Maternal mortality in Cambodia, Thailand, Malaysia and Sri Lanka: a systematic review of local and national policy and practice initiatives.

Abstract

Alexa McArthur: Master of Clinical Science Student a1187533 email: [email protected] Protocol for the degree of Master of Clinical Science within The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide Review question / objective The primary objectives of this systematic review are to compare and evaluate the health policy positions across Cambodia, Thailand, Malaysia and Sri Lanka as they relate to maternal mortality and the provision of midwifery services. The specific questions this review will seek to address are: What are the strategies to reduce maternal mortality in Cambodia, Thailand, Malaysia and Sri Lanka? Which strategies have had the greatest impact in relation to a change in maternity care practice within the countries of interest? Background Maternal mortality is defined as death resulting either directly during pregnancy or childbirth or indirectly as a result of complications of either pregnancy or childbirth. It is a leading cause of death and disability among women in low income countries. It is estimated that worldwide each year more than 500,000 women die during pregnancy or childbirth, and at least 10 million women suffer injuries, infection and disabilities.1 Evidence suggests that increasing the number of births overseen by skilled birth attendants, as opposed to traditional birth attendants, is the single most effective means of decreasing the maternal mortality rate.2 For many years in low income countries, traditional birth attendant training has been promoted by the World Health Organisation, where ‘lay midwives’ who are usually older women within the community have been trained to give assistance to women during pregnancy and childbirth.3 Recently, reports have concluded that traditional birth attendants have not made a significant impact on reducing maternal mortality and morbidity.3 The skill level or training that traditional birth attendants have received can vary widely, and the degree to which they can identify complications and then make a referral has been questioned.3 A new focus on training skilled birth attendants has emerged, and in 2004 a joint statement was released by the World Health Organisation (WHO), International Confederation of Midwives (ICM) and the International Federation of Gynaecology and Obstetrics (FIGO), concerning the role of the skilled birth attendant, and their cental importance.2 A skilled birth attendant is a health professional (midwife, doctor or nurse) who has been accredited, educated and trained to manage normal, uncomplicated births. He/she is also able to identify, manage and/or refer complicated cases to the nearest referral health centre.2 This is in contrast to traditional birth attendants who are not primarily healthcare professionals, but often older women within the community. In many instances, funding has ceased for traditional birth attendant training, and the new focus has been to build the capacity of skilled birth attendants. The Millenium Development Goal for maternal health (MDG-5) is to see the maternal mortality ratio reduced by three-quarters by the year 2015.1 This is a very ambitious target, given that other targets were to cut poverty in half, and child mortality by two-thirds. But what is the best way forwards? Is there one approach, one policy that will fit every country? While it might be simplistic to assume that what has worked in one country may be helpful in another, it may be of benefit to consider the emerging themes and similarities that arise between these countries. For this reason I am focusing only on textual papers that highlight the strategies that have decreased maternal mortality rates. For the purpose of this review, the focus will be on women giving birth in Cambodia, Thailand, Malaysia and Sri Lanka. These countries have been chosen as they lie within a similar geographical context, yet Thailand, Malaysia and Sri Lanka have all been able to drastically reduce their maternal mortality rate over recent years.3 Cambodia has one of the highest maternal mortality rates in southeast Asia, 266 per 100,000 live births4, and where 68% of births take place without the help of a skilled birth attendant.5 In 2008, the maternal mortality rates were 30 (per 100,000 live births) in Sri Lanka, 42 (per 100,000 live births) in Malaysia, and 47 (per 100,000 live births) in Thailand.4 Accuracy in collection of maternal mortality data is often questioned, but a concerted effort since the mid 90's with improved data collection from many countries has been established with support from WHO, UNICEF, UNFPA and the World Bank.4 Cambodia is defined as a low income country by the World Bank, as it had a gross national income per capita of $935 (USD) or less in 2008.6 Over the last few decades, Thailand, Malaysia and Sri Lanka have all managed to improve maternal health, through a variety of strategies. Sri Lanka and Thailand are defined as lower middle income countries, with a Gross national product (GNP) of between $936 - 3,855 USD, and Malaysia as an upper middle income country, with a GNP of $3,856 - $11,905 USD.6 From the authors' perspective, having worked in maternal health in both low and high income countries, the main question to explore is whether financial reasons alone, (providing more healthcare professionals, better facilities for emergencies, etc) are responsible for this improvement, or are there other reasons/strategies that can be identified? For the purpose of this review, a skilled birth attendant will include any health personnel trained to give the necessary supervision, care, and advice to women during pregnancy, labour and in the postnatal period. When traditional birth attendant funding was ceased in 1990, it was on the recommendation of international agencies and academics, but with little evidence base to support this decision.7 Some have argued that the new culture of evidence-based practice is responsible for this shift away from primary health care principles, which support community participation. While it is difficult to assess the effectiveness of traditional birth attendant training, with a focus on community mobilisation, there has been a shift to skilled birth attendant training within a district hospital setting, with the major focus on midwives and doctors, which is easier to evaluate.8 The impact of skilled attendance at birth is influenced by a variety of factors, such as the level of resources available (both staff and equipment), and access issues (long distances to reach health care facility, expense of transport). A prohibiting factor may be the expense of accessing treatment.9 Interventions that can be easily scheduled, such as immunisation services and antenatal care, were much easier to administer, whereas clinical services that require access over 24 hours, such as skilled birth and/or emergency care were harder to provide.10 Others argue that traditional birth attendants still have a place alongside skilled birth attendants and that by working together, in collaboration and true partnership, respecting each others skills, the greatest impact on improving maternal mortality will be achieved.11 Wider issues involve women's status and position of disadvantage. Maternal mortality rates worldwide tend to reflect the position of women within their culture. The more highly women are treated in society, the less likely they are to die during childbirth.12 This also directly relates to education for girls, better nutrition for pregnant women and access to family planning. Commitment from governments to provide the health system structure is vital, not only to provide a skilled birth attendant for each pregnant woman, but also the importance of health clinics and hospitals where referrals can be managed appropriately.12 There are many policy papers and reports from countries such as Cambodia, Thailand, Malaysia and Sri Lanka, around these issues of safer motherhood. There have also been large systematic reviews conducted looking at who is attending to birthing women, and the effectiveness they have had on birth outcomes. However, a search of the literature has not located a pooled synthesis of textual findings about the major (policies) factors surrounding maternity care in the above mentioned countries. The aim of this review is to systematically search and appraise all relevant articles of text and opinion, and policy papers in order to determine effective strategies to reduce maternal mortality in Cambodia, Thailand, Malaysia and Sri Lanka. Inclusion Criteria Types of participants The review will consider studies that include: Pregnant and birthing women who receive care from a skilled birth attendant. Types of intervention(s)/phenomena of interest The review will consider studies that describe: 1. The health system / service delivery structures and underlying policy. 2. The maternity care provided by a skilled birth attendant. Types of outcomes The primary outcomes of interest in this review are: Strategies that have reduced maternal mortality rates. Secondary outcomes of interest to this review include: Strategies that have had the greatest impact in relation to: Changes to health system structures related to pregnancy and childbirth (including resources / finances) Change in cultural practices related to pregnancy and birth Empowerment of women and their position in society (and what impact this has had with respect to their choice of pregnancy and birth care). Types of papers This review will consider government reports, expert opinion, discussion papers, position papers, and other forms of text, published in the English language. Technical reports, statistical reports and epidemiological reports will be excluded. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases will be searched from 2000, to reflect the approximate timing when traditional birth attendant training was being phased out, and before skilled birth attendant training as an official programme was being promoted. The databases to be searched include: MEDLINE (from 2000) CINAHL (from 2000) EMBASE (from 2000) Cochrane Central Register of Controlled Trials Health Technology Assessment (HTA) Database Scopus ISI Web of Knowledge LILACS Mednar database Pan American Health Organisation (PAHO) World Health Organisation (WHO) The search for unpublished studies will include: Proquest dissertations and theses, Index to theses, Australian digital theses program digital dissertations, and the Networked digital library of theses and dissertations (NDLTD). The Internet will also be searched for reports of projects within the following organisations such as United Nations, World Bank and USAID. Initial keywords to be used will be: skilled birth attendant(s), midwifery, midwife, midwives, lay midwives, nurse midwives, nurses, doctors, maternal mortality rate, survival (rates), safety, training, train, education, upskill, safer motherhood, Cambodia, Thailand, Malaysia, Sri Lanka. Assessment of methodological quality Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix II).The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Textual papers will, where possible be pooled using the Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI). This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation. These categories are then subjected to a metasynthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form. Synthesis will involve both the aggregation of categories, and the use of interpretive techniques to summarise the findings of individual studies into a product of practical value. The text will be read and re-read, to identify the meaning of the content, and the degree to which the text has ‘authority’ surrounding the issues serving the best interests of women giving birth in low income countries. Conflicts of interest No conflict of interest declared.