Quality of basic maternal care functions in low-income countries – Authors' reply
Authors: Margaret Elizabeth Kruk, Hannah H Leslie
Journal: The Lancet Global Health (2017)

We appreciate the comment from Angeliki Antonakou and Dimitrios Papoutsis on our Article1Kruk ME Leslie HH Verguet S Mbaruku G Adanu RMK Langer A Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys.Lancet Glob Health. 2016; 11: e845-e855Summary Full Text Full Text PDF Scopus (162) Google Scholar on quality of maternal care in low-income countries. They expressed a concern that the quality index might result in artificially lower scores for primary care facilities if sicker women were using these more often than secondary care facilities. However, the opposite is true. Five of the seven process indicators in the 12-item index were indicators for the performance of a signal function (basic emergency obstetric procedure) in the past 3 months. If higher-risk women were delivering in primary care facilities, it would actually result in higher quality scores for primary care facilities because of the greater opportunity to perform these procedures in primary care facilities than in secondary care facilities. We agree with the writers that it would nonetheless be valuable to have information about risk profiles of women. Unfortunately, such information is rarely collected in lower-income countries and not available in this dataset. More generally, we are in complete agreement with Antonakou and Papoutsis on the importance of appropriate care and avoidance of excessive interventions for women during pregnancy and delivery, as embodied by the standards of care in the UK. In the countries under study, however, several challenges limit a primary care, risk-based approach. In four of the five countries, fewer than half of pregnant women completed four antenatal care visits, thus risk is difficult to establish.2Kenya National Bureau of Statistics and ICF MacroKenya Demographic and Health Survey 2008–2009. KNBS and ICF Macro, Calverton2010Google Scholar, 3National Institute of Statistics of RwandaMinistry of HealthICF InternationalRwanda Demographic and Health Survey 2010. NISR, MOH, and ICF International, Calverton2012Google Scholar, 4Uganda Bureau of Statistics and ICF InternationalUganda Demographic and Health Survey 2011. Uganda Bureau of Statistics and ICF International, Kampala and Calverton2012Google Scholar, 5National Bureau of Statistics and ICF MacroTanzania Demographic and Health Survey 2010. National Bureau of Statistics and ICF Macro, Dar es Salaam2011Google Scholar, 6Namibia Ministry of Health and Social Services and ICF InternationalNamibia Demographic and Health Survey 2013. Namibia Ministry of Health and Social Services and ICF International, Windhoek and Rockville2014Google Scholar Half of primary care clinics did not have 24-h coverage by a skilled health worker and 60% of primary care clinics did not have referral capacity.1Kruk ME Leslie HH Verguet S Mbaruku G Adanu RMK Langer A Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys.Lancet Glob Health. 2016; 11: e845-e855Summary Full Text Full Text PDF Scopus (162) Google Scholar Primary care systems in these five countries do not have today the capacity to provide the timely response to intrapartum complications required to avert maternal and neonatal mortality. Alternative configurations of care that ensure access to emergency services while meeting women's preferences are urgently needed. We declare no competing interests. Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveysMore than 40% of facility deliveries in these five African countries occurred in primary care facilities, which scored poorly on basic measures of maternal care quality. Facilities with caesarean section capacity, particularly those with birth volumes higher than 500 per year, had higher scores for maternal care quality. Low-income and middle-income countries should systematically assess and improve the quality of delivery care in health facilities to accelerate reduction of maternal and newborn deaths. Full-Text PDF Open AccessQuality of basic maternal care functions in low-income countriesMargaret Kruk and colleagues (November, 2016)1 report on the quality of basic maternal care and the association with the volume of deliveries and surgical capacity in five sub-Saharan African countries. They conclude that, in low-income countries, facilities with caesarean section capacity and with birth volumes greater than 500 per year had higher scores for maternal care quality. Full-Text PDF Open Access