Comparing maternal health services in four countries

While the availability and use of trained midwives can shape the quality of care received in pregnancy and childbirth, a number of other underlying health systems structures and processes are important. The management of health workforces, the mix of public and private provision and the impact of reforms affect quality of care across countries.

During a comparative study, conducted in 2001-2002, researchers at the London School of Hygiene and Tropical Medicine, UK examined how the structure and operation of a health system influences maternal health care provision and outcomes in Bangladesh, Russia, South Africa and Uganda.

Significant conclusions from the study include:

• Health outcomes in pregnancy and childbirth are not rigidly linked to quantifiable inputs, such as number of staff or proportion of women delivering with a skilled attendant. Instead, there is a range of possible health outcomes from any given set of these variables. Much of this range will be dictated by the larger systems structures in which these factors operate.
• The connection between the numbers of mothers dying during pregnancy and childbirth and use of skilled attendants will be mediated by elements such as health centre workplace dynamics, national reforms shaping practice, or formal and informal private practice by health workers.
• The impact of private providers on maternal health depends on the services they offer, the populations they serve, and their interactions and relationships with other health providers.
• Private sector providers can be difficult to regulate. In urban areas they compete with the public sector, but in rural areas they can fill a gap where the public sector does not operate.
• Health sector reform can put a strain on health workers. However, a lack of reform can slow improvements in maternal health services, as is the case in Russia.
• User fees can increase staff motivation but may reduce demand for services. Removing fees may not necessarily increase demand.
• Informal fee charging and medical staff working in both private and public sectors take place in various forms. Public sector doctors may also operate private clinics to which they may refer their patients, while ward staff may re-sell drugs or charge for services.

The four country comparison reveals some common elements where the structure of health care systems can affect maternal health care. Implications for policy include:

• It is essential to look beyond the simple measurable inputs into a health system, such as numbers of staff or use of services, in order to understand how to improve quality and outcomes. 
• The effectiveness of birth attendants depends on the system in which they work.  The mix of staff, human resource allocations and the accessibility of emergency care can affect health outcomes.
• Income disparities allow the private sector to attract public sector staff. But where public services are not available, the private sector can play an essential role in maternal care.
• Informal health care providers may be poorly linked to the rest of the health system, bringing increased risks for women.
• Informal practices can undermine state policies on free care, but may operate to support public sector workers in positions that would be otherwise unfilled.
• The impact of any reform will depend on the structure of the system and how the reform is implemented.  There is no simple cause-and-effect link between a reform and its impact.

Source(s):
‘Health systems factors influencing maternal health services: a four-country comparison’ Health Policy 73(2): 127-38, by J. Parkhurst et al, 2005
HINARI subscribers can access the full-text article here. Full document.

Funded by: UK Department for International Development (Health Systems Development Knowledge Programme)

id21 Research Highlight: 10 August 2005

Further Information:
Justin Parkhurst
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: +44 (0) 20 7927 2359
Fax: +44 (0) 20 7637 5391
Contact the contributor: justin.parkhurst@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

Other related links:
'Taking aim: using 'near misses' to evaluate maternal health care'

'Antenatal care reborn? Healthcare for pregnant women in developing countries'

'Motherhood in the city: poor urban women and maternal health care provision in sub-Saharan Africa'

'Spreading safe motherhood messages in Nepal'

'Is there a fast track to better pregnancy outcomes in Kenya?'

See id21's collection of links relevant to maternal and child health.

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