Please find below a review of maternal care in low- and middle-income countries, which concludes: ‘evidence of more use, not better outcomes’. As a personal comment, this is an indictment of the quality of health care available in hospital facilities. This low quality of care is largely due to the failure of health systems to empower health workers (in adequate numbers) to deliver the services for which they were trained.
CITATION: Demand-side interventions for maternal care: evidence of more use, not better outcomes. Taylor E. Hurst, Katherine Semrau, Manasa Patna, Atul Gawande and Lisa R. Hirschhorn. BMC Pregnancy and Childbirth 2015, 15:297 doi:10.1186/s12884-015-0727-5
Background: Reducing maternal and neonatal mortality is essential to improving population health. Demand-side interventions are designed to increase uptake of critical maternal health services, but associated change in service uptake and outcomes is varied. We undertook a literature review to understand current evidence of demand-side intervention impact on improving utilization and outcomes for mothers and newborn children.
Methods: We completed a rapid review of literature in PubMed. Title and abstracts of publications identified from selected search terms were reviewed to identify articles meeting inclusion criteria: demand-side intervention in low or middle-income countries (LMIC), published after September 2004 and before March 2014, study design describing and reporting on >1 priority outcome: utilization (antenatal care visits, facility-based delivery, delivery with a skilled birth attendant) or health outcome measures (maternal mortality ratio (MMR), stillbirth rate, perinatal mortality rate (PMR), neonatal mortality rate (NMR)). Bibliographies were searched to identify additional relevant papers. Articles were abstracted using a standardized data collection template with double extraction on a sample to ensure quality. Quality of included studies was assessed using McMaster University’s Quality Assessment Tool from the Effective Public Health Practice Project (EPHPP).
Results: Five hundred and eighty two articles were screened with 50 selected for full review and 16 meeting extraction criteria (eight community mobilization interventions (CM), seven financial incentive interventions (FI), and one with both). We found that demand-side interventions were effective in increasing uptake of key services with five CM and all seven FI interventions reporting increased use of maternal health services. Association with health outcome measures were varied with two studies reporting reductions in MMR and four reporting reduced NMR. No studies found a reduction in stillbirth rate. Only four of the ten studies reporting on both utilization and outcomes reported improvement in both measures.
Conclusions: We found strong evidence that demand-side interventions are associated with increased utilization of services with more variable evidence of their impact on reducing early neonatal and maternal mortality. Further research is needed to understand how to maximize the potential of demand-side interventions to improve maternal and neonatal health outcomes including the role of quality improvement and coordination with supply-side interventions.
SELECTED EXTRACTS (selected by Neil PW)
Maternal mortality results in approximately 800 deaths every day.. Since 1990, there has been a 45 % reduction in maternal mortality; however, limited access to quality routine and emergency care during pregnancy and delivery leaves a large number of women at risk of preventable death
The three delays model proposes that mortality can be largely attributed to a 1) delay in the decision to seek care, 2) delay in arrival at a health facility, and 3) delay in the provision of care .
The weak association between increased uptake of maternal health services and health outcome measures may be explained by the quality and effectiveness of care received in health facilities . Poor quality care will not translate to better health outcomes even if there is increased utilization of services.
Poor quality of facility-based care has been identified as one of the factors contributing to maternal mortality and morbidity, highlighting the need to simultaneously increase utilization and invest in developing health systems that can offer quality care to meet the increased demand for services
in a study in rural Tanzania by Kruk et al., 40 % of women who delivered in a facility bypassed their nearest facility. One of the reasons cited for this choice was perception of poor quality care
more work is needed to understand the contextual factors associated with the variable impact on maternal and neonatal mortality and the potential role of simultaneous investment in supply side factors,  such as staff, medical equipment and supplies, referral systems and quality of care delivered.
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