It can be hard to imagine the challenges some women and their families face whilst trying to access timely and effective maternity care:
“By the time they struggled to get her an admission card, by the time she was admitted, by the time her file was made up, by the time the midwife was called, by the time the midwife finished eating, by the time the midwife came, by the time the husband went and bought some gloves, by the time the midwife examined the woman, by the time the doctor could be found, by the time the husband went out to buy drugs, IV set, drip and bottle of ether, by the time the haematologist was called, by the time the haematologist came and took blood from the poor tired husband, by the time the day and night nurses changed duty, by the time the day and night doctors changed duty, by the time the t’s had been properly crossed and all the i’s dotted and the husband signed the consent form, the woman died.”
Extract from a letter by F Tahzib, University of Sokoto, Nigeria (1989), cited in Thaddeus & Maine (1994)
Although it was written almost 30 years ago, this powerful excerpt serves to illustrate some of the numerous and persistent barriers that still prevent many women from receiving effective and timely care, even once they reach a health facility.
A group of researchers from the University of Oxford decided to examine the literature on this topic in order to better understand these facility-level (otherwise known as Phase III) delays. Previous studies had tended to focus on the challenges women face in reaching a hospital on time, rather than what happened once they arrived.
PLOS has now published this systematic review in its MHTF-PLOS Maternal Health Collection. The review identifies 32 different barriers that can prevent women from receiving timely and appropriate obstetric care once they arrive at a medical facility, and classifies these into 6 categories: human resources; drugs and equipment; facility infrastructure; policy and guidelines; patient-related and referral-related.
The most commonly cited barriers in the literature were:
- inadequate training/skills mix
- drug procurement/logistics problems
- staff shortages
- lack of equipment
- low staff motivation
Two important conclusions emerge from this work and are worth highlighting:
- Although patient-side delays in the decision to seek care and in reaching a medical facility are responsible for a great number of maternal deaths, focusing only on these delays can mask the fact that many health facilities in the developing world are still chronically under-resourced and unable to cope effectively with serious obstetric complications. Providers and policy-makers must work together to address supply-side barriers alongside demand-side factors if further reductions in maternal mortality are to be achieved.
- Simple, replicable tools to assess facility-level barriers are badly needed to assist health managers in identifying facilities that deliver sub-optimal care, and in both making and monitoring the required improvements. No generally accepted methodology exists and this makes comparisons between countries very difficult. The authors call for the introduction of benchmark indicators that assess the content and quality of maternal care, rather than the rates of skilled attendance at birth alone.
Read the systematic review.
Take a look at the MHTF-PLOS Maternal Health Collection.