To ensure maternal mortality is reduced, quality of care needs to be monitored and improved alongside increasing skilled delivery coverage rates


Dr M Mathai, Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, 1211 Geneva 27, Switzerland. Email


Please cite this paper as: Mathai M. To ensure maternal mortality is reduced, quality of care needs to be monitored and improved alongside increasing skilled delivery coverage rates. BJOG 2011; 118 (Suppl. 2): 12–14.

Measuring progress in maternal health

In 2000, the leaders of all 191 member nations of the United Nations committed to achieve eight specific goals—the Millennium Development Goals (MDGs)—by 2015. Goal 5—‘to improve maternal health’—includes two targets: to reduce the maternal mortality ratio by 75%, from the levels seen in 1990, and to achieve universal access to reproductive health by 2015.1 With the deadline approaching, concerns that these targets may not be achieved have led to increased global interest and collaboration to help countries to achieve their targets.2

Unfortunately, reduction in maternal mortality, the principal measure of interest in tracking progress towards the maternal health MDG, is difficult to measure accurately. Only one in seven births globally occurs in countries that have civil registration systems that might be considered as complete, with the correct attribution of the cause of death.3 For countries with less reliable information on births and deaths, or no information at all, the United Nations Inter-Agency Group develops estimates of maternal mortality trends periodically. Among the estimated 358 000 maternal deaths in 2008, 109 000 (30%) occurred in South Asia. In South Asian countries, the estimated annual rate of maternal mortality reduction between 1990 and 2008 was below the 5.5% annual rate required to remain on track to achieve the agreed target in 2015.

Interventions to reduce levels of maternal mortality include ensuring that all women have access to family planning and safe termination of pregnancy services, if required, and to skilled care during pregnancy, childbirth and the postpartum period, including access to emergency care for those who develop complications. Given the difficulties in tracking maternal mortality reduction globally, one approach used to monitor progress in achieving MDG 5 is to measure the proportion of births attended by skilled health personnel. The overall coverage of births by skilled attendants in South Asia is low,4 but there are variations between and within countries. For example, Sri Lanka and the southern Indian states of Kerala and Tamil Nadu5 have achieved high rates of skilled care at birth, whereas Nepal and the northern Indian states of Uttar Pradesh and Bihar have significantly lower rates.

Improving coverage of services

At a global level, the need to increase skilled care at birth and to implement strategies to achieve universal access to professional care has been discussed.6,7 At a regional level, there is consensus on the need to increase coverage of births by skilled attendants.8 South Asian countries have implemented various strategies to achieve this objective. For example, Bangladesh initiated a short training programme for community-based skilled birth attendants,9 whilst simultaneously improving coverage of emergency obstetric care services.10,11 Nepal’s Safe Delivery Incentive Programme aims to encourage the greater use of professional care at childbirth through cash incentives for women giving birth in public health facilities and an incentive to the health provider for each attended birth at the facility or at home.12 The Government of India’s Janani Suraksha Yojana (JSY, a safe motherhood scheme) is a conditional cash transfer scheme that provides incentives for women to give birth in health facilities.13 All of these have contributed to an increase in the skilled delivery coverage rate.

Is the coverage of births by skilled health personnel an appropriate indicator of progress towards better maternal health? What does it measure? The coverage rate for skilled care at birth is certainly easier to measure than maternal mortality. However, this indicator only suggests that there was reported contact with a health provider. It does not indicate what was carried out during this contact or assess the quality of care provided.

Furthermore, the relationship between births assisted by a health professional and maternal mortality in observational data is complex.14 At country level, a downward trend in maternal mortality is observed alongside increasing levels of births attended by skilled providers, but the strength of this association and whether there is a causal link are unclear. A skilled birth attendant is expected to be competent to provide care during normal childbirth and to recognise and manage appropriately any complications that may arise during and immediately after childbirth.15 Appropriate management of complications would include adequate medicines and supplies, and timely referral to, and management in, higher level facilities when required. In low-coverage areas, it is highly likely that women seek care in facilities only when there are problems, often arriving too late to prevent death or serious morbidity.

Better coverage but poorer quality services

Efforts to increase the skilled delivery coverage rate, especially through the offer of incentives for women to give birth in heathcare facilities, must be accompanied by steps to ensure that good-quality care is provided. In most South Asian countries, public health facilities are overcrowded and under-resourced. Although incentive schemes may encourage women to seek care in facilities, there are many other barriers to be addressed, for example, under-the-table payment for services, separation from the family in a strange environment, and discriminatory and rude behaviour of staff towards marginalised population groups.

A recent investigation into several maternal deaths occurring in a district hospital in India16 reported that closer-to-home primary health centres were not providing childbirth services. Women were required to travel great distances to access skilled care during delivery, and thus become eligible for the financial incentive under the JSY scheme. It was reported that the hospitals lacked the capacity to handle increased case loads of women, and attendance by a skilled birth attendant at the district hospital could not be ensured. Emergency obstetric care was not always available, even at the district hospital, and women were forced to travel further to even more distant teaching hospitals. Maternal deaths occurred in facilities whilst awaiting definitive treatment or whilst in transit between facilities. There were many issues related to poor infection control, irrational use of oxytocin and antibiotics, and women being subjected to abuse and violence during labour. However, as the authors noted, ‘... none of these are measured as indicators when monitoring success in maternal health’.

Improving quality of care

Any programme that aims to increase facility births as a means of increasing national rates for skilled attendance at birth should also focus on ensuring that every pregnant woman who reaches the place of care has access to quality care during and following childbirth. The actions required may involve training to improve the knowledge, attitudes and skills of the existing workforce, ensuring evidence-based standards of care are in place and implemented by providers, ensuring the availability of essential medicines and supplies at facilities, performing timely infrastructure maintenance in health facilities, improving leadership and teamwork to ensure optimal use of resources, improving communications, transport and referral systems, and encouraging increased participation of women and their families in quality improvement processes. It is important that all facility births and deaths are registered. Information on births, deaths, severe morbidity and key interventions in facilities must be reviewed at regular intervals and used to improve quality of care.

The success of the Indian state of Tamil Nadu in reducing maternal mortality has been reported elsewhere.5,17 Among the many interventions adopted in the state to improve maternal health, there was one simple intervention that contributed to better quality of care. This was the introduction of a birth companion during childbirth in all public facilities in the state. Having a birth companion is an evidence-based practice that is common in high-resource settings, but is unusual in public health facilities in South Asia. Providers in busy maternity facilities in South Asia often cite overcrowding, lack of privacy and an increased risk of infection for not allowing birth companions during childbirth. Unfortunately, the few midwifery staff in these facilities are busy with clinical and administrative work, and lack time and the skills required to provide individualised support for women during childbirth.

During the implementation of this simple intervention, facility staff worried that relatives would interfere with the birthing process. These concerns were discussed and the successful experiences of birth companions in labour from the busy maternity unit of a large private not-for-profit teaching hospital in the same state were shared. The Tamil Nadu birth companion scheme was introduced through a governmental order in a phased manner throughout all public hospitals in the state. Birth companions provided support during labour and childbirth, provided timely nutrition and hydration, and ensured that women received the attention of health providers when required. Although no formal assessment was performed, the general impression is that women and their families were happy with the birth companion scheme.

The introduction of birth companions in public hospitals in Tamil Nadu has also contributed to better information on the quality of care provided. Over the last few years, family members of deceased women have been invited to the monthly district level maternal death review meetings. Family members are asked to recall events preceding the maternal death and for their views on the problems faced. At these meetings, information obtained from the birth companion about the quality of care provided in the facility has been revealing and has contributed to improvements.

Quality maternal health care should be focused on the mother–baby dyad. It should be safe, timely, effective, efficient and equitable. Above all, it should be acceptable to women and their families. Improvement in the quality of care can occur only if there is a willingness among care providers to review information, to recognise problems, to identify solutions and to accept change. Objective assessments of quality of care have been performed,18 but require time and resources, thus making regular monitoring and feedback for quality improvement difficult. Information from women and their birth companions on the care provided may be biased, but is inexpensive. If used well, the feedback can be employed to improve the quality of skilled care and thus contribute to MDG 5.


The author is a staff member of the World Health Organization. The views expressed in this article are those of the author, and do not necessarily represent the views of the World Health Organization or its Member States.

Disclosure of interests

No competing interests to disclose.