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Planning for Universal Access

Table of Contents Newborns: no longer going unnoticed The Greatest Risks to Life are in its Beginning Progress and some Reversals No Longer Falling Between the Cracks Planning for Universal Access

Benchmarks for supply-side needs

It would be ill-advised to separate the plan for scaling up access to newborn care from that of care during pregnancy, childbirth and the postpartum. Planning requires benchmarks. The current recommendations suggest that maternal and newborn health facilities should be organized with at least one "comprehensive" and four "basic" essential obstetric care facilities per 500 000 population, that is, one facility for 3000 births per year. These recommendations do not fit the reality of health districts, which are often considerably smaller. In sub-Saharan Africa, where most of the stagnation occurs, the average district has around 120 000 inhabitants; in South-East Asia they are often much smaller units.

Estimating the need for first-level care for mothers and babies is straightforward: eventually all should have access. The problem is to decide on the optimal level of decentralization – the compromise between access and efficiency.

The requirement for back-up care is more difficult to assess, since only some expectant mothers and their babies will eventually need such interventions – but they cannot be identified beforehand. The percentage of mothers and their babies who need such care is the subject of debate. Estimates vary considerably, without a strong empirical basis ( ³⁷ ). According to current guidelines from the United Nations Children’s Fund, the United Nations Population Fund and WHO, the percentage of mothers who develop serious complications is 15% – but this does not mean that all need back-up care: many of these complications can be resolved within the first-level package. On the basis of more recent evidence and ongoing research, this percentage can probably be revised downwards, to a low-end estimate of 7%, including 2–3% who are surgical cases. The proportion of newborns requiring back-up care is often very much underestimated – while the need for sophisticated equipment to save their lives is overestimated. The percentage of newborns for whom back-up care would make the difference between survival and a high risk of dying is probably between 9% and 15%, but the evidence is scarce.

In a district of 120 000 inhabitants, and assuming a birth rate of 30 per 1000 inhabitants, there would be a workload of 3600 mothers and newborns requiring first-level care, of whom some 600–650 would also require back-up. Midwives working in a team can easily assist at least 175 births per year ( ³⁸ ). Such a district would require some 20 midwives, or equivalent skilled attendants, to provide first-level care to all mothers and their newborns in the district, in hospital and in decentralized midwifery-led birthing facilities of 60–80 beds.

A practical and cost-effective arrangement would be for one team of 9–10 midwives (or equivalent staff) to be stationed in the hospital ( ³⁸ ). The others would be stationed in other birthing facilities in the district. In a more dispersed population, smaller birthing facilities, with perhaps five midwives each, would be an option that would still provide round-the-clock service, but with higher quality control and emergency evacuation costs. In large, sparsely populated districts, the only solution may be to station individual midwives in villages – as has been the policy in Indonesia. This greatly improves access, but poses problems of quality assurance, 24-hour availability and the effectiveness and cost of emergency referral links.

A district like this would require the services of one full-time equivalent doctor and his or her supporting team to provide back-up care for the 600 or more mothers and babies with problems that go beyond the competence of the first-level staff. Given the imperative of 24-hour availability and the range of skills required for back-up care, a single gynaecologist-obstetrician per district is not a viable option. Alternatives, such as improving the skills of all-round medical staff or specialized technicians, have successfully been tried out in a large number of resource-poor countries, with considerable success. Such upgrading of skills has to cover both obstetric and neonatal care, a consideration that has received too little attention so far.

Room for optimism, reasons for caution

Where credible services are offered, uptake can increase dramatically. For example in Dakar, Senegal, the opening of a surgical theatre in an urban maternity unit immediately led to an 80% increase in the number of births in the unit. There is obviously a huge demand waiting to be tapped.

Globally the availability of nationally representative data for skilled attendants at birth is high and data are available for 93.5% of all live births. From this we know that 61.1% of births worldwide are attended by a professional who, at least in principle, has the skills to do so. Extrapolating from data available on 58 countries representing 76% of births in the developing world, the use of a skilled attendant at delivery – the key feature of first-level care – increased significantly, from 41% in 1990 to 57% in 2003, a 38% increase between 1990 and 2003. The greatest improvements occurred in South-East Asia (from 34% in 1990 to 64% in 2003) and northern Africa (from 41% in 1990 to 76% in 2003). These trends represent an increase of more than 85% in both regions. Hardly any change was observed, however, in sub-Saharan Africa, where rates remained at around 40% – among the lowest in the world. Within these regional averages there are significant differences between countries and between urban and rural areas. Almost all of the increases in births with a skilled attendant are driven by increases in the presence of medical doctors at birth. In fact, most regions, with the exception of sub-Saharan Africa, show decreasing use of other types of professional assistance. There is a marked increase in the proportion of deliveries that take place in health facilities, both in rural and urban areas (see Figure 5.6).

This tendency towards increased use of professional maternal and newborn care services should not give rise to excessive optimism. There are many places where hospitals with trained professional staff exist, and yet mortality remains staggeringly high. In 1996, for example, Brazzaville, Congo, had a maternal mortality ratio of 645 per 100 000, university hospital and health care facilities notwithstanding ( ³⁹ ). Delivery care is not merely a matter having a hospital with trained clinicians, it is also a question of how professional staff perform and behave ( ⁴⁰ ).

Two tendencies are particularly worrying. First, there is the difference between what the qualification of midwife, nurse-midwife or doctor guarantees and the actual level of skills and competence. In a seminal study of their capacities in four countries, there was little correspondence between knowledge and skills, and all types of providers showed large differences between their actual skill levels and international reference standards. This was also the case for crucial life-saving skills, for newborns, and also for their mothers ( ⁴¹ ).

Second, maternal and newborn care is an area where commercialization of health care delivery – overt or covert – finds a readily exploitable public. Payments for a spontaneous vaginal delivery amount to at least 2% of annual household cash expendi-ture in Benin and Ghana; in cases of interventions for complications, costs reached a high of 34% of annual household cash expenditure ( ⁴² ). With an ample potential clientele, supply-induced overuse of medical technology is rife, with consequent risk of iatrogenesis and financial exploitation of clients. The worldwide epidemic of caesarean section is a typical example, but not the only one (see Box 5.3)

Closing the human resource and infrastructure gap

Information is now becoming available on the infrastructure and personnel available to provide this kind of care, but it is still very fragmentary. In Bangladesh, Benin, Bhutan, Chad, Morocco, Nicaragua, Niger, Senegal and Sri Lanka, for example, five years of monitoring the adequacy of emergency care shows a mixed picture, but with a consistent lack of first-level care in most settings and an inappropriate spread of facilities ( ⁵⁴ – ⁵⁶ ). The situation is very different from country to country, but appears to be worse in the countries whose outcomes were stagnating or in reversal between 1990 and 2002.

The number of beds available in the maternity wards of health facilities of many countries is well below their needs and unevenly distributed. The main constraint, however, is the shortage of skilled professionals. Examples of the extent of the shortage in human resources can be seen in Figure 5.7, which compares the benchmarks set out above with an exhaustive on-the-spot inventory of staff in both public and private facilities. The gaps are most pronounced, in all countries, for the personnel typically entrusted with first-level maternal and newborn care.

It will take time and money to make up for these shortages: midwives are in short supply, especially outside the capital cities, and in many countries the scarcity is becoming more pronounced. It will also take time and money to establish the health care network infrastructure, both for first-level and back-up care. This is particularly true for countries in sub-Saharan Africa and others in stagnation or reversal.

Scenarios for scaling up

WHO has established scenarios to make up for these shortages in 75 countries, and move towards universal access to both first-level and back-up maternal and newborn care (details on the scenarios and associated costs are available at: http/www.who.int/whr). Together, these countries account for more than 75% of the world’s population, almost 90% of all births worldwide, and approximately 95% of all maternal and neonatal deaths. At present, some 43% of births in these countries take place in health facilities, with skilled attendants, though the level of skills is highly variable, and only a fraction of these mothers and their babies have access to the full range of maternal and newborn health interventions. There is thus a double agenda of reaching all mothers and newborns, and of improving the quality and range of interventions made available.

The pace of scaling up depends on the specific circumstances and difficulties each country is facing. It is likely to be slowest in the countries that currently face the greatest challenges: the lowest levels of coverage, poorly developed and fragile health systems, and unfavourable circumstances. Taking into account the specific situation of the 75 countries, it seems realistic, in 12 countries, to provide access to the full set of first-level and back-up care for 95% of mothers and newborns by 2010, and to do the same in 18 other countries by 2015. For 25 countries, however, it is unlikely that coverage could be scaled up beyond 65% by 2015, and to universal access before 2025; in a fourth group of 20 countries, where current coverage is lowest, the supply gap most pronounced, health systems weakest and the environment most unfavourable, it seems possible to reach 50% by 2015, but full coverage may well require a further 15 years.

According to these scenarios, coverage with maternal and newborn care in the 75 countries taken together would grow from its present 43% (with a limited package of care) to around 73% (with a full package of care) in 2015. Table 5.1 shows some of the implications this has for the stock of health professionals and for the infrastructure for first-level and back-up maternal and newborn care. A first estimate of the potential impact of this scaling up suggests a reduction of maternal mortality, in these 75 countries, from a 2000 aggregate level of 485 to 242 per 100 000 births by 2015, and of neonatal mortality from 35 per thousand live births to 29 by the same date.

Costing the scale up

The cost of implementing these scenarios up to 2015 is estimated at US$ 39 billion (US$ 1 billion in 2006 increasing, as coverage expands, to US$ 6 billion in 2015), additional to current expenditure on maternal and newborn health. This corresponds to around US$ 0.22 per inhabitant per year initially, expanding to US$ 1.18 in 2015 (see Figure 5.8; a breakdown of the estimated costs is given in Box 5.4).

Of this investment, 18% would be to scale up access to 50% in the 20 countries facing the greatest challenge (the equivalent of US$ 1.25 per inhabitant per year); 17% for the 25 countries that would reach 65% coverage (US$ 0.87 per inhabitant per year); 9% for the 18 countries that can reach 95% coverage by 2015 (US$ 0.74 per inhabitant per year); and 56% for the 12 countries that can reach full coverage as of 2010 (US$ 0.61 per inhabitant per year). This outlay corresponds to a growth in the level of public expenditure on health, compared with current levels, of respectively 30%, 5%, 7% and 3% per year.

The largest effort is needed in the poorest and most aid-dependent countries, despite the fact that cost estimates in these countries may be biased downwards because they reflect the current prices of labour and commodities, which are much lower than elsewhere. National authorities and the international community have to be aware that, if the scenarios are implemented, the results obtained will be slowest in the countries where the largest effort is made. In a superficial analysis this may appear an inefficient way of allocating the world’s resources to maternal and newborn health – but it is necessary in order to reduce the growing gaps between countries and to move towards the MDGs in all countries of the world.

Footnotes

³⁷ Maine D, McCarthy J, Ward V. Guidelines for monitoring progress in reduction of maternal mortality. New York, NY, United Nations Children’s Fund, 1992.

³⁸ Van Lerberghe W, Lafort Y. The role of the hospital in the district; delivering or supporting primary health care? Current Concerns SHS Papers, 1990:1–36.

³⁹ Le Coeur S, Pictet G, M’Pelé P, Lallemant M. Direct estimation of maternal mortality in Africa. Lancet, 1998, 352:1525–1526.

⁴⁰ Buekens P. Over-medicalisation of maternal care in developing countries. Studies in Health Services Organisation and Policy, 2001, 17, 195–206.

⁴¹ Harvey SA, Ayabaca P, Bucagu M, Djibrina S, Edson WN, Gbangbade S et al. Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement. International Journal of Gynaecolology and Obstetrics, 2004, 87:203–210.

⁴² Borghi J, Hanson K, Acquah CA, Ekanmian G, Filippi V, Ronsmans C et al. Costs of near-miss obstetric complications for women and their families in Benin and Ghana. Health Policy and Planning, 2003, 18:383–390.

⁴³ Buekens P, Curtis S, Alayon S. Demographic and Health Surveys: caesarean section rates in sub-Saharan Africa. BMJ, 2003, 326:136.

⁴⁴ Kristensen MO, Hedegaard M, Secher NJ. Can the use of cesarean section be regulated? A review of methods and results. Acta Obstetricia Gynecologica Scandinavica, 1998, 77:951–960.

⁴⁵ Walker R, Turnbull D, Wilkinson C. Strategies to address global cesarean section rates: a review of the evidence. Birth, 2002, 29:28–39.

⁴⁶ Carroli G, Belizan J. Episiotomy for vaginal birth (Cochrane Review). Cochrane Database of Systematic Reviews, 1999, 3:CD000081.

⁴⁷ Fraser WD, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour (Cochrane Review). Cochrane Database of Systematic Reviews, 1999, 4:CD000015.

⁴⁸ Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald S. Prophylactic use of oxytocin in the third stage of labour. Cochrane Database of Systematic Reviews, 2001, 4:CD001808.

⁴⁹ Jeffery P, Jeffery R, Lyon A. Labour pains and labour power, London, Zed Books, 1989.

⁵⁰ Van Hollen C. Invoking vali: painful technologies of modern birth in south India. Medical Anthropology Quarterly, 2003, 17:49–77.

⁵¹ Bouvier-Colle MH, Prual A, de Bernis L et le groupe MOMA. Morbidité maternelle en Afrique de l’Ouest. Resultats d’une enquete en population a Abidjan, Bamako, Niamey, Nouakchott, Ougadougou, Saint-louis et Kaolack [Maternal mortality in West Africa. Results from a population-based survey in Abidjan, Bamako, Niamey, Nouakchott, Ougadougou, Saint-louis et Kaolack]. Paris, Ministère des Affaires Etrangères – Cooperation et Francophonie, 1998.

⁵² Ellis M, Manandhar N, Manandhar DS, Costello AM. Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developing country: unmatched case-control study. BMJ, 2000, 320:1229–1236.

⁵³ Dujardin B, Boutsen M, De S, I, Kulker R, Manshande JP, Bailey J et al. Oxytocics in developing countries. International Journal of Gynecology and Obstetrics, 1995, 50:243–251.

⁵⁴ AMDD Working Group on Indicators. Program note. Using UN process indicators to assess needs in emergency obstetric services in Morocco, Nicaragua and Sri Lanka. International Journal of Gynecology and Obstetrics, 2003, 80:222–230.

⁵⁵ AMDD Working Group on Indicators. Program note. Using UN process indicators to assess needs in emergency obstetric services: Bhutan, Cameroon and Rajasthan, India. International Journal of Gynecology and Obstetrics, 2002, 77: 277–284.

⁵⁶ Goodburn EA, Hussein J, Lema V, Damisoni H, Graham W. Monitoring obstetric services: putting the UN guidelines into practice in Malawi. I: developing the system. International Journal of Gynecology and Obstetrics, 2001, 74:105–117.

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