Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

Roder‐DeWan, Sanam; Nimako, Kojo; Twum-Danso, Nana A.Y.; Amatya, Archana; Langer, Ana; Kruk, Margaret E

doi:10.1136/bmjgh-2020-002539

Cited by 50 publications

(61 citation statements)

References 89 publications

(67 reference statements)

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“…Prior to COVID-19, our study shows that some hospitals were already overburdened with large volumes of births and overcrowding, in some cases with nearly 200% BOR rates and with one health worker delivering an average of 1000 women per year. The association between overcrowding and poor provision and experience of care has been argued by others in Nepal [ 43 ] and elsewhere [ 44 , 45 ], and is reinforced by our study. Before the pandemic, by-passing of the primary referral health facilities (low-volume) was already a challenge in Nepal leading to overcrowding at the higher level facilities (medium-and high-volume) [ 32 , 44 , 46 ].…”

Section: Discussionsupporting

confidence: 88%

“…Just prior to the COVID-19 pandemic, Roder-DeWan and colleagues called for a health system redesign of MNH services in low and middle-income countries, strengthening primary level referral facilities to provide comprehensive services, reducing overcrowding in high-level referral facilities, and providing the care needed to women closer to home [ 44 ]. The COVID-19 pandemic may actually provide an opportunity for health systems to reimagine their systems to do this as evidence from our study and others have shown reduction in institutional deliveries at higher-level facilities overall [ 5 , 7 ].…”

Section: Discussionmentioning

confidence: 99%

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The perfect storm: Disruptions to institutional delivery care arising from the COVID-19 pandemic in Nepal

Peterson

Gurung

et al. 2021

J Glob Health

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Background The COVID-19 pandemic has led to system-wide disruption of health services globally. We assessed the effect of the pandemic on the disruption of institutional delivery care in Nepal. Methods We conducted a prospective cohort study among 52 356 women in nine hospitals to assess the disruption of institutional delivery care during the pandemic (comparing March to August in 2019 with the same months in 2020). We also conducted a nested follow up cohort study with 2022 women during the pandemic to assess their provision and experience of respectful care. We used linear regression models to assess the association between provision and experience of care with volume of hospital births and women’s residence in a COVID-19 hotspot area. Results The mean institutional births during the pandemic across the nine hospitals was 24 563, an average decrease of 11.6% ( P < 0.0001) in comparison to the same time-period in 2019. The institutional birth in high-medium volume hospitals declined on average by 20.8% ( P < 0.0001) during the pandemic, whereas in low-volume hospital institutional birth increased on average by 7.9% ( P = 0.001). Maternity services halted for a mean of 4.3 days during the pandemic and there was a redeployment staff to COVID-19 dedicated care. Respectful provision of care was better in hospitals with low-volume birth (β = 0.446, P < 0.0001) in comparison to high-medium-volume hospitals. There was a positive association between women’s residence in a COVID-19 hotspot area and respectful experience of care (β = 0.076, P = 0.001). Conclusions The COVID-19 pandemic has had differential effects on maternity services with changes varying by the volume of births per hospital with smaller volume facilities doing better. More research is needed to investigate the effects of the pandemic on where women give birth and their provision and experience of respectful maternity care to inform a “building-back-better” approach in post-pandemic period.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 99%

The perfect storm: Disruptions to institutional delivery care arising from the COVID-19 pandemic in Nepal

Peterson

Gurung

et al. 2021

J Glob Health

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“…Existing studies have revealed that a lot of PHC facilities in Northern Ghana[ 21 ] and elsewhere [ 19 , 20 ] are less attractive to women seeking maternal care because of lack of midwives, maltreatment of clients, and poor experience of women with the existing healthcare referral system. It is against this background that some scholars have argued that bypassing PHC to higher level facilities may be important for women to obtain quality maternal healthcare[ 18 ]. To improve upon the relevance and practical feasibility of the current Ghana healthcare gatekeeper and referral system, deliberate policy reforms aimed at strengthening the service delivery capacities of PHC facilities are needed.…”

Section: Discussionmentioning

confidence: 99%

Bypassing primary healthcare facilities for maternal healthcare in North West Ghana: socio-economic correlates and financial implications

Amoro

Abiiro

Alatinga

2021

BMC Health Serv Res

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Background Bypassing primary health care (PHC) facilities for maternal health care is an increasing phenomenon. In Ghana, however, there is a dearth of systematic evidence on bypassing PHC facilities for maternal healthcare. This study investigated the prevalence of bypassing PHC facilities for maternal healthcare, and the socio-economic factors and financial costs associated with bypassing PHC facilities within two municipalities in Northwestern Ghana. Methods A quantitative cross-sectional design was implemented between December 2019 and March 2020. Multistage stratified sampling was used to select 385 mothers receiving postnatal care in health facilities for a survey. Using STATA 12 software, bivariate analysis with chi-square test and binary logistic regression models were run to determine the socio-economic and demographic factors associated with bypassing PHC facilities. The two-sample independent group t-test was used to estimate the mean differences in healthcare costs of those who bypassed their PHC facilities and those who did not. Results The results revealed the prevalence of bypassing PHC facilities as 19.35 % for antenatal care, 33.33 % for delivery, and 38.44 % for postnatal care. The municipality of residence, ethnicity, tertiary education, pregnancy complications, means of transport, nature of the residential location, days after childbirth, age, and income were statistically significantly (p < 0.05) associated with bypassing PHC facilities for various maternal care services. Compared to the non-bypassers, the bypassers incurred a statistically significantly (P < 0.001) higher mean extra financial cost of GH₵112.09 (US$19.73) for delivery, GH₵44.61 (US$7.85) for postnatal care and ₵43.34 (US$7.65) for antenatal care. This average extra expenditure was incurred on transportation, feeding, accommodation, medicine, and other non-receipted expenses. Conclusions The study found evidence of bypassing PHC facilities for maternal healthcare. Addressing this phenomenon of bypassing and its associated cost, will require effective policy reforms aimed at strengthening the service delivery capacities of PHC facilities. We recommend that the Ministry of Health and Ghana Health Service should embark on stakeholder engagement and sensitization campaigns on the financial consequences of bypassing PHC facilities for maternal health care. Future research, outside healthcare facility settings, is also required to understand the specific supply-side factors influencing bypassing of PHC facilities for maternal healthcare within the study area.

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“…Health system redesign to shift births to hospitals may improve coverage of appropriate newborn care in theory, however, requires significant political leadership and infrastructure and policy investment. To avoid exacerbating current disparities and improve equitable access to birth and newborn care, redesign will need to consider geographic, socioeconomic, and other barriers [ 40 ].…”

Section: Discussionmentioning

confidence: 99%

Equity in newborn care, evidence from national surveys in low- and middle-income countries

Peven

Mallick

Taylor

et al. 2021

Int J Equity Health

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Background High coverage of care is essential to improving newborn survival; however, gaps exist in access to timely and appropriate newborn care between and within countries. In high mortality burden settings, health inequities due to social and economic factors may also impact on newborn outcomes. This study aimed to examine equity in co-coverage of newborn care interventions in low- and low middle-income countries in sub-Saharan Africa and South Asia. Methods We analysed secondary data from recent Demographic and Health Surveys in 16 countries. We created a co-coverage index of five newborn care interventions. We examined differences in coverage and co-coverage of newborn care interventions by country, place of birth, and wealth quintile. Using multilevel logistic regression, we examined the association between high co-coverage of newborn care (4 or 5 interventions) and social determinants of health. Results Coverage and co-coverage of newborn care showed large between- and within-country gaps for home and facility births, with important inequities based on individual, family, contextual, and structural factors. Wealth-based inequities were smaller amongst facility births compared to non-facility births. Conclusion This analysis underlines the importance of facility birth for improved and more equitable newborn care. Shifting births to facilities, improving facility-based care, and community-based or pro-poor interventions are important to mitigate wealth-based inequities in newborn care, particularly in countries with large differences between the poorest and richest families and in countries with very low coverage of care.

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Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

Cited by 50 publications

References 89 publications

The perfect storm: Disruptions to institutional delivery care arising from the COVID-19 pandemic in Nepal

The perfect storm: Disruptions to institutional delivery care arising from the COVID-19 pandemic in Nepal

Bypassing primary healthcare facilities for maternal healthcare in North West Ghana: socio-economic correlates and financial implications

Equity in newborn care, evidence from national surveys in low- and middle-income countries

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