A few weeks ago a letter written by Manuela Straneo and Piera Fogliati (Doctors with Africa CUAMM), Claudia Hanson (Karolinska Institute, Stockholm) and Godfrey Mbaruku (Ifakara Health Institute, Tanzania) was published in The Lancet. It was actually more an appeal than a letter – a plea issued in one of the world’s most influential medical journals asking top-level policy-makers to focus greater attention on an issue that risks being overlooked precisely because it is nothing new: maternal mortality during childbirth or due to childbirth-related complications.

What is striking and worthy of mention is not the lack of healthcare facilities in some settings (in this case Tanzania) but rather – paradoxically – an excess of rural delivery sites. Indeed, the extensive network of primary healthcare facilities throughout the country makes it possible even for women in rural areas to get to one by foot. However, this is precisely the problem: the large number of such facilities actually lowers the quality of the services provided, because the low delivery volumes in individual facilities makes it difficult for staff to gain sufficient childbirth experience. As a result, in a country where 51.8% of institutional deliveries take place in primary healthcare facilities, pregnant women still face an extremely high risk of delivery-related complications or death.

Thus safe childbirth is far less likely in remote rural areas, the poorest and most marginalized in African countries. Yet decisions could be made “from above” to organize healthcare systems differently, reducing the number of rural delivery sites without reducing access to critical health services by the women who live in such areas. We talked about this with Manuela Straneo, a doctor, public health expert and co-author of the letter, who underscored the need to tailor health policies to fit the needs of different countries and settings in order to ensure the right to health for all.

A letter in The Lancet to draw attention to the right to safe childbirth through quality health care services: who is the appeal actually addressed to?

A few months ago The Lancet published a series of articles on maternal health that highlighted the existence of two “extreme situations” with regard to maternal health care: either “too little, too late” or “too much, too soon”. It isn’t difficult to guess which countries find themselves at either end of this continuum.

Our letter was addressed to everyone who is working to reduce maternal mortality in low-resource settings such as those found in Sub-Saharan Africa. Every year some 200,000 women and one million newborns die in Africa alone; there are also another one million stillbirths. We wrote our appeal to urge that greater focus be put on childbirth services in first-line primary healthcare facilities. Standards need to be defined to ensure safe childbirth at this level as well. This is crucial because more than half of all deliveries (52% in Tanzania) tend to take place in such facilities. But it is also crucial in order to improve equity: the women who give birth in these facilities are the poorest of the poor, thus it is they who bear the greatest burden in terms of the poor quality of health services.

The letter explains how although there is no lack of health facilities in Tanzania where women can give birth, the quality of the services provided there is poor. The reason is that there are so many of them, in fact, that the delivery volumes in each are too low to allow staff to gain sufficient childbirth experience. What is the association between the delivery volumes in individual facilities and the quality of care provided?

Tanzania offers a perfect example of this problem. After gaining its independence in 1961, the country became one of the first to roll out primary health care. The extensive network of primary healthcare facilities there means that 85% of the population can get to one by foot in an hour or less. Thanks to this network, some areas of the country have achieved nearly universal coverage for maternal health services. By analyzing the situation in Tanzania we can learn lessons that can help us understand other African settings.

The extensiveness of the health network is good for the population in many ways; they can go to a facility for vaccinations, prenatal care and care for children under the age of 5. But childbirth services are more complex: you can’t plan the timing of deliveries, so you must provide an around-the-clock service. Complications during delivery are not that frequent, but when they arise they can put the lives of both mother and baby at risk in the space of just a few hours. And without sufficient practice, how can midwives keep their skills sharp enough to know how to resuscitate a newborn who has stopped breathing, or stop a mother’s bleeding during childbirth? Doctors with Africa CUAMM’s work in Tanzania has brought to light the fact that delivery volumes in individual facilities in rural areas are low: there is an abundance of these facilities, and many handle only a few deliveries a year. So while coverage has gone up, low delivery volumes mean that the quality of the services provided has gone down.

What is the optimal caseload to ensure that the staff of individual facilities are able to provide quality childbirth services? We don’t have any hard data on this yet, and we wanted to make this known by having our letter published in one of the most widely-read and influential medical journals. Our aim was to focus readers’ attention on an area where services could be improved for the most vulnerable women, those at highest risk of mortality.

The word “solution” might not be the most apt in a context such as this. What suggestions, then, would you and your colleagues make in order to improve the situation?

In high-resource countries such as Italy, delivery sites have been centralized in recent years in order to ensure higher-quality care for mothers and their babies. But what is the right solution for low-resource countries? Whatever it is, it must surely be embraced by local health authorities and the women using the service. It’s the job of those who have been working in such settings for decades to save the lives of women and children – including Doctors with Africa CUAMM – to put forth suggestions about how this complex service could be improved. Studies carried out by CUAMM in partnership with the University of Siena in Tanzania’s Iringa and Njombe Regions have shown that it would be possible to cut down on the number of rural delivery sites without making the distance that women must walk to give birth excessively long. However, in order to improve the organization of childbirth services, we need more data, particularly with regard to optimal delivery volumes.

References

• http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30342-2/fulltext
• Straneo M., Fogliati P., Azzimonti G., Mangi S., Kisika F., Where do the rural poor deliver when high coverage of health facility delivery is achieved? Findings from a community and hospital survey in Tanzania, published in PLoS One, 2014; 9
• Fogliati P., Straneo M., Brogi C. et al., How can childbirth care for the rural poor be improved? A contribution from spatial modelling in rural Tanzania, published in PLoS One, 2015; 10