The Cochrane Database of Systematic Reviews recently published a qualitative evidence synthesis of factors that influence the provision of intrapartum and postnatal care by skilled birth attendants (SBAs) in low- and middle-income countries. The review included 31 studies outlining the perceptions of doctors, midwives, nurses, auxiliary nurses and their managers in countries across sub-Saharan Africa, Asia and Latin America.
The authors evaluated each identified factor according to the quality of supporting evidence. Below are some of the challenges to providing high quality maternity care that were supported by the strongest evidence.
Human resources
- Staff shortages and heavy workloads hinder health workers’ ability to provide high quality care to every patient and can cause stress and frustration.
- Lack of specialists or experienced staff such as anesthesiologists can lead to unsafe task-shifting to unqualified personnel.
- Insufficient salaries, benefits and financial incentives often negatively affect motivation among health workers.
- Unsupportive management can leave health workers’ concerns unacknowledged or unaddressed.
Education and training
- Inadequate pre-service and in-service training limits health workers’ ability to provide skilled care, especially for high-risk pregnancies or deliveries.
- In-service trainings can be unaffordable, inconvenient or inaccessible for some staff members.
Commodities and health services infrastructure
- Unreliable availability of drugs, supplies and equipment can force health workers to administer suboptimal medications or provide care under unsafe or unsanitary conditions.
- Scarcity of blood or infrastructure for blood transfusions is dangerous in cases of obstetric emergencies such as postpartum hemorrhage.
- Poor access to electricity, fuel or clean water is a barrier to high quality care.
- Suboptimal physical layout or insufficient space can make health workers’ jobs more difficult.
Referral mechanisms
- Reluctance of mothers to be referred to a higher-level facility may result in midwives feeling pressured to handle high-risk deliveries when they are not comfortable doing so.
- Absence of transport or fuel prohibits transfer to another health facility.
Other challenges included in the review were lack of awareness about current evidence-based practices, nonexistent clinical guidelines or protocols, incomplete patient information, inadequate data management, distrust among different cadres of providers, disrespectful care and poor communication.
Meeting the needs of health workers is essential to ensuring that women receive high quality maternity care. This will require additional research, investment in education and training, strong health system support, increased access to essential resources and continuous monitoring.
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Read the full Cochrane review.
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