Improving Maternal Survival in South Asia - What Can We Learn from Case Studies?

Abstract

Technical interventions for maternal healthcare are implemented through a dynamic social process. Peoples' behaviours—whether they be planners, managers, providers, or potential users—influence the outcomes. Given the complexity and unpredictability inherent in such dynamic processes, the proposed cause-and-effect relationships in any one context cannot be directly transferred to another. While this is true of all health services, its importance is magnified in maternal healthcare because of the need to involve multiple levels of the health system, multiple types of care providers from the highly skilled specialist to community-level volunteers, and multiple technical interventions, without the ability to measure significant change in the outcome, the maternal mortality ratio. Patterns can be followed however, in terms of outcomes in response to interventions. From these case studies of implementation of maternal health programmes across five states of India, Pakistan, and Bangladesh, some patterns stand out and seem to apply virtually everywhere (e.g. failure of systems to post staff in difficult areas) while others require more data to understand the observed patterns (e.g. response to financial incentives for improving maternal health systems; instituting available accessible safe blood). The patterns formed can provide guidance to programme managers as to what aspects of the process to track and micro-manage, to policy-makers as to what features of a context may particularly influence impacts of alternative maternal health strategies, and to governments more broadly as to the factors shaping dynamic responses that might themselves warrant intervention.

Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal

“…Adequate preparation through effective training, ongoing professional development, supportive supervision, appropriate infrastructure, sufficient supplies and equipment, support from communities and other health workers, and rapid referral mechanisms were all judged by SBAs to be necessary to quality care. These are consistent with findings in other low and middle‐income countries (McPake & Koblinsky ; Chodzaza & Bultemeier ; Sychareun et al . ).…”

Unmasking the open secret of posting and transfer practices in the health sector

“…The academic and grey literature shows widely shared agreement in the global health, development and anti-corruption communities that health care worker and administrator posting and transfer practices are problematic ( McPake and Koblinsky 2009 ; Nugroho 2011 ; Olowu 1999 ; World Bank 1997 ). Media coverage suggests that these concerns are shared by the public in at least some affected countries ( The Statesman 2002 ; The Statesman 2007 ; United News of India 2011 ; Press Trust of India 2011 ).…”

“…Actual posting and transfer practice is likely a negotiated outcome of transferee and transferor preferences and objectives, embedded in larger political and social dynamics of the health system and beyond. Academics and policy-makers have stated that MI posting and transfer contributes to health worker shortages in the most deprived areas; health care worker and administrator demotivation; poor co-operation among and within health care cadres; inefficiency; delays in reform and public health programme implementation; lack of accountable relationships between health care workers and administrators and the communities they serve as well as among health care system cadres; and inability to accurately monitor health care worker and administrator performance and to develop rational training, recruitment and scale-up plans ( Collins et al 2000 ; McPake and Koblinsky 2009 ; Second Administrative Reforms Commission 2008 ; Tjoa et al 2010 ; Diarra 2012 ).…”

Safe Motherhood Case Studies: Learning with Stakeholders in South Asia—An Introduction

“…The debates, including the resulting patterns of issues and solutions that became the grist of these stakeholders' meetings (Box 2), are further detailed in the summary paper, and individual papers in this issue of the Journal (14). Such debates on issues of human resources, financing, management gaps, and availability of blood are just a beginning; much more experimenting and learning on these and other implementation issues of safe motherhood are needed, along with stakeholders' dialogue to foster change and achieve scale for safe motherhood programmes based on more localized learning.…”