Health systems factors influencing maternal health services: a four-country comparison

Abstract

It is widely understood that maternal health care relies on the entire health system. However, little empirical, country-specific, research has been done to trace out the ways in which health system elements can shape maternal health outcomes. This study seeks to redress this situation, by providing an example of how a health systems approach can benefit the understanding of maternal health services. A comparative analysis was conducted based on extensive case studies of maternal health and health systems in Bangladesh, Russia, South Africa, and Uganda. A number of cross-cutting health system characteristics affecting maternal health were identified by comparing these diverse settings. The most important common systems issues underlying maternal health care were found to be the human resource structures, the public–private mix of service provision, and the changes involved with health sector reforms. Specific country contexts can further determine many factors influencing maternal health outcomes and service performance. Systems issues were found to influence the access to and utilization of services, quality of care provided, and ultimately maternal health outcomes. This paper provides a first step in tracing out how such broad systems issues actually work to influence maternal health.

Introduction

It is widely acknowledged that most maternal mortality is avoidable, with proven technical interventions well understood [1], [2]. Access to basic surgery for caesarean sections, blood supplies for hemorrhage, and drugs for eclampsia and infection can avert a large proportion of maternal deaths, and some authors have argued that provision of these technical emergency interventions has featured too low on policy agendas [3], [4]. Others have discussed the effective organization of delivery care—by discussing the merits of home versus hospital delivery, alternative birth attendants, or maternal waiting homes to improve referrals of complications [5], [6], [7]. There have also been calls for social interventions to increase the age of first pregnancy, and to encourage contraceptive use [8], [9], [10].

However, according to Graham, “it has long been recognized that maternal health services are dependent on the functioning of the entire health system” [11: 703], and there has been a growing appreciation in the maternal health literature of the importance of approaching issues from a health systems perspective. Despite a large international focus on delivering cost-effective technical interventions, many middle and low-income countries seem unable to establish systems that effectively provide these required solutions. While the technical aspects of services needed to promote maternal health have been identified and used for decades in the developed world, these do not operate in isolation. The health systems factors that shape the use and effectiveness of existing services or technical inputs are less well understood.

To date, there appear to have only been a small number of conceptual studies discussing the links between health systems and maternal health. Campbell, for instance, has drawn on Roemer's work to highlight the importance of various larger system components, such as resources, organization, management, and economic support for the delivery of maternal services [1]. Others have identified how health sector reforms such as decentralization, privatization, and sector-wide approaches to health financing might possibly improve or hinder maternal or reproductive health provision [2], [10], [12], with McDonagh and Goodburn reviewing the limited existing evidence on this subject [13]. These works recognize the importance of structures and organizational elements on the outcomes and utilization of services, yet there is still large gaps in knowledge on how key systems characteristics affect maternal health care.

Comparison of statistics across different countries illustrates that similar levels of technical inputs, such as numbers of emergency facilities, or percentages of births with a skilled attendant, can lead to very different maternal health outcomes—as seen, for instance, in the relatively high Maternal Mortality Ratio (MMR) in Mexico and the Former Soviet Union, despite near universal hospital delivery [1]. A health systems approach can aid in identifying the essential systemic elements that affect how such technical inputs eventually lead to the availability, use and quality of maternal health services. This paper presents a comparative systems-based analysis of maternal health care in four countries—two low income (Uganda and Bangladesh) and two middle income (South Africa and Russia).

While each country is a unique case, the results of the comparative study specifically highlight three key areas where health systems play significant roles in shaping how specific inputs can work to improve maternal outcomes. The first is the use and quality of human resources, in particular skilled birth attendants. Second is the importance of achieving an appropriate mix of public and private services, and the implications for quality and accessibility of care to women. The third is the impact of health sector reforms, and specifically user fees, on maternal services. Our discussion of vastly different country case studies illustrates how in each of these the setup and operation of the health systems, in conjunction with these inputs, influence maternal health service provision and eventual outcomes.