropriate care. The importance of the third delay has been downplayed in many previous studies of maternal mortality; however, it is likely to be a source of considerable inequity in access to emergency obstetric care in developing countries. The perspectives of, and pragmatic input from, health care providers in developing countries concerning these health-system failures have rarely been sought on a large scale or sufficiently considered in planning global efforts to improve maternal health.
Methods
A systematic literature review was conducted to identify and categorise phase III barriers to the provision of effective and timely maternal health care in developing countries. Following this review, an extensive online survey was conducted between July 2010 and March 2011. The target audience were facility-based maternal health care providers working in developing countries. Participants were randomised to one of five condition-specific surveys on the five major causes of maternal mortality: postpartum haemorrhage; sepsis; pre-eclampsia/eclampsia; obstructed/prolonged labour and complications of termination of pregnancy. For each survey, seven internationally recommended interventions were selected based on a review of current practice guidelines. Participants were asked to rate the availability of these interventions in their facility, and to identify specific barriers to their implementation. Participants were also invited to contribute to an online ‘crowdsourcing’ forum where they submitted, discussed and ranked ideas to overcome the barriers identified.
Findings
Forty-two eligible studies were included in the literature review. Thirty-two conceptually unique facility-level barriers were identified and categorised into six themes (drugs and equipment; policy and guidelines; human resources; facility infrastructure; patient-related and referral-related). The five most commonly cited barriers were inadequate training/skills mix (86 per cent of articles); drug procurement/logistics problems (67 per cent); staff shortages (60 per cent); lack of equipment (52 per cent) and low staff motivation (45 per cent).
A total of 1,479 direct care providers from 99 developing countries completed the online survey. Participants were drawn from 963 facilities, which together deliver over 3 million women annually. Of the 35 key interventions evaluated, participants reported that 15 were routinely implemented in at least 70 per cent of the facilities surveyed. The 20 interventions with <70 per cent routine coverage included assisted vaginal delivery (24 per cent of facilities); post-termination of pregnancy vacuum aspiration (41 per cent); screening for proteinuria (57 per cent); blood transfusion for postpartum haemorrhage (59 per cent); clean delivery practices (60 per cent); partogram use in labour (67 per cent), and magnesium sulphate for pre-eclampsia (67 per cent). The most common intervention-specific barriers identified were: the inadequate content, dissemination and enforcement of clinical guidelines; inadequate pre-service and in-service training; lack of authorisation for certain procedures; lack of specific resources; staff preference for less effective or non-recommended practices, and the cost of treatment for patients. A total of 132 solutions were submitted via the ‘crowdsourcing’ forum and the ‘crowd’ voted for twelve winning ideas that they would like to see implemented.
Interpretation
This project highlights how a focus on patient-side delays in the decision to seek care can conceal the fact that many health facilities in the developing world are still chronically under-resourced and unable to cope effectively with serious obstetric complications. A wide range of facility-level barriers to emergency obstetric care is in operation, which may result in many thousands of avertable maternal deaths worldwide. Both the literature review and the survey highlighted human resources issues as a major barrier leading to delays in women receiving timely and appropriate obstetric care. These included both the number of staff available and issues relating to training and skills-mix and access to evidence-based guidelines.
The results of this study suggest that more emphasis needs to be put on addressing supply-side health systems barriers alongside demand-side factors if further reductions in maternal mortality are to be achieved. This project also demonstrates that a large-scale consultation of frontline health workers using online technologies is feasible in developing country settings. In the future, the views of these direct health care providers should be routinely included in the development of strategies to implement best practices in maternal health care.