Gaurav Sharma: Where do women seek family planning, antenatal, and maternity care in low and middle income countries?

gaurav_sharmaA series of papers entitled “Who cares for women?” was launched at the London School of Hygiene and Tropical Medicine on Wednesday 13 January 2016. The objective: to provide the most up-to-date and extensive analysis of Demographic and Health Surveys across 57 low and middle income countries, focused on the provision of family planning, antenatal care, and maternity services in terms of where women seek care, and the quality of care they receive.

Unfortunately, the findings show that far too many women still do not access these essential services at all, especially the poorest women in Sub-Saharan Africa and Asia. The authors from LSHTM’s Maternal Healthcare Markets Evaluation Team (MET) also found that whilst the public sector provides the majority of care across these services worldwide, the private sector too plays a substantial role, providing 19% of maternity care, 32% of antenatal care services, and 22% of family planning services. Although the role of the private sector varies across countries, it tends to be less equitable than the public sector.

As part of my own research into quality of care in South Asia and Africa, I have experienced firsthand the dynamics of care seeking and service provision. Contextual factors have a huge influence on care seeking and service delivery, which requires a nuanced understanding. These dynamics cannot be understood from cross-sectional studies alone. The heterogeneity of health workers and their incentives for providing quality services also varies depending on the context.

The complexity of organising, managing, and implementing health services—including regulation of providers in public and private sectors—is unique to different settings. For example, the private sector may range from poorly trained and/or unqualified informal providers to those working in smaller pharmacies, and from one-room clinics up to larger multispecialty tertiary hospitals offering the state-of-the-art facilities and services.

Furthermore, women may choose to seek care from different sectors and providers across the continuum of pregnancy and childbirth, for example seeing a private provider for antenatal care, but a public one for labour and delivery. Many health workers also have dual practices, working after-hours in the private sector to supplement their incomes.

In theory, the public sector is more manageable and may be easier to regulate by national authorities, but this is not always the case, especially in low and middle income settings. Political environments in countries can be fluid at times, which affects financing, regulation, and functioning of hospitals in both sectors.

In terms of what surveys can tell us, there can be limitations. For example, there are instances where data collection exercises exclude those without a fixed address, specifically the poorest and the most marginalised. National planners need special strategies to reach these groups. Contextual determinants such as socio-cultural factors, economics, political situation, nutritional status, and female literacy are some of the confounding factors which make it hard to infer causality or attribute success to programmatic interventions. These are not easily captured in many research designs. In addition, there are inherent challenges in the measurement of mortality in low and middle income settings.

Despite many limitations associated with using DHS estimates and aggregating survey findings to global and regional levels, this work by the London School offers one of the first and most comprehensive endeavors to examine cadres providing antenatal care, family planning and labour, and childbirth services across low and middle income countries. Although, there were no clear answers on the way forward during the panel discussion, there was a consensus that it is necessary to strengthen all sectors to improve quality, and that there must be a strong focus on equity and appropriate regulation.

The London School’s work should encourage countries and donors to find avenues to capitalise on available DHS datasets to answer these important questions around who cares for women in their country context. This will also be an opportunity to strengthen national statistical capacity and improve health information systems at national and subnational levels. Additional studies to investigate who provides care and what quality of care is provided at different settings will help in formulating quality improvement strategies for both public and private sectors. In India, where I currently work, understanding these factors will help national authorities make strategic investments and improve the quality of care irrespective of where women may access it.

MET’s series launch event—Who cares for women—is available to view/listen online.

Gaurav Sharma is a public health physician with over 10 years of clinical, programmatic, and management experience in several low and middle-income countries. His areas of expertise include reproductive, maternal and newborn health. Gaurav is affiliated to the Maternal, Adolescent, Reproductive and Child health (MARCH) Centre at the London School of Hygiene and Tropical Medicine, where he also supports the Maternal Healthcare Markets Evaluation Team (MET).

Competing interests: The author declares that he has no personal financial interests to be obtained by the publication of this blog. However, the author belongs to the same department as the some of the authors of the published papers discussed in the blog and is also involved in separate research work with the Maternal Healthcare Markets Evaluation Team (MET) at the London School of Hygiene & Tropical Medicine.