Quality must be at the heart of "Universal health coverage" in maternity care

Universal health coverage means ensuring that everyone, everywhere can access quality health services, where and when they need them, without facing financial hardship. This lofty ambition remains far from the realities of a majority of mothers’ experiences of childbirth around the world.

Maternal health suffers from some of the most stark health inequalities. In sub-Saharan Africa a woman’s lifetime risk of dying in pregnancy or childbirth is 1 in 36–compared with 1 in 4,900 in high-income countries, with nearly all these deaths from preventable causes. In sub-Saharan Africa half of all mothers still deliver without the assistance of a skilled birth attendant.

Even in countries with better health outcomes overall, maternal illness and death happens disproportionately to the most vulnerable women, those who are effected by geographical, social, and economic barriers that exclude them from accessing care when they need it.

Universal health coverage remains a critical goal in improving the barriers to access and tackling these inequalities. Particularly critical is the potential to remove financial barriers such as user fees, with their disproportionate burden on the poorest, especially women, who often have primary responsibility for the health care of their family but limited access to the family’s cash. Furthermore, even when universal coverage is limited to core services this usually includes basic reproductive and maternal health services, including necessary interventions for safe, effective contraception. It is these basic services that are proven to prevent the vast majority of maternal deaths.

Yet experience in maternal healthcare indicates that coverage alone does not bring the anticipated benefits in health outcomes. Coverage will only lead to the desired outcomes if that care is of good quality, underpinned by evidence to ensure it is effective, delivered by appropriately trained staff when and where they are needed.

For example, in the quest for universal coverage, India invested heavily in skilled birthing attendants but saw only minimal reductions in maternal mortality. And in other countries such as Kenya the removal of user fees has led to the desired increase in uptake of facility based births, but this has led to overcrowding in some facilities and challenged the system’s ability to maintain or improve quality of care.

The team at the University of Birmingham have been working with the World Health organization (WHO) and our international partners to seek practical and meaningful solutions to these challenges and generate the underpinning evidence.

In a country such as Malawi, there are so few doctors that there is no way they alone can provide access to essential maternal healthcare, such as caesarean sections for emergencies during childbirth. So the backbone of health provision is actually provided by non-physician clinicians, who provide many of the roles usually undertaken by doctors but with local, shorter and less expensive training. We have examined the data and shown that such non-physician clinicians can safely perform caesarean sections.

International shortages in midwives are just as stark. So even for those women accessing facilities they often do not receive the care they need. We are working across 15 facilities in Malawi to reduce the burden on midwives whilst improving care. We have worked with local teams to introduce task-sharing of appropriate roles such as taking routine patient observations to less highly trained hospital workers. With the right training, tools and support we are seeing improved quality of care.

Renewed international focus on universal health coverage will hopefully catalyse significant action. Maternal health is a clear area of need, where there would be much benefit from equitable access. A change is long overdue for those mothers still denied access to affordable and quality care.

Find out more information on the University of Birmingham’s research into Global Maternal Health. You can also find further information on the University of Birmingham’s research into the causes of miscarriage.

Dr David Lissauer

Institute of Metabolism and Systems Research