Delivering quality: safe childbirth requires more than facilities
Authors: Günther Fink, Jessica Cohen
Journal: The Lancet Global Health (2019)

Using one of the most comprehensive datasets on maternal and perinatal mortality from low-income and middle-income settings to date, Sabine Gabrysch and co-authors1Gabrysch S Nesbitt RC Schoeps A et al.Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials.Lancet Glob Health. 2019; 7: e1074-e1087Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar studied the relationship between facility delivery and a remarkable set of mortality outcomes, including antepartum and intrapartum stillbirths, early newborn mortality, and direct maternal mortality in Ghana. Although facility delivery on its own was not protective against mortality, the study1Gabrysch S Nesbitt RC Schoeps A et al.Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials.Lancet Glob Health. 2019; 7: e1074-e1087Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar offers evidence that delivery in a higher-quality facility (particularly those well equipped to handle emergencies) was associated with substantial reductions in the probability of intrapartum stillbirth. Even though the study design and data do not allow any precise guidance on mechanisms, the most probable channel for this benefit is the increase in caesarean section availability in case of labour complications. The overall weak association found between facility delivery and mortality is consistent with observational studies from low-income countries,2Godlonton S Okeke EN Does a ban on informal health providers save lives? Evidence from Malawi.J Dev Econ. 2016; 118: 112-132Crossref Scopus (38) Google Scholar as are the protective effects for delivery in a high-quality facility on mortality.3Leslie HH Fink G Nsona H Kruk ME Obstetric facility quality and newborn mortality in malawi: a cross-sectional study.PLoS Med. 2016; 13e1002151 Crossref PubMed Scopus (52) Google Scholar Remarkably, Gabrysch and colleagues1Gabrysch S Nesbitt RC Schoeps A et al.Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials.Lancet Glob Health. 2019; 7: e1074-e1087Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar find that the association between facility delivery and mortality did not improve, but might actually have deteriorated over time in this context. One possible explanation for these negative trends is the increasing pressure on Ghanaian health facilities—institutional delivery shares increased from 52% to 68% within 5 years. Combined with an annual population growth of 2–3%, this pressure implies a substantial increase in the typical workload of health facilities over a relatively short period of time that was probably not matched by commensurate increases in staffing and equipment. As the experience of the Janani Suraksha Yojana programme in India4Lim SS Dandona L Hoisington JA James SL Hogan MC Gakidou E India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation.Lancet. 2010; 375: 2009-2023Summary Full Text Full Text PDF PubMed Scopus (484) Google Scholar and the free-delivery policy in Kenya5Gitobu CM Gichangi PB Mwanda WO The effect of Kenya's free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilities.BMC Pregnancy Childbirth. 2018; 18: 77Crossref Scopus (45) Google Scholar have shown, incentivising facility delivery without ensuring adequate quality of care is unlikely to result in major health improvements. Although the findings of Gabrysch and colleagues1Gabrysch S Nesbitt RC Schoeps A et al.Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials.Lancet Glob Health. 2019; 7: e1074-e1087Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar might be disappointing from a public health perspective, they are consistent with historical trends in high-income countries. In the USA the rapid transition from home to hospital-based deliveries in the early 1900s was not associated with any reduction in maternal mortality until hospital quality improved and, in particular, until the heightened risk of hospital-acquired puerperal sepsis was adequately addressed.6Thomasson MA Treber J From home to hospital: the evolution of childbirth in the United States, 1928–1940.Explor Econ Hist. 2008; 45: 76-99Crossref Scopus (20) Google Scholar In light of all the evidence, a clear shift in focus from quantity to quality seems urgently needed. A key challenge in the redirection from access to quality is the relatively scarce evidence regarding how to improve the quality of health care in low-income settings.7Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (870) Google Scholar A growing body of literature shows that simply providing health workers with job aids and training cannot meaningfully and consistently improve outcomes.8Semrau KEA Hirschhorn LR Marx Delaney M et al.Outcomes of a coaching-based WHO safe childbirth checklist program in India.New Engl J Med. 2017; 377: 2313-2324Crossref PubMed Scopus (136) Google Scholar, 9Rowe AK Rowe SY Peters DH Holloway KA Chalker J Ross-Degnan D Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review.Lancet Glob Health. 2018; 6: e1163-e1175Summary Full Text Full Text PDF PubMed Scopus (176) Google Scholar One of the main challenges in this area is the complex nature of quality of perinatal care in clinical settings. Facility quality is neither easy to measure nor static as a concept; quality of care varies within facility across providers, across patients, even across day and time, with much higher maternal and newborn mortality within facilities at night and on weekends.10Lamadrid-Figueroa H Montoya A Fritz J et al.Hospitals by day, dispensaries by night: hourly fluctuations of maternal mortality within Mexican health institutions, 2010–2014.PLoS One. 2018; 13e0198275 Crossref Scopus (6) Google Scholar Quality metrics used in the literature—including the signal functions used in the study by Gabrysch and co-authors—have major shortcomings. Large innovations in quality measurement are needed to support the development of new strategies to improve quality.7Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (870) Google Scholar As challenging as improving the quality of care will be, these efforts alone might be insufficient to reduce delivery-related mortality. Maternal and newborn outcomes are established by more than the brief hours women spend with providers during labour, delivery, and the immediate postpartum period. Perinatal outcomes are strongly influenced by a range of other related factors, such as the quality and use of prenatal care and the strength of emergency referral systems. Transforming maternal care quality will also involve engaging the patient herself. Women express strong stated and revealed preferences for high-quality maternal care, but evidence is scant regarding how to inform and empower women to choose and reach high-quality providers.11Cohen J Rothschild C Golub G Omondi GN Kruk ME McConnell M Measuring the impact of cash transfers and behavioral ‘nudges’ on maternity care in Nairobi, Kenya.Health Aff (Millwood). 2017; 36: 1956-1964Crossref Scopus (12) Google Scholar More evidence is needed on how to make simple and transparent quality information readily available to pregnant women and on how to remove barriers to reaching high-quality care more generally. Together with system-level quality improvement efforts, reducing barriers between women and high-quality maternity providers can accelerate the transformation from facility delivery to safe delivery. We declare no competing interests. Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trialsFacility birth does not necessarily convey a survival benefit for women or babies and should only be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safe-guarding uncomplicated births. Full-Text PDF Open Access