Quality care during labour and birth: A multi-country analysis of health system bottlenecks and potential solutions

Background: Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth. Methods: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system “bottlenecks”, factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care. Results: Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships. Conclusions: Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery. This study used quantitative and qualitative research methods to collect information, assess health system bottlenecks and identify solutions to scale up maternal and newborn care interventions in 12 high burden countries: Afghanistan, Cameroon, Democratic Republic of Congo (DRC), Kenya, Malawi, Nigeria, Uganda, Bangladesh, India, Nepal, Pakistan and Vietnam. The maternal-newborn bottleneck analysis tool (see Additional file 1) was developed to assist countries in the identification of bottlenecks to the scale up and provision of nine maternal and newborn health interventions across the seven health system building blocks as described previously [14,15]. The tool (see Additional file 1) was utilised during a series of national consultations supported by the global Every Newborn Steering Group between July 1st and December 31st, 2013. The workshops for each country included participants from Ministries of Health, UN agencies, the private sector, non-governmental organisations (NGOs), professional associations, academia, bilateral agencies and other stakeholders. For each workshop, a facilitator, orientated on the tool, facilitated the discussions and helped groups reach consensus on specific bottlenecks for health system building blocks [15]. This paper, second in the series, focuses on the bottlenecks related to scale up of SBA, BEmOC and CEmOC. Tracer interventions were defined for each package to focus the workshop discussion. For skilled care at birth, the tracer intervention was the use of the partograph. The partograph is usually available as a pre-printed paper form on which observations on the mother and foetus during labour are recorded. The aim of the partograph is to provide a pictorial overview of labour to alert skilled birth attendants to deviations in maternal or foetal wellbeing and labour progress. For BEmOC, the tracer intervention was assisted vaginal delivery, which refers to the application of either forceps or a vacuum device to assist the mother in effecting vaginal delivery of a foetus. For CEmOC, the tracer intervention was caesarean section, the procedure of delivering a baby through incisions made in the mother’s abdominal wall and uterus. Data received from each country were analysed and the graded health system building blocks were converted into heat maps. Bottlenecks for each health system building block were graded using one of the following options: not a bottleneck (=1), minor bottleneck (=2), significant bottleneck (=3), or very major bottleneck (=4). We first present the grading in heat maps according to the very major or significant health system bottlenecks as reported by all 12 countries, then by mortality contexts (neonatal mortality rate [NMR] <30 deaths per 1000 live births and NMR ≥30 deaths per 1000 live births) and then by region (countries in Africa and countries in Asia) (Figure 2a-c). We developed a second heat map showing the specific grading of bottlenecks for each health system building block by individual country (Figure 3a-c). Very major or significant health system bottlenecks for labour and birth. NMR: Neonatal Mortality Rate *Cameroon, Kenya, Malawi, Uganda, Bangladesh, Nepal, Vietnam. **Democratic Republic of Congo, Nigeria, Afghanistan, India, Pakistan. See additional file 2 for more details. Part A: Grading according to very major or significant health system bottlenecks for skilled birth attendance as reported by twelve countries combined. Part B: Grading according to very major or significant health system bottlenecks for basic emergency obstetric care (BEmOC) as reported by twelve countries combined. Part C: Grading according to very major or significant health system bottlenecks for comprehensive emergency obstetric care (CEmOC) as reported by twelve countries combined. Individual country grading of health system bottlenecks for labour and birth. Part A: Heat map showing individual country grading of health system bottlenecks for skilled birth attendance (SBA) and table showing total number of countries grading significant or major bottleneck for calculating priority building blocks. Part B: Heat map showing individual country grading of health system bottlenecks for basic emergency obstetric care (BEmOC) and table showing total number of countries grading significant or major bottleneck for calculating priority building blocks. Part C: Heat map showing individual country grading of health system bottlenecks for comprehensive emergency obstetric care (CEmOC) and table showing total number of countries grading significant or major bottleneck for calculating priority building blocks. DRC: Democratic Republic of the Congo. Finally, we categorised context specific solutions from the countries into thematic areas linked to the specific bottlenecks (Tables ​(Tables11 and ​and2).2). We undertook a literature review to identify further case studies and evidence-based solutions for each defined thematic area (Additional file 2). For more detailed analysis of the steps taken to analyse the intervention specific bottlenecks, please refer to the overview paper [15]. The findings of the national MNH bottleneck analyses were also compared with results of the biennial WHO Maternal, Newborn, Child, Adolescent Health (MNCAH) policy surveys where information is collected from national Ministries of Health [16]. Summary of solution themes and proposed actions for quality care during labour and birth (part A). Summary of solution themes and proposed actions for quality care during labour and birth (part B).