Potential effect of regionalised care in a low-resource setting
Authors: Maya I Brasher, Msandeni Chiume
Journal: The Lancet Global Health (2019)

In The Lancet Global Health, Mark Shrime and colleagues1Shrime MG Iverson KR Yorlets R et al.Predicted effect of regionalised delivery care on neonatal mortality, utilisation, financial risk, and patient utility in Malawi: an agent-based modelling analysis.Lancet Glob Health. 2019; 7: e932-e939Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar present a fitting contribution to the literature on the potential role of regionalisation in health care. Internationally, WHO recommends regionalised care as one of its principles of perinatal care.2Chalmers B Mangiaterra V Porter R WHO principles of perinatal care: the essential antenatal, perinatal, and postpartum care course.Birth. 2001; 28: 202-207Crossref PubMed Scopus (120) Google Scholar The difficulty in implementing these principles is the inability to extrapolate conclusions regarding regionalisation from high-resource to low-resource health systems, as Shrime and colleagues show. The authors used an agent-based model—a computational model that has only been applied to public health and health policy in the past two decades.3Tracy M Cerdá M Keyes KM Agent-based modeling in public health: current applications and future directions.Annu Rev Public Health. 2018; 39: 77-94Crossref PubMed Scopus (125) Google Scholar This type of model has not previously been used to analyse potential effects of regionalisation. Shrime and colleagues first created a status-quo model that seems well validated according to available data from Malawi. Regionalisation was simulated within the current system to consider both health outcomes and outcomes regarding social determinants of health. The validation of the status-quo model allowed for reliable output from simulations enforcing regionalisation. This validation is key for allowing us to foresee potential obstacles to implementing regionalised perinatal care in Malawi. The study assessed four different scenarios of regionalisation: scenario 1 restricted deliveries to facilities currently capable of providing caesarean sections; scenario 2 was scenario 1, but with selected facilities upgraded to also provide caesarean sections; scenario 3 restricted delivery to facilities that provided five or more basic emergency obstetric and neonatal care services; and scenario 4 was scenario 3, but with selected facilities upgraded to provide the same level of care. Shrime and colleagues found that scenarios 1 and 2 reduced neonatal mortality by 11·4 deaths per 1000 livebirths (scenario 1; 95% posterior credible interval [PCI] 9·8–13·1) and 11·6 deaths per 1000 livebirths (scenario 2; 10·2–13·1), whereas scenarios 3 and 4 did not affect neonatal mortality. The study is well thought-out but raises questions about the role of prenatal care and postnatal comprehensive care in neonatal mortality and the role of education in improving informed decision-making about delivery location. Finally, additional emphasis is needed on the insufficiency of infrastructure in Malawi before regionalisation can be considered as proposed by the study models. To assess the study's outcomes, we need to consider them in context of the current health-care system in Malawi. Infection, birth asphyxia, and complications of prematurity are major contributors to neonatal mortality in low-income countries, including Malawi.4The Partnership for MaternalNewborn & Child HealthNewborn death and illness.http://www.who.int/pmnch/media/press_materials/fs/fs_newborndealth_illness/en/Date: 2011Date accessed: May 17, 2019Google Scholar Neonates with these conditions require comprehensive care at regionalised centres. They also require the mother to have received adequate prenatal care for optimal management of high-risk deliveries. The effects of regionalisation on neonatal mortality are difficult to discuss without an evaluation of access to prenatal and postnatal care in Malawi.5Machira K Palamuleni M Women's perspectives on quality of maternal health care services in Malawi.Intl J Womens Health. 2018; 10: 25-34Crossref PubMed Scopus (20) Google Scholar, 6Kakhi JJ Sithole L Factors associated with the utilization of postnatal care services among Malawian women.Malawi Med J. 2019; 31: 2-11Crossref PubMed Scopus (11) Google Scholar, 7Chimtembo LK Maluwa A Chimwaza A Chirwa E Pindani M Assessment of quality of postnatal care services offered to mothers in Dedza district, Malawi.Open J Nursing. 2013; 3: 343-350Crossref Google Scholar Additionally, the reality in Malawi is that centres that provide caesarean sections do not automatically provide comprehensive obstetric and neonatal care. Decreased neonatal mortality was seen in scenarios 1 and 2, suggesting that the observed mortality benefit was related to the method of delivery. These results further support the need for interventions focusing on a continuum of care from prenatal to postnatal care to address the primary contributors to neonatal mortality. This analysis also found that women were required to travel longer distances in scenario 1 (increase of 7·2 km, 95% PCI 4·5–9·9) and in scenario 2 (4·4 km, 1·5–7·2) than in the status quo (p<0·0001), out-of-pocket costs tripled (p<0·0001; status quo vs scenario 1 and scenario 2, and the risk of catastrophic expenditure significantly increased from a baseline of 6·4% (95% PCI 6·1–6·6) to 14·7% (14·5–14·9) in scenario 1 and 11·3% (11·0–11·5) in scenario 2. Shrime and colleagues used a choice model within an agent-based model to simulate behaviours of pregnant women in Malawi by studying the choices Malawian women make regarding where to give birth and factors that influence this decision. This simulation raises the following questions. Did mothers fully understand that the potential risks to themselves and their babies' change on the basis of where they give birth? If not, would more mothers choose to travel farther to a regionalised centre once they did understand this risk, and would this decrease their disutility despite increased personal costs? Education to ensure informed decision-making is especially important for patients with low health literacy, as is true for many Malawian women. Finally, Shrime and colleagues acknowledged that the time horizon is of a single pregnancy, and that their results might overestimate mortality benefits. It is important to emphasise the magnitude of this limitation. If government policy enforced regionalisation as shown by this model, patient volumes would be shifted heavily from health centres to regionalised centres. This shift means that the system would need to account for increased access to medications, equipment, and physical space to accommodate patient volume, and for a large increase in trained health personnel to provide the level of care proposed. Even if other resources were obtained, the authors and policy makers need to consider the deficit of physicians, nurse clinicians, and other health-care workers who can provide appropriate peripartum and postpartum care for the mother and perinatal care for the baby. Malawi does not currently have the infrastructure to accommodate the demands that would be placed by regionalisation, thus making this a crucial concern when considering applications of this study's results. Overall, Shrime and colleagues have undertaken a worthwhile project in trying to predict effects of regionalisation on neonatal mortality, utilisation, financial risk, and patient satisfaction in Malawi. The literature and hands-on experience support regionalisation for improving neonatal outcomes, but the results of this study show the complexities of trying to implement regionalisation into low-resource settings. The high rates of financial devastation and disutility, even with improved neonatal mortality, are interesting and important findings. Without additional infrastructure development, educational support, and cultural analysis, the enforcement of regionalised care scenarios such as those the study assessed can lead to diminished health outcome benefits, or even absence of benefit altogether. We declare no competing interests. Predicted effect of regionalised delivery care on neonatal mortality, utilisation, financial risk, and patient utility in Malawi: an agent-based modelling analysisPolicies restricting women to give birth in facilities with caesarean section capabilities is likely to result in significant decreases in neonatal mortality and might allow Malawi to meet its goal of halving its neonatal mortality by 2030. However, this improvement comes at the cost of increased distances to care and worsening financial risks among women. Full-Text PDF Open Access