Demand for better care by women linked with the expansion of basic services, rather than political pressure, has helped to improve midwifery services in low to middle-income countries, according to international research involving the University of Southampton.
An examination of maternal and newborn health systems for the Lancet Series on Midwifery found that after initial investment in maternal and newborn health infrastructure, a virtuous cycle developed in these countries - with increased demand for care leading to the deployment of more midwives, better services, improved outcomes, and again, in-turn, more demand and investment.
Co-author of the paper Professor Zoë Matthews, a social scientist at the University of Southampton, says: "We found that initial investment in services was crucial in kick-starting this cycle, which ultimately saw more and more women wanting to make use of the vital care that midwives provide for them and their babies.
"This cycle was driven largely by the women themselves, as well as committed health professionals, intent on improving standards and levels of care. Political backing and commitment came later in the process when people began to see the benefits. However, political will does help to maintain the momentum towards covering whole populations with care around childbirth."
The researchers, funded partly through a grant from the Bill and Melinda Gates Foundation, used Demographic and Health Surveys, World Health Organization (WHO) reports, interviews with health system workers and numerous other relevant papers and documents to examine care-giving at childbirth over a 20-30 year period.
The study found 21 countries on-track or making good progress towards the Millennium Development Goals (MDGs) on improving maternal health, which now have less than 500 days to be achieved.
Further concentrated work was then conducted on four countries, Burkina Faso, Cambodia, Indonesia and Morocco, which have shown sustained and substantial reduction of maternal and newborn deaths, while deploying midwives as a core element of their health strategy.
In these countries, findings showed:
- A virtuous cycle of initial investment, improvement, care, demand and further investment was established.
- A concentration on quality of care only happened when uptake of care increased substantially.
- The deployment of midwives was driven by health care professionals.
- Political endorsement of improving maternal and newborn health services only came after the population appreciated its benefits and became more vocal on the issue.
Professor Matthews comments: "This study shows how initial investment and enthusiasm at the grass-roots of maternal and newborn health services can snowball and lead to greater investment and improved systems - ultimately saving women and babies lives.
"No one is pretending that care in these four countries is perfect, but they can act as good examples to others of how it is possible to improve services, promote midwifery and ultimately, substantially reduce mortality rates."
The paper, Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality, was led by Dr Wim Van Lerberghe of WHO and co-authored by Professor Matthews together with a number of colleagues internationally. It can be found at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60919-3/fulltext
The paper is one of four in the Lancet Series on Midwifery which examine both midwifery and the people who provide it. The series provides an examination of the evidence base that distinguishes between what care is needed, how it is provided, and who should provide it - offering essential information to educators, regulators, health system planners and decision makers. A summary of all four papers can be found here: http://www.
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