“Our findings suggest that the current strategy of ‘birth at any clinic’ is likely wrong, and that poor quality is undermining the goal of reducing maternal and newborn mortality around the world,” said Margaret Kruk, associate professor of global health at Harvard Chan School and lead author of the study.
More than 40% of health facility births in five African countries are taking place in poor-quality facilities with crucial deficiencies in staffing, infrastructure, referral systems, and routine and emergency care practices.
Since 2000, when world leaders established eight “Millennium Development Goals” (MDGs) at a United Nations Summit—one of which was to improve maternal health and another to reduce child mortality—low-income countries with high maternal mortality rates have been encouraging women to give birth in nearby health facilities rather than at home.
The thinking was that giving birth in a health facility designated to handle deliveries would save women’s and newborns’ lives because birth complications are unpredictable. In practice, many delivery facilities are small primary care clinics offering only basic services.
But preliminary evidence from countries that have dramatically increased facility deliveries, such as India, has suggested that this has not led to reduced maternal and infant mortality.
Other evidence, from high-income countries, has suggested that facilities that handle a high volume of births (more than 500 a year) and that have the capacity to perform Caesareans have the highest quality of neonatal and obstetric care.
Given that there is little information available about the quality of primary care facilities in low-income countries, the researchers decided to analyse data from health system surveys funded by USAID about deliveries and quality of care in five sub-Saharan African countries with high maternal mortality—Kenya, Namibia, Rwanda, Tanzania, and Uganda.
They measured the quality of basic maternal care functions at 1,715 healthcare facilities using an index of 12 indicators, including the availability of skilled providers, a functional ambulance, electricity, clean water, and antibiotics. They also looked at whether quality was linked to volume of births per year or to a facility’s capacity to perform Caesareans.
They found that nearly 90% of the facilities studied did not have the capacity to perform Caesarean sections, and that those clinics delivered 44% of all babies born in a healthcare facility. Small primary care clinics scored, on average, only 3,8 out of 10 on a basic index of quality; facilities with surgical capability had nearly double this score.
“As we have already done in wealthy countries, we need to get women in countries in sub-Saharan Africa, and in other countries with high rates of maternal and neonatal mortality, into larger, better healthcare facilities to deliver their babies,” said Kruk. “Governments in lower-income countries and their global partners need to urgently pivot from promoting access alone to improving quality of care for childbirth.”
