Metrics for monitoring local inequalities in access to maternity care: developing a basket of markers from routinely available data.

BACKGROUND: Equal access for all based on need is part of a conceptualisation of quality underpinning recent UK NHS policies. OBJECTIVE: To develop metrics for access to maternity care from routinely available data in order to inform inequalities monitoring and commissioning. DESIGN: Cross-sectional cohort design using case-note audit and postnatal questionnaire. SETTING: London hospital, UK, in an area of relative socio-economic deprivation. METHODS: Stage 1: Identification of potential markers. Stage 2: Testing of markers via case note audit and postnatal questionnaire. Stage 3: Selection of final basket of markers of access to maternity services. RESULTS: Of 71 possible markers identified, 32 used information obtainable from maternity case notes. After testing in the case-note audit, 21 were discarded, and 11 included in the final basket covering: timely entry to maternity care; appropriate assessment and identification of needs of individuals; referral and communication with other related health and social care services. CONCLUSION: It is possible to devise a local basket of markers covering a range of important entry and in-system access metrics. Such a tool offers an unobtrusive means to audit the effectiveness of some of the processes intended to help women move through the maternity and related health and social care systems during pregnancy, and to monitor progress on reducing social inequalities in access over time.

Zambian women's experiences of urban maternity care: results from a community survey in Lusaka.

Urban African maternity care systems face problems, as rapid population growth puts them under increasing pressure. In 1983 a decentralised system with midwife-run maternity units at health centres was initiated in Lusaka. A community-based survey of 1210 women conducted in 1999 examined access, coverage and quality of care in these maternity services. Results were generally positive: 99% of respondents received some antenatal check-ups and three quarters had five or more. Institutional delivery rate was 89.5%. Home birth was associated with belonging to a "very poor" household. Sixty three per cent of births were in the decentralised units. Eighty nine per cent reported care as "good" or "very good", but 21% remembered someone who had treated them badly during labour, principally by shouting or scolding. One fifth of women reported having been left alone for "too long" in labour. Less than half of the women said they would like a lay labour companion and three quarters would prefer a companion at the delivery.

Tools for monitoring the effectiveness of district maternity referral systems.

It is widely accepted that substantial reductions in maternal mortality and severe morbidity are impossible to achieve without an effective referral system for complicated cases. Early detection and referral to higher levels of care might also substantially reduce neonatal deaths due to the complications of childbirth. The general goal of such a referral system is that patients are dealt with in the right place with effective treatment provided at the minimum of cost. There are real challenges, however, in monitoring the effectiveness of such referral systems once put in place. This paper describes some of the tools used to review pregnancy-related referrals in Lusaka, Zambia. The tool-mix used provided information for monitoring five different aspects of the referral system: the distribution of births across levels of facility and population coverage; the use of essential obstetric care (EOC) level facilities by women with complications; the progress towards a reduction of maternal mortality at referral facility level; inappropriate use of EOC level facility; and perinatal outcomes at peripheral facility level. Apart from the information on coverage, the data came from routinely collected facility statistics, registers and medical notes. Findings for Lusaka are reported. Consideration is given to issues of interpretation of specific indicators, and to how such tools might be used in conjunction with others, in order to help district managers to monitor the effectiveness of district maternity referral systems.

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study.

OBJECTIVES: To explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile. DESIGN: Qualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic. SETTING: Santiago, Chile. PARTICIPANTS: Qualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women. MAIN OUTCOME MEASURES: Rates of caesarean section in different types of institutions; consultants' views on private practice; work patterns in private practice; women's reasons for choosing private care; women's preferences on method of delivery. RESULTS: Private health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the "programming" (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians. CONCLUSIONS: Policies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.

Cesarean birth trends in Chile, 1986 to 1994.

BACKGROUND: Despite indications of high cesarean section rates in various parts of Latin America, relatively few comprehensive studies of national birth intervention trends have been conducted in that continent. Recent national statistics suggest that Chile may now have the highest reported cesarean section rate in the world. This paper examines cesarean birth trends in Chile with reference to changing patterns in health care financing. METHODS: The growth in the national cesarean birth rate is analyzed, with reference to regional patterns, differences according to insurance coverage, and recent shifts in the financing pattern of health care provision, using insurance fund data and hospital reporting systems data for both public and private sector care from the mid-1980s to mid-1990s. RESULTS: Chile had a cesarean birth rate of 37.2 percent for the 301,955 births covered by either the National Health Fund or private health insurance in 1994. This was a one-third increase from the 1986 rate of 27.7 percent. The private health insurance sector revealed consistently far higher cesarean section rates than the National Health Fund sector (59% vs 28.8% in 1994); intrasectoral rates remained fairly stable over the 8-year period. CONCLUSIONS: The overall increase in Chile's cesarean section rate correlates with the growth in the proportion of all births whose care was privately insured during these years (from 7.5% to 24.8%). This change may be partly explained by the doubling (to 32%) of the percentage of women with a personal obstetrician rather than a "duty" practitioner attending the birth of their baby.