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The 3-Delays Model has helped in the identification of access barriers to obstetric care in low and middle-income countries by highlighting the responsibilities at household, community and health system levels. Critiques of the Model include its one-dimensionality and its limited utility in triggering preventative interventions. Such limitations have prompted a review of the evidence to establish the usefulness of the Model in optimising timely access to intrapartum care. To determine the current utility of the 3-Delays Model and its potential for supporting a solution-based approach to accessing intrapartum care. We conducted a qualitative evidence synthesis across several databases and included qualitative findings from stand-alone studies, mixed-methods research and literature reviews using the Model to present their findings. Papers published between 1994 and 2019 were included with no language restrictions. Twenty-seven studies were quality appraised. Qualitative accounts were analysed using the 'best-fit framework approach'. This synthesis included twenty-five studies conducted in Africa, Asia, Latin America and the Caribbean. Five studies adhered to the original 3-Delays Model's structure by identifying the same factors responsible for the delays. The remaining studies proposed modifications to the Model including alterations of the delay's definition, adding of new factors explaining the delays, and inclusion of a fourth delay. Only two studies reported women's individual contributions to the delays. All studies applied the Model retrospectively, thus adopting a problem-identification approach. This synthesis unveils the need for an individual perspective, for prospective identification of potential issues. This has resulted in the development of a new framework, the Women's Health Empowerment Model, incorporating the 3 delays. As a basis for discussion at every pregnancy, this framework promotes a solution-based approach to childbirth, which could prevent delays and support women's empowerment during pregnancy and childbirth. [ABSTRACT FROM AUTHOR]

Introduction High maternal and infant mortality continue to be major challenges to the attainment of the Millennium Development Goals for many low and middle-income countries. There is now evidence that voucher initiatives can increase access to maternal health services. However, a dearth of knowledge exists on the cost implications of voucher schemes. This paper estimates the incremental costs of a demand and supply side intervention aimed at increasing access to maternal health care services. Methods This costing study was part of a quasi-experimental voucher study conducted in two districts in Eastern Uganda to explore the impact of demand and supply - side incentives on increasing access to maternal health services. The provider's perspective was used and the ingredients approach to costing was employed. Costs were based on market prices as recorded in program records. Total, unit, and incremental costs were calculated. Results The estimated total financial cost of the intervention for the one year of implementation was US$525,472 (US$1 = 2200UgShs). The major cost drivers included costs for transport vouchers (35.3%), health system strengthening (29.2%) and vouchers for maternal health services (18.2%). The average cost of transport per woman to and from the health facility was US$4.6. The total incremental costs incurred on deliveries (excluding caesarean section) was US$317,157 and US $ 107,890 for post natal care (PNC). The incremental costs per additional delivery and PNC attendance were US$ 23.9 and US$ 7.6 respectively. Conclusion Subsidizing maternal health care costs through demand and supply - side initiatives may not require significant amounts of resources contrary to what would be expected. With Uganda's Gross Domestic Product (GDP) per capita of US$551 (2012). Incremental cost per additional delivery represents about 5% of Uganda's GDP per capita to save a mother and probably her new born. For many low income countries, this may not be affordable, yet reliance on donor funding is often not sustainable. Alternative ways of raising additional resources for health must be explored. These include; encouraging private investments in critical sectors such as rural transport, health service provision; mobilizing households to save financial resources for preparedness, and financial targeting for the most vulnerable. [ABSTRACT FROM AUTHOR]

Background: A community health programme in Narok County in Kenya aimed to improve skilled birth assistance during childbirth through two demand side interventions. First, traditional birth attendants (TBAs) were co-opted into using their influence to promote use of skilled birth attendants (SBAs) at health facilities during delivery, and to accompany pregnant women to health facilities in return for a Ksh500 (Approximately USD5 as of August 2016) cash incentive for each pregnant mother they accompanied. Secondly, a free Motherpack consisting of a range of baby care items was given to each mother after delivering at a health facility. This paper estimates the impact of these two interventions on trends of facility deliveries over a 36-month period here.Methods: Dependency or inferred causality was estimated between reorientation of TBAs and provision of Motherpacks with changes in facility delivery numbers. The outcome variable consists of monthly facility delivery data from 28 health facilities starting from January 2013 to December 2015 obtained from the District Health Information Systems 2 (DHIS2). Data were collected on the 13th, 14th or 15th of each month, resulting in a total of 35 collections, over 35 months. The intervention data consisted of the starting month for each of the two interventions at each of the 28 facilities. A negative binomial generalized linear model framework is applied to model the relationship as all variables were measured as count data and were overdispersed. All analyses were conducted using R software.Findings: During the 35 months considered, a total of 9095 health facility deliveries took place, a total of 408 TBAs were reached, and 2181 Motherpacks were distributed. The reorientation of TBAs was significant (p = 0.009), as was the provision of Motherpacks (p = .0001). The number of months that passed since the start of the intervention was also found to be significant (p = 0.033). The introduction of Motherpacks had the greatest effect on the outcome (0.2), followed by TBA intervention (0.15). Months since study start had a much lower effect (0.05).Conclusion: Collaborating with TBAs and offering basic commodities important to mothers and babies (Motherpacks) immediately after delivery at health facilities, can improve the uptake of health facility delivery services in poor rural communities that maintain a strong bias for TBA assisted home delivery. [ABSTRACT FROM AUTHOR]

Background: India has experienced a steep rise in institutional childbirth. The relative contributions of public and private sector facilities to emergency obstetric care (EmOC) has not been studied in this setting. This paper aims to study in three districts of Gujarat state, India:(a) the availability of EmOC facilities in the public and private sectors; (b) the availability and distribution of human resources for birth attendance in the two sectors; and (c) to benchmark the above against 2005 World Health Report benchmarks (WHR2005).Methods: A cross-sectional survey of obstetric care facilities reporting 30 or more births in the last three months was conducted (n = 159). Performance of EmOC signal functions and availability of human resources were assessed.Results: EmOC provision was dominated by private facilities (112/159) which were located mainly in district headquarters or small urban towns. The number of basic and comprehensive EmOC facilities was below WHR2005 benchmarks. A high number of private facilities performed C-sections but not all basic signal functions (72/159). Public facilities were the main EmOC providers in rural areas and 40/47 functioned at less than basic EmOC level. The rate of obstetricians per 1000 births was higher in the private sector.Conclusions: The private sector is the dominant EmOC provider in the state. Given the highly skewed distribution of facilities and resources in the private sector, state led partnerships with the private sector so that all women in the state receive care is important alongside strengthening the public sector. [ABSTRACT FROM AUTHOR]

Background: Institution-based childbirth, with the ultimate goal of universal access to skilled birth attendance (SBA), has been selected as a key strategy to reduce the maternal mortality rate in many developing countries. However, the question of how to engage traditional birth attendants (TBAs) in the advocacy campaign for SBA poses a number of challenges. This paper aims to demonstrate how TBAs in rural regions of China have been integrated into the health system under a policy of institutional delivery.Methods: Research was conducted through literature and document reviews and individual in-depth interviews with stakeholders of the safe motherhood program in rural Guangxi Zhuang Autonomous Region, China. A total of 33 individual interviews were conducted with regional and local politicians, policy makers, health managers, health providers, civil society members, village cadres for women affairs, former TBAs, village maternal health workers, mothers and their mother-in-laws.Results: Since 1998, TBA's traditional role of providing in-home care during childbirth has been restructured and their social role has been strengthened in rural Guangxi. TBAs were redesigned to function as the linkage between women and the health system. A new policy in 1999 shifted the role of TBAs to village maternal health workers whose responsibilities were mainly to promote perinatal care and institution-based delivery of pregnant women. This successful transformation involved engaging with government and other actors, training TBAs for their new role, and providing incentives and sanctions for human resources management.Conclusions: The China experience of transforming the role of TBAs in Guangxi rural area is an example of successfully engaging TBAs in promoting institution-based childbirth. [ABSTRACT FROM AUTHOR]

As most pregnancy-related deaths and morbidities are clustered around the time of childbirth, quality of care during this period is critical to the survival of pregnant women and their babies. Despite the wide acceptance of partograph as the central tool to optimize labour outcomes for over 40 years, its use has not successfully improved outcomes in many settings for several reasons. There are also increasing questions about the validity and applicability of its central feature --"the alert line"-- to all women regardless of their labour characteristics. Apart from the known deficiencies in labour care, attempts to improve quality of care in low resource settings have also failed to address and integrate women's birth experience into quality improvement processes. It was against this background that the World Health Organization (WHO) embarked on the Better Outcomes in Labour Difficulty (BOLD) project to improve the quality of intrapartum care in low- and middle-income countries. The main goal of the BOLD project is to reduce intrapartum-related stillbirths, maternal and newborn mortalities and morbidities by addressing the critical barriers to the process of good quality intrapartum care and enhancing the connection between health systems and communities. The project seeks to achieve this goal by (1) developing an evidence-based, easy to use, labour monitoring-to-action decision-support tool (currently termed Simplified, Effective, Labour Monitoring-to-Action -- SELMA); and (2) by developing innovative service prototypes/tools, co-designed with users of health services (women, their families and communities) and health providers, to promote access to respectful, dignified and emotionally supportive care for pregnant women and their companions at the time of birth ("Passport to Safer Birth"). This two-pronged approach is expected to positively impact on important domains of quality of care relating to both provision and experience of care. In this paper, we briefly describe the rationale for innovative thinking in relation to improving quality of care around the time of childbirth and introduce WHO current plans to improve care through research, design and implementation of innovative tools and services in the post-2015 era. [ABSTRACT FROM AUTHOR]

Background: India launched a national conditional cash transfer program, Janani Suraksha Yojana (JSY), aimed at reducing maternal mortality by promoting institutional delivery in 2005. It provides a cash incentive to women who give birth in public health facilities. This paper studies the extent of program uptake, reasons for participation/ non participation, factors associated with non uptake of the program, and the role played by a program volunteer, accredited social health activist (ASHA), among mothers in Ujjain district in Madhya Pradesh, India. Methods: A cross-sectional study was conducted from January to May 2011 among women giving birth in 30 villages in Ujjain district. A semi-structured questionnaire was administered to 418 women who delivered in 2009. Socio-demographic and pregnancy related characteristics, role of the ASHA during delivery, receipt of the incentive, and reasons for place of delivery were collected. Multinomial regression analysis was used to identify predictors for the outcome variables; program delivery, private facility delivery, or a home delivery. Results: The majority of deliveries (318/418; 76%) took place within the JSY program; 81% of all mothers below poverty line delivered in the program. Ninety percent of the women had prior knowledge of the program. Most program mothers reported receiving the cash incentive within two weeks of delivery. The ASHA's influence on the mother's decision on where to deliver appeared limited. Women who were uneducated, multiparious or lacked prior knowledge of the JSY program were significantly more likely to deliver at home. Conclusion: In this study, a large proportion of women delivered under the program. Most mothers reporting timely receipt of the cash transfer. Nevertheless, there is still a subset of mothers delivering at home, who do not or cannot access emergency obstetric care under the program and remain at risk of maternal death. [ABSTRACT FROM AUTHOR]

From 2000 to 2010, Rwanda implemented comprehensive health sector reforms to strengthen the public health system, with the aim of reducing maternal and newborn deaths in line with Millennium Development Goal 5, among many other improvements in national health. Based on a systematic review of the literature, national policy documents and three Demographic & Health Surveys (2000, 2005 and 2010), this paper describes the reforms and the policies they were based on, and provides data on the extent of Rwanda's progress in expanding the coverage of four key women's health services. Progress took place in 2000–2005 and became more rapid after 2006, mostly in rural areas, when the national facility-based childbirth policy, performance-based financing, and community-based health insurance were scaled up. Between 2006 and 2010, the following increases in coverage took place as compared to 2000–2005, particularly in rural areas, where most poor women live: births with skilled attendance (77% increase vs. 26%), institutional delivery (146% increase vs. 8%), and contraceptive prevalence (351% increase vs. 150%). The primary factors in these improvements were increases in the health workforce and their skills, performance-based financing, community-based health insurance, and better leadership and governance. Further research is needed to determine the impact of these changes on health outcomes in women and children. De 2000 à 2010, le Rwanda a appliqué des réformes globales du secteur sanitaire pour renforcer le système de santé publique, afin de réduire les décès maternels et néonatals, conformément à l'objectif 5 du Millénaire pour le développement, parmi beaucoup d'autres améliorations de la santé nationale. Sur la base d'une analyse systématique des publications, des politiques nationales et de trois enquêtes démographiques et sanitaires (2000, 2005 et 2010), l'article décrit les réformes et les politiques sur lesquelles elles étaient fondées, et renseigne sur l'étendue des progrès du Rwanda dans l'élargissement de la couverture de quatre services clés pour la santé des femmes. Les progrès ont commencé en 2000–2005 et se sont accélérés après 2006, principalement dans les zones rurales, quand les autorités ont généralisé la politique nationale d'accouchement en institution, le financement basé sur les performances et l'assurance maladie communautaire. De 2006 à 2010, les augmentations suivantes de la couverture ont été enregistrées par rapport à 2000–2005, en particulier en zone rurale, où vivent la plupart des femmes pauvres : accouchements avec assistance qualifiée (augmentation de 77% contre 26%), accouchements en institution (augmentation de 146% contre 8%) et prévalence de la contraception (augmentation de 351% contre 150%). Ces avancées étaient principalement dues à l'augmentation du nombre et des compétences du personnel de santé, au financement basé sur les performances, à l'assurance maladie communautaire et à la consolidation du leadership et de la gouvernance. De nouvelles recherches sont nécessaires pour déterminer l'impact de ces changements sur l'état de santé des femmes. Desde el año 2000 hasta 2010, se implementaron en Ruanda reformas integrales al sector salud para fortalecer el sistema de salud pública, con la finalidad de disminuir las tasas de muertes maternas y de recién nacidos en línea con el Objetivo 5 de Desarrollo del Milenio, entre muchas otras mejoras en salud nacional. Basado en una revisión sistemática de la literatura, documentos de políticas nacionales y tres Encuestas Demográficas y de Salud (2000, 2005 y 2010), este artículo describe las reformas y las políticas en las cuales se basaron, y expone datos sobre los avances en ampliar la cobertura de cuatro servicios clave de salud de las mujeres. Los avances ocurrieron entre 2000 y 2005 y se aceleraron después del 2006, principalmente en las zonas rurales, con la ampliación de la política nacional referente al parto institucional, la financiación basada en el desempeño y el seguro médico a nivel comunitario. Entre 2006 y 2010, se efectuaron los siguientes aumentos en cobertura, comparados con el plazo del 2000 al 2005, particularmente en zonas rurales, donde vive la mayoría de las mujeres pobres: partos con asistencia calificada (un aumento del 77% frente al 26%), parto institucional (un aumento del 146% frente al 8%) y prevalencia de uso de anticonceptivos (un aumento del 351% frente al 150%). Los principales factores en estas mejoras fueron los aumentos en la fuerza laboral en salud y sus habilidades, financiación basada en el desempeño, seguro médico a nivel comunitario y mejor liderazgo y gobernancia. Aún se necesitan más investigaciones para determinar el impacto de estos cambios en la salud de las mujeres. [ABSTRACT FROM AUTHOR]

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Background: Achieving maternal mortality reduction as a development goal remains a major challenge in most low-resource countries. Saving Mothers, Giving Life (SMGL) is a multi-partner initiative designed to reduce maternal mortality rapidly in high mortality settings through community and facility evidence-based interventions and district-wide health systems strengthening that could reduce delays to appropriate obstetric care.Methods: An evaluation employing multiple studies and data collection methods was used to compare baseline maternal outcomes to those during Year 1 in SMGL pilot districts in Uganda and Zambia. Studies include health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and population-based investigation of community maternal deaths. Population-based evaluation used standard approaches and comparable indicators to measure outcome and impact, and to allow comparison of the SMGL implementation in unique country contexts.Results: The evaluation found a 30% reduction in the population-based maternal mortality ratio (MMR) in Uganda during Year 1, from 452 to 316 per 100,000 live births. The MMR in health facilities declined by 35% in each country (from 534 to 345 in Uganda and from 310 to 202 in Zambia). The institutional delivery rate increased by 62% in Uganda and 35% in Zambia. The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 25 in Uganda and from 7 to 11 in Zambia. Partial EmONC care became available in many more low and mid-level facilities. Cesarean section rates for all births increased by 23% in Uganda and 15% in Zambia. The proportion of women with childbirth complications delivered in EmONC facilities rose by 25% in Uganda and 23% in Zambia. Facility case fatality rates fell from 2.6 to 2.0% in Uganda and 3.1 to 2.0% in Zambia.Conclusions: Maternal mortality ratios fell significantly in one year in Uganda and Zambia following the introduction of the SMGL model. This model employed a comprehensive district system strengthening approach. The lessons learned from SMGL can inform policymakers and program managers in other low and middle income settings where similar approaches could be utilized to rapidly reduce preventable maternal deaths. [ABSTRACT FROM AUTHOR]

Background: Encouraging institutional birth is an important component of reducing maternal mortality in low-resource settings. This study aims to identify and understand the determinants of persistently low institutional birth in rural Nepal, with the goal of informing future interventions to reduce high rates of maternal mortality.Methods: Postpartum women giving birth in the catchment area population of a district-level hospital in the Far-Western Development Region of Nepal were invited to complete a cross-sectional survey in 2012 about their recent birth experience. Quantitative and qualitative methods were used to determine the institutional birth rate, social and demographic predictors of institutional birth, and barriers to institutional birth.Results: The institutional birth rate for the hospital's catchment area population was calculated to be 0.30 (54 home births, 23 facility births). Institutional birth was more likely as age decreased (ORs in the range of 0.20-0.28) and as income increased (ORs in the range of 1.38-1.45). Institutional birth among women who owned land was less likely (OR = 0.82 [0.71, 0.92]). Ninety percent of participants in the institutional birth group identified safety and good care as the most important factors determining location of birth, whereas 60 % of participants in the home birth group reported distance from hospital as a key determinant of location of birth. Qualitative analysis elucidated the importance of social support, financial resources, birth planning, awareness of services, perception of safety, and referral capacity in achieving an institutional birth.Conclusion: Age, income, and land ownership, but not patient preference, were key predictors of institutional birth. Most women believed that birth at the hospital was safer regardless of where they gave birth. Future interventions to increase rates of institutional birth should address structural barriers including differences in socioeconomic status, social support, transportation resources, and birth preparedness. [ABSTRACT FROM AUTHOR]

Background: Delays in accessing skilled delivery services are a major contributor to high maternal mortality in resource-limited settings. In 2015, the government of The Gambia initiated a results-based financing intervention that sought to increase uptake of skilled delivery. We performed a midline evaluation to determine the impact of the intervention and explore causes of delays.Methods: A mixed methods design was used to measure changes in uptake of skilled delivery and explore underlying reasons, with communities randomly assigned to four arms: (1) community-based intervention, (2) facility-based intervention, (3) community- and facility-based intervention, and (4) control. We obtained quantitative data from household surveys conducted at baseline (n = 1423) and midline (n = 1573). Qualitative data came from semi-structured interviews (baseline n = 20; midline n = 20) and focus group discussions (baseline n = 27; midline n = 39) with a range of stakeholders. Multivariable linear regression models were estimated using pooled data from baseline and midline. Qualitative data were recorded, transcribed, translated and thematically analyzed.Results: No increase was found in uptake of skilled delivery services between baseline and midline. However, relative to the control group, significant increases in referral to health facilities for delivery were found in areas receiving the community-based intervention (beta = 0.078, p < 0.10) and areas receiving both the community-based and facility-based interventions (beta = 0.198, p < 0.05). There was also an increase in accompaniment to health facilities for delivery in areas receiving only community-based interventions (beta = 0.095, p < 0.05). Transportation to health facilities for delivery increased in areas with both interventions (beta = 0.102, p < 0.05). Qualitative data indicate that delays in the decision to seek institutional delivery usually occurred when women had limited knowledge of delivery indications. Delays in reaching a health facility typically occurred due to transportation-related challenges. Although health workers noted shortages in supplies and equipment, women reported being supported by staff and experiencing minimal delays in receiving skilled delivery care once at the facility.Conclusions: Focusing efforts on informing the decision to seek care and overcoming transportation barriers can reduce delays in care-seeking among pregnant women and facilitate efforts to increase uptake of skilled delivery services through results-based financing mechanisms. [ABSTRACT FROM AUTHOR]

Background: Reducing maternal mortality is a top priority in Latin American countries. Despite the progress in maternal mortality reduction, Brazil and Colombia still lag behind countries at similar levels of development. Methods: Using data from the Demographic Health Survey, this study quantified and compared, by means of concentration indices, the socioeconomic-related inequity in access to four key maternal health interventions in Brazil and Colombia. Decomposition analysis of the concentration index was used for two indicators – skilled attendance at birth and postnatal care in Brazil. Results: Coverage levels of the four key maternal health interventions were similar in the two countries. More specifically, we found that coverage of some of the interventions (e.g. ante-natal care and skilled birth assistance) was higher than 90% in both countries. Nevertheless, the concentration index analysis pointed to significant pro-rich inequities in access in all four key interventions in both countries. Interestingly, the analysis showed that Colombia fared slightly better than Brazil in terms of equity in access of the interventions studied. Finally, the decomposition analysis for the presence of a skilled attendant at birth and postnatal care in Brazil underlined the significance of regional disparities, wealth inequalities, inequalities in access to private hospitals, and inequalities in access to private health insurance. Conclusions: There are persistent pro-rich inequities in access to four maternal health interventions in both Brazil and Colombia. The decomposition analysis conducted on Brazilian data suggests the existence of disparities in system capacity and quality of care between the private and the public health services, resulting in inequities of access to maternal health services. [ABSTRACT FROM AUTHOR]