The scale, scope, coverage, and capability of childbirth care

This is the third paper in a Lancet Series of six papers about maternal health. It focuses on health care during delivery, or ‘intrapartum care’.MethodsThis paper draws on evidence from Demographic and Health Surveys, health facility assessments and the wider literature to analyse the status of care during delivery across low- and middle-income countries (LMICs).Key points

• While facility-based deliveries and deliveries by skilled birth attendants (SBAs) are increasing across the globe, more can be done to increase the impact of this on maternal mortality and morbidity (ill health)
• Policy-maker and government focus on training SBAs and providing emergency obstetric care (EmOC) can sometimes mean a relative lack of focus on other aspects, for example staff maintaining skills and facilities providing routine care as well as emergency care
• The authors propose looking also at timely access to care, especially for women who live in remote places or are most vulnerable. They have designed a framework depicting the ‘pathways’ to care for routine and emergency deliveries, focusing on the need to ensure women can plan ahead, access transport to facilities or maternity waiting homes, and access referrals between facilities when needed
• The authors argue that it is unethical to promote facility deliveries in places where facilities have inadequate capacity, no referral plans in place, or where providers are absent, unskilled or lack confidence because they practice their delivery skills infrequently. They argue that childbirth at facilities should only be promoted if facilities can be proven to guarantee a basic EmOC standard
• The paper identifies a wide range of models of care in place across LMICs
• It discusses the benefits and risks of different models of care, ranging from countries where most deliveries occur in smaller facilities led by midwives to countries where most deliveries happen in large central hospitals led by doctors.
• While midwife-led models may have less trained or confident providers because they see low numbers of deliveries, they are often easier for women to access. In doctor led central models, they are more equipped to deal with emergencies but women may not attend because of access or transport issues and high costs. These types of facilities are also at risk of ‘overmedicalisation’ (a tendency towards unnecessary medical interventions) and shorter patient stays
• There is no one model of care that can be prescribed for all settings. LMICs should choose their model of care based on research into their setting

ConclusionThe Sustainable Development Goals era gives us an opportunity to review and improve how we measure and plan intrapartum care. We need to focus research and planning on the birth location and its capacity to provide quality, respectful care; the establishment and maintenance of birth attendant skills; women’s ability to access timely routine and emergency care; and women’s ability to be transferred promptly through the correct care pathways when complications arise.To read the original article for free after registering, click here.To read the Sustainable Development Goals, click here.Campbell, O., Calvert, C., Testa, A., Strehlow, M., Benova, L., Keyes, E., Donnay, F., Macleod, D., Gabrysch, S., Rong, L., Ronsmans, C., Sadruddin, S., Koblinsky, M., & Bailey, P. (2016). The scale, scope, coverage, and capability of childbirth care. The Lancet Maternal Health Series Paper 3, (Early online publication).