By Florence Mgawadere
Nothing brings more joy to a family than the birth of a child. Yet, sadly, this unimaginable joy is cut off for many, as around the world, approximately 303,000 women die prematurely during pregnancy, childbirth or in the postnatal period each year. Additionally, each year about 2.6 million babies are stillborn and 2.5 million babies die within the first month after birth. While major progress has been made to improve mortality outcomes for women and newborns, a significant gap continues to exist between high-income and low/middle-income countries (LMIC). LMICs account for approximately 99% of the deaths and most of these are preventable.
While many LMICs have made significant progress in improving access to care, a new reality is at hand: poor quality care in the health system is now responsible for a greater number of deaths than insufficient access to care. It is widely acknowledged that the quality of care provided for mothers and babies falls short of current evidence-based practice and is, in many cases, not women- and baby-friendly. Women suffer more from disrespectful and abusive care than from the labour pain itself.
In one of our research studies, women described time of birth as tense and fraught. One woman said “I thought they were going to handle me like a queen but they didn’t. When you feel pain, they tell you that they are not responsible for your pregnancy. These words have hurt me.”
Research shows that uptake of care and quality of care are closely linked; there are numerous examples in the academic literature describing where and how poor quality of care has stopped women from accessing care services, even where these were available and affordable. In one study, women felt that healthcare providers “don’t care about human life”, “insult people like they’re not a human being” and “will maltreat you like a slave“. The fear of disrespect and abuse often hold women back from seeking institutional care and some women do not report on time and sadly die. However, it is unacceptable that women should die in the hands of skilled providers.
Many healthcare facilities in low-income countries are still under-resourced and unable to cope effectively with serious obstetric complications. Emergency obstetric care (EmOC) is an evidence-based service required to manage potentially life-threatening complications that affect many women during pregnancy, childbirth, and the immediate postpartum period. Poor quality of EmOC services, as defined by a lack of essential medical supplies and lack of training among healthcare providers resulting in a lack of competency, has been reported in sub-Saharan Africa. In other words, availability of EmOC is well below minimum UN target coverage levels.
This situation has left healthcare providers without an enabling environment to provide necessary obstetric care. As a result, provision of sub-standard care has led to women dying of preventable causes such as obstetric hemorrhage, eclampsia, sepsis and complications of abortions.
To complicate matters, skilled workers have attributed disrespectful and abusive care to poor working environments leading to longer waiting times, neglect of patients, and, poor-quality care. It is very difficult to change skilled workers' views on this. I have worked as a midwife in an under-resourced maternity unit and it was so frustrating when we failed to provide the care required due to lack of basic resources.
Improving the health of women and reducing deaths during this critical period, therefore, remains a global priority. There is need to address supply-side health systems barriers (eg staffing/equipment) alongside demand-side factors (eg health-seeking behaviour) if further reductions in maternal mortality are to be achieved. At the Centre for Maternal and Newborn Health (CMNH), Liverpool School of Tropical Medicine, we work to improve the availability and quality of healthcare for mothers and babies, contributing to a global reduction in maternal and newborn mortality and morbidity and improvement in quality of life. We conduct implementation research to inform interventions to end preventable maternal deaths in LMIC. For example, we conducted a study to explore factors associated with maternal mortality in Malawi and explored what is quality in maternal and newborn healthcare.
CMNH also designs and delivers practical and competency-based capacity development interventions to equip healthcare providers with the knowledge and skills to provide effective, good quality maternal and newborn healthcare across the continuum of care spectrum. These approaches have been adopted as best practice by the Ministries of Health and Professional Associations in many countries.
"Women are not dying of diseases we can't treat... but they are dying because societies have yet to make the decision that their lives are worth saving” - Professor Mahmoud Fathalla, a past president of the International Federation of Obstetricians and Gynaecologists. Adopting a clear quality strategy, organizing services to maximize outcomes not access alone, strengthening healthcare worker skills, and enlisting the public in demanding better quality care will bring better outcomes. Low-quality care suggests policy makers must commit to reforming the foundations of healthcare systems.
Florence Mgawadere is Senior Research Associate at CMNH. She is a nurse and midwifery expert in maternal health with over 15 years international clinical and research experience low- and middle-income settings. She has a Master’s in public health from the University of Malawi and PhD from the University of Liverpool. She joined the Centre for Maternal and Newborn Health after several years of clinical, teaching, research and programme experience in the University of Malawi and MoH-Malawi. She is passionate about improving the quality of care for women and their newborn babies in developing countries through evidence-based practice.