Encouraging facility-based delivery as a strategy to increase skilled attendance at birth in order to reduce maternal and neonatal deaths has been a priority in the global maternal health agenda for decades. However, it has been widely recognized that expanding facility-based births without addressing issues of equity, quality and dignity is not sufficient for improving maternal health. In a recent paper published in Health Policy and Planning, Dominic Montagu and colleagues examined trends in delivery location in Africa and Asia using data from Demographic and Health Surveys and offered policy recommendations for future efforts.
Trends in delivery location
Between 2003 and 2013, the percentage of women who delivered in health facilities increased in every region of the world. Except for urban Western Africa, this trend was observed in both urban and rural areas.
Despite an overall surge in facility-based deliveries, large socioeconomic disparities persist. In most regions, more than 80% of women in the wealthiest quintile give birth at a facility, while the same is true of fewer than half of those in the poorest quintile. In Southeast Asia, only 17% of the poorest women deliver in a facility.
Implications for health systems
In response to this upward trend in facility-based deliveries, and taking into account resource limitations in many parts of Africa and Asia, the authors put forth four policy recommendations for improving maternal health:
- Additional investment in mid-level facilities and a shift away from low-volume facilities in rural areas for maternity care
- Assured access for rural women before and after delivery through funding for transport infrastructure, travel vouchers, targeted subsidies and residence support
- More specialization of maternity facilities and dedicated maternity wards within larger institutions
- A renewed focus on quality improvement at all levels of private and public facilities providing delivery services
Evidence suggests that women are able to judge the quality of health facilities and make decisions about where they will seek care accordingly. The authors argue that as countries continue to strengthen their roads and transport systems, more women will bypass the nearest facilities, choosing instead to travel farther distances for higher quality, respectful maternity care.
Moving forward under the Sustainable Development Goals
Increases in facility-based delivery have not yielded proportional decreases in maternal mortality, illustrating the importance of high quality care. Achieving the global and national maternal mortality targets under the Sustainable Development Goals (SDGs) will require tackling wider health systems issues to ensure that all facilities have the necessary infrastructure, supplies and well-trained workforce to care for women once they arrive at the hospital.
Source of graphics: Montagu et al. Where women go to deliver: Understanding the changing landscape of childbirth in Africa and Asia. Health Policy and Planning 2017, czx060.
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