Assessment of Community-based Antenatal and Delivery Care and the Evolution of Its Health Systems in Myanmar

Abstract

Background In developing countries, including Myanmar, antenatal and delivery care services are mostly provided by health care providers in the community. However, it is not known who are actually providing these services and to what extent. Accessing antenatal and delivery care according the guidelines, meeting the women's expectations, and assuring the quality of care, is important for improving maternal health. More importantly, presence of a well functioning health system is a prerequisite in order to operate at full capacity to reach the health goals. Adequate information about maternal health care at the community level from the perspectives of health care providers and women, and that of the enabling health systems, is required for the decision-makers for effective and efficient planning. Nevertheless, the information is scarce and therefore this study should help to fill the knowledge gap and provide a holistic view on antenatal and delivery care at the community level and its system evolution. Objectives 1. To identify the perspectives of community health personnel and women on maternal health services in the community and its consistency 2. To determine the quality of care related to antenatal and delivery care services provided at the community level regarding hypertensive disorders during pregnancy and postpartum hemorrhage and 3. To assess the evolution of health systems focusing on maternal health and the coverage of antenatal care and skilled birth attendance in Myanmar Methodology A cross-sectional study using quantitative and qualitative methods was applied. To answer all objectives, the study was divided into two parts. The first part was conducted in three townships each having a high maternal mortality ratio. Health care providers who worked in the community of the study townships and women who had a history of delivery within six months prior to the start of data collection were eligible. The second part was a mixed methods of reviewing relevant documents and key informant interview. For the first part, 324 health care providers and 1,743 women participated. Data collection was done using a self-administered questionnaire for health care providers and face-to-face interviews for women. The main outcomes from the health care providers were their perceptions on who provided and who should provide antenatal and delivery care services in the community. The variables of antenatal care services were (1) history taking on underlying medical diseases and previous obstetric complications; (2) measurement of maternal weight and blood pressure; (3) basic investigation on detection of anemia and proteinuria; (4) providing information on importance of continuity of antenatal care and counselling for birth preparedness; (5) basic care on iron supplement and tetanus immunization; (6) initial care for women with pregnancy complications and referred place for the complications. Services received during delivery care comprised (1) delivery kits being brought with the attendants as a proxy indicator for infection control and (2) services provided during labor and delivery, and referred places for complications. The main outcomes of women were antenatal and delivery care services received and expected to receive. The services were similar to that of health personnel. To assess quality of antenatal and delivery care services, vignettes were developed based on the actual information of antenatal and delivery care received by the women who were diagnosed as hypertensive disorder in pregnancy and postpartum hemorrhage during their last pregnancy and child birth. Eight cases were selected out of the total 126 for vignette development. Selection of the cases for vignette development was based on type of complication (hypertensive disorder in pregnancy or postpartum hemorrhage), severity and total antenatal care scores (see below), delivery attendant and associated other complications. All community health care providers in the study township were invited through township medical officers. One obstetrician was invited to participate for expert opinion. With their consent, each provider was provided with the pilot tested eight vignettes and related questionnaires for self-administered responses. They were requested to assess and score the antenatal and delivery care services received by the women in the vignettes in terms of (1) the appropriate attendant for antenatal care according to women's previous medical and obstetric history, (2) rating the quality of antenatal care services of measuring body weight, blood pressure, investigations for anemia and proteinuria, counseling, iron supplement/treatment and tetanus immunization, (3) the appropriate birth attendant based on the antenatal care history of the women in the vignettes, (4) acceptable duration from labor until delivery, (5) quality of complication management: timeliness of referral and treatment before referral, (6) final decision on overall quality of antenatal and delivery care, and (7) perceived attributed factors for the situation of service quality to the women in the vignettes. The second part was a mixed methods of reviewing relevant documents, and key informant interview. Documents related to Myanmar health systems from the perspectives of the World Health Organization's six building blocks were retrieved from web search and hard copies from related departments and institutes. Seventeen purposively selected representative key informants from related departments who were knowledgeable on Myanmar health systems were interviewed. In Part I, basic information of health care providers and women were presented using percentage and median as appropriate. The association of perceptions on who provided and should provide the targeted services and type of health personnel was tested using Chi square or Fisher exact tests where appropriate, and Cramer's V was used to measure the strength of association. Agreement of all health care providers on who provided and should provide the services was assessed using prevalence adjusted and bias adjusted kappa. The agreement of women on antenatal and delivery care services received and that they expected to receive was also analyzed using prevalence adjusted bias adjusted kappa. Services with fair agreement were denoted as having disparity and factors associated with disparity services was analyzed using multinomial logistic regression. In the case of hypertensive disorder in pregnancy and postpartum hemorrhage vignettes, Chi square or Fisher exact test was used for testing the association between proportion of good quality service ratings and types of health care provider. The strength of association was assessed with Cramer's V. Discrepancy between the perceptions of community health care providers and that of expert was checked. In Part II, data from documents and key informants were analyzed using both quantitative and qualitative methods. Descriptive statistics and regression analyses were used for quantitative information. Thematic analysis was used and the information from the key informants was organized using Atlas.ti software version 6.2. Results Midwives were found to be the key antenatal and delivery care providers in the community. The majority of all health care providers showed consistent perceptions on the midwives' activities on routine antenatal and delivery care and the care for women with pregnancy or delivery complications. Auxiliary midwives were ranked as the second line health care providers for the majority of antenatal and delivery care services in the community. They were consistently perceived as being the ones who should provide the services of blood test for hemoglobin level, urine test for protein level, and provision of iron supplements in addition to performing physical examination to the women in their community. Routine antenatal and delivery care services received by the women was inconsistent with the guideline. Women's expectations of the services were almost similar to what they actually received. The disparity services were logistic dependent: hemoglobin testing, urine testing, and provision of iron supplements. Antenatal care service utilization, socio-economic and demographic, and geographical accessibility to the nearest health facility were associated with the disparity services. Perceptions of different health care providers on the quality of antenatal and delivery care for women with hypertensive disorders in pregnancy and postpartum hemorrhage were different based on types and severity of the complications. Within the study period of health systems evolution, it was found persistently weak across the six building blocks and coverage of antenatal care and skilled birth attendants showed a slow progress within the limited resources. Conclusion Midwives play a key role in antenatal and delivery care in the community with the assistance of voluntary auxiliary midwives. Possible task shifting between midwives and auxiliary midwives were proposed. Antenatal care services received was still far from the standard and improving women's expectations is crucial to increase their awareness on the value of the services. Requirements for ensuring logistic supply of antenatal care was highlighted. The quality of antenatal and delivery care provided to women with hypertensive disorders in pregnancy and postpartum hemorrhage in the community required improvement. A certain level of antenatal care and skilled birth attendance coverage was improved within the evolution of persistently weak health systems.