Maternal Health Task Force


“Dropping Out” Before Delivery: When Skilled Care Is not High Quality Care

By: Adaeze Wosu, Doctoral Student, Johns Hopkins Bloomberg School of Public Health; Adanna Chukwuma, Young Professional, Health, Nutrition and Population Global Practice, World Bank Group; Chinyere Mbachu, Research Associate, Health Policy Research Group, University of Nigeria; Kelechi Weze, Doctoral Student, Harvard T. H. Chan School of Public Health

Nneka’s story

Nneka* is a 28-year old Nigerian woman. She and her husband have been married for three years and run a small chicken farm in their village. Neither has a formal education. After Nneka discovers she is pregnant with her first child, she walks 30 minutes to the nearest health clinic to receive antenatal care from a nurse-midwife. Several months later as her labor begins, Nneka asks her husband to take her to the local traditional birth attendant’s house to deliver her baby. The baby is delivered safely, but Nneka bleeds heavily afterwards. When the traditional birth attendant’s efforts fail to stop the bleeding, Nneka’s husband rushes her to the general hospital for specialized care—but it is too late. Nneka dies, her husband is inconsolable and her child is left motherless and at increased risk of death.

The continuum of maternal health care

Scenarios like Nneka’s are common in many places around the world, particularly in low-resource settings. Women who receive skilled care during pregnancy often “drop out” during a critical period of the continuum of care and end up delivering at home or in the community without a certified, properly trained health professional, putting themselves and their newborns at risk.

Most studies examining factors that influence drop-out from the skilled care continuum have focused on individual-level demographic characteristics, suggesting that women who drop out of skilled care after the antenatal period tend to be like Nneka: less educated, poor and living in a rural area. The existing literature exploring how women’s past experiences affect their subsequent care-seeking decisions is more limited. Might the way Nneka was treated during the antenatal period have influenced her decision not to seek skilled delivery care?

Evidence from 28 countries in Africa

Researchers from the World Bank Group, Johns Hopkins Bloomberg School of Public Health, the University of Nigeria’s Health Policy Research Group and the Harvard T.H. Chan School of Public Health recently published an open access paper in BMC Pregnancy and Childbirth to explore the reasons why women like Nneka drop out of skilled care before delivery. Based on nationally representative data from 115,374 births in 28 African countries, we compared women’s antenatal care experiences to the recommendations put forth by the World Health Organizations (WHO)’s focused antenatal care model. Using multilevel modelling to adjust for several individual-level and country-level factors, we explored the relationships between women’s antenatal care experiences with a skilled provider and whether they sought skilled delivery care. Since several countries did not have a standard definition for a skilled provider, we used WHO’s definition.

Overall, only 66% of mothers who received antenatal care from a skilled provider went on to deliver with a skilled birth attendant. However, when women received the recommended services during antenatal care, the likelihood of skilled birth attendance increased significantly. On average, the odds of retention in skilled birth attendance was 18% higher if blood pressure was checked at least once during antenatal care, 55% higher if a urine test was conducted, 31% higher if a blood test was done, 18% higher if a woman was told about pregnancy complications and 12% higher if she received a tetanus injection.

Skilled care versus high quality care

These findings highlight an important point: Receiving health care from a skilled provider, regardless of how “skilled” is defined, does not necessarily guarantee high quality care. In this study, many women who saw a skilled health care provider during pregnancy did not receive all of the evidence-based practices recommended for antenatal care. If women do not receive the high quality antenatal care that they need and deserve, they may choose not to return for labor and delivery or postpartum care. Improving maternal health services throughout the continuum of care is critical to ensuring skilled birth attendance and, ultimately, reducing maternal and newborn deaths.

* Nneka’s story is based on real qualitative data—the name has been changed to protect confidentiality.

Read the full, open access article, “Quality of antenatal care predicts retention in skilled birth attendance: A multilevel analysis of 28 African countries.”

Explore other posts from the Quality of Maternal Health Care blog series.

Learn about the skilled birth attendance indicator and other strategies for measuring quality of maternal health care.

Categories: Contributor Posts Quality of Maternal Health Care


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