Global Health Policy

By Anna D. Gage, Fei Carnes, Jeff Blossom, Jalemba Aluvaala, Archana Amatya, Kishori Mahat,
doi: 10.1377/hlthaff.2018.05397 Address Malata, Sanam Roder-DeWan, Nana Twum-Danso, Talhiya Yahya, and Margaret E. Kruk
HEALTH AFFAIRS 38,
NO. 9 (2019): 1576–1584
This open access article is
distributed in accordance with the
terms of the Creative Commons
In Low- And Middle-Income
Countries, Is Delivery In High-
Attribution (CC BY 4.0) license.

Quality Obstetric Facilities

Geographically Feasible?
Anna D. Gage (agage@
hsph.harvard.edu) is a student ABSTRACT Delivery in a health facility is a key strategy for reducing
in the Department of Global
Health and Population,
maternal and neonatal mortality, yet increasing use of facilities has not
Harvard T. H. Chan School of consistently translated into reduced mortality in low- and middle-income
Public Health, in Boston,
Massachusetts.
countries. In such countries, many deliveries occur at primary care
facilities, where the quality of care is poor. We modeled the geographic
Fei Carnes is a geographic
information systems (GIS)
feasibility of service delivery redesign that shifted deliveries from primary
specialist in the Center for care clinics to hospitals in six countries: Haiti, Kenya, Malawi, Namibia,
Geographic Analyses, Harvard
University, in Cambridge, Nepal, and Tanzania. We estimated the proportion of women within two
Massachusetts. hours of the nearest delivery facility, both currently and under redesign.
Jeff Blossom is the GIS Today, 83–100 percent of pregnant women in the study countries have
service manager in the Center two-hour access to a delivery facility. A policy of redesign would reduce
for Geographic Analyses,
Harvard University. two-hour access by at most 10 percent, ranging from 0.6 percent in
Malawi to 9.9 percent in Tanzania. Relocating delivery services to
Jalemba Aluvaala is a
research fellow in the hospitals would not unduly impede geographic access to care in the study
Department of Paediatrics countries. This policy should be considered in low- and middle-income
and Child Health, University of
Nairobi School of Medicine, in countries, as it may be an effective approach to reducing maternal and
Kenya.
newborn deaths.
Archana Amatya is an
assistant professor of
community medicine and
public health at the Tribhuvan

University Teaching Hospital,
in Kathmandu, Nepal.
Kishori Mahat is an advisor in
Quality Assurance and
Regulation, Nepal Health
Sector Support Programme,
Department for International
Development, in Kathmandu.
Address Malata is principal of
the College of Nursing, Malawi
University of Science and
Technology, in Limbe.
Sanam Roder-DeWan is a
researcher in the Ifakara
Health Institute, in Dar es
Salaam, Tanzania.
Nana Twum-Danso is CEO of
MAZA, in Accra, Ghana.
D
espite substantial reductions in
the past twenty years, maternal
and neonatal mortality remains
high in many low- and middle-
income countries. In 2015 the
globally agreed-upon Sustainable Development
Goals set targets for countries to reduce maternal
and neonatal mortality by 2030. In 2017 eighty-
two countries had maternal mortality ratios over
the target of 70 per 100,000 live births,1 and
eighty had neonatal mortality rates above the
target of 12 per 1,000 live births.2
Increasing the rate of deliveries within health
facilities has been the main strategy for reducing
maternal and neonatal mortality in many low-
and middle-income countries, and this strategy
has coincided with some of the reduction in rates
in the past twenty years. Yet increased facility
delivery does not translate into reduced mortali-
ty if the facilities provide poor-quality care.3–5
Reducing maternal and neonatal mortality and
stillbirths is highly dependent on the quality of
obstetric and newborn care—in particular, rapid
recognition and effective treatment of complica-
tions that often arise without warning.6 While
blood transfusion, surgical care, and emergency
neonatal care are not required in every delivery,
women must have rapid access to them when
complications arise. As maternal and infant mor-
tality rates in low- and middle-income countries
fall, more deaths are caused by more complex
conditions, which makes high-quality care more
important than ever.7
In 2005 the World Health Organization
(WHO) proposed a “close to client” approach
to the provision of delivery and newborn care,
with delivery for most women in nearby primary
care facilities and referrals to higher-level facili-

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ties for complications.8 Many low- and middle-
income countries have adopted this approach
and designated primary care clinics as delivery
facilities to maximize access. Across five coun-
tries in sub-Saharan Africa, more than 40 percent
of deliveries occurred in primary health care
facilities between 2006 and 2010.9 However,
lower-level facilities frequently lack providers
skilled in caring for patients with obstetric emer-
gencies, advanced equipment, and blood for
transfusion. These factors—combined with low
volumes of deliveries, which makes retaining
skills difficult—mean that primary care facilities
are poorly suited for dealing with complex ob-
stetric emergencies that can arise suddenly and
unexpectedly.6,10 The only available recourse for
emergency complications is referral, which often
fails to get women and newborns to lifesaving
care in time and raises the risk of maternal mor-
tality and severe morbidity.11,12
As countries seek to accelerate mortality re-
duction to meet the Sustainable Development
Goal targets, they are revisiting the close-to-
client model for delivery care. The Lancet Global
Health Commission on High Quality Health Sys-
tems in the SDG Era recommended service de-
livery redesign as one way to get better outcomes
from health systems.13 Service delivery redesign
is the notion that systems should be oriented to
maximize outcomes rather than to minimize dis-
tance. Thus, care should be provided at the level
of the system best able to guarantee good out-
comes. For maternal and newborn care, this
means delivery care in higher-level facilities with
well-trained providers; functioning equipment;
and access to emergency surgery, transfusion,
and advanced newborn care.13 This is the norm
in many high- and middle-income countries,
where nearly all deliveries are conducted in hos-
pitals or birthing facilities near hospitals to en-
sure the rapid provision of advanced care when
needed.14 Even in these highly functioning sys-
tems, deliveries in larger regional centers are
often safer than deliveries in smaller facili-
ties.15,16 Rare births farther from hospitals have
clear referral pathways with comprehensive
ground and air ambulance networks to support
transfers when needed.17
While evidence from low-income countries is
limited, a study in five countries found that facil-
ities that can perform cesarean sections and that
conduct over five hundred deliveries per year
had higher-quality basic maternal care functions
than nonsurgical clinics did.9 Higher-level facili-
ties are also better equipped to provide newborn
care and provide appropriate treatment for sick
newborns more often than health centers and
clinics do.18,19 Given high rates of avertable mor-
tality, service delivery redesign could enable low-
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and middle-income countries to realize large
benefits in terms of maternal and newborn Talhiya Yahya is head of the
Quality Management Unit,
survival. Ministry of Health, Community
However, shifting all deliveries to higher-level Development, Gender, Elderly,
facilities would result in increased distance to and Children, in Dar es
delivery care for some women, particularly those Salaam.
in rural areas. It is therefore important to bal-
Margaret E. Kruk is an
ance concerns of quality and access to achieve associate professor in the
the best health outcomes in an equitable man- Department of Global Health
ner. Spatial modeling in two districts of Tanza- and Population, Harvard T. H.
Chan School of Public Health.
nia suggests that limiting delivery services to
fewer, more capable facilities would have little
adverse impact on geographic accessibility to
those services.20 However, no study to date has
modeled shifting all deliveries to hospitals at a
national scale in low- and middle-income coun-
tries.We used geospatial modeling to assess how
a policy to shift all delivery care from the current
mix of facilities to hospitals would change geo-
graphic access to care in six low- and middle-
income countries.
Study Data And Methods
Study Design And Data We modeled delivery
service redesign in Haiti, Kenya, Malawi, Nami-
bia, Nepal, and Tanzania—all countries with
high maternal and newborn mortality. The coun-
tries were selected based on the availability of
geocoded master facility lists and nationally rep-
resentative data on delivery care at the facility
level for the past ten years.
In all six countries we first identified facilities
that performed delivery care from geocoded mas-
ter facility lists and divided these into hospitals
and nonhospitals.We used data from the Service
Provision Assessment for availability of delivery
services in Haiti (2013), Malawi (2013), and
Namibia (2009), where facility censuses were
available. This assessment, implemented by
the US-based Demographic and Health Survey
Program in collaboration with national statisti-
cal agencies, collects data from nationally repre-
sentative sets of health facilities. In Nepal facility
geocodes and delivery service availability were
provided by correspondence with the Ministry
of Health in November 2017. In Kenya facility
geocodes were from an October 2011 export of
the Kenya Master Facility List. In Tanzania facil-
ity geocodes were from a February 2018 export of
the Health Facility Registry.
Information on delivery service provision was
not included in either the Kenya or Tanzania
master facility lists. In these countries we used
the Service Provision Assessment surveys to
identify the types of facilities that offered care
for normal deliveries and classified the facilities
accordingly.21 Based on national policies, we
classified all hospitals, health centers, and ma-
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Global Health Policy
ternity centers in Kenya and all hospitals, mater-
nity homes, health centers, and public dispensa-
ries in Tanzania as currently providing delivery
services.
We used country-specific definitions of hospi-
tals. This included public, private, district, and
referral hospitals, though we considered only
public facilities in a subanalysis (see the online
appendix).22 Information on the availability of
cesarean section was available only from facili-
ties with a Service Provision Assessment, which
precluded a more detailed analysis.
Estimating Access We estimated the percen-
tages of pregnant women who would live more
than two hours of travel time from a delivery
facility if all births occurred at the nearest hos-
pital rather than the nearest delivery facility of
any kind (nonhospitals and hospitals).23 A two-
hour travel time is the current WHO standard
for reaching emergency obstetric care, though
we also conducted a sensitivity analysis using a
one-hour travel time.24
We developed a cost surface model based on
the methods used by Piera Fogliati and coauthors
to estimate the travel cost (that is, the travel time
in seconds) per pixel using digital road network,
elevation, and land cover data.20 We created two
surfaces—for driving and walking—and then
overlaid them on the assumption that women
would walk to the nearest road and then take
motorized transport to the facility. Driving
speeds were determined by road type, while
walking speeds were determined by slope and
land cover (see the appendix for cost surface data
sources and further details).22 Population distri-
bution data were from WorldPop, which esti-
mates the annual number of pregnancies per
square kilometer.25,26
We estimated the cumulative travel times from
each pixel to the nearest facility that offered de-
livery services and to the nearest hospital. We
summed the numbers of pregnant women within
two hours of a facility and divided by the total
number of pregnant women in the country to
estimate the percentage with two-hour access.
We additionally estimated the average time to
the nearest delivery facility or hospital for all
pregnant women in the country.
Analysis Based on a previously developed in-
dex9 designed to capture the inputs and process-
es necessary for providing basic maternal care,
we calculated the basic maternal care functions
score for all delivery facilities and in hospitals in
the six countries using the Service Provision As-
sessment surveys (the index components are
listed in the appendix).22 We also assessed cur-
rent delivery locations, using the most recent
Demographic and Health Survey for each study
country. For the most recent birth to each wom-
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A policy to provide
obstetric services in
hospitals would not
unduly compromise
access.
an in the past three or five years (the time period
differed across countries), we classified the place
of birth as not a facility (that is, the woman’s or
a traditional birth attendant’s home), a nonhos-
pital facility (that is, a health center, dispensary,
or clinic), or a hospital. Below we report these
characteristics (using sampling weights) as well
as other relevant country characteristics.We also
describe access to delivery facilities and map
the current and redesign scenarios.
Analyses were conducted in Stata, version 14.1,
and ArcGIS, version 10.4.1. The Harvard Univer-
sity Human Research Protection Program deter-
mined that this analysis was exempt from review.
Limitations This analysis had several limita-
tions. First, because we lacked detailed data
about the current availability of delivery services
in Tanzania and Kenya, we made assumptions
based on delivery type. This likely led to an over-
estimate of the number of facilities that provided
delivery services in these countries, which would
result in a conservative estimate for the percent-
age of people losing access under redesign.
Second, following standard procedures in geo-
graphic modeling, we assumed that women
would have ready access to motorized transport
at the speed that the road allowed. Travel times
to all facilities (in the current model and under
redesign) would likely be longer in the rainy
season or at night and be influenced by transport
delays. We addressed this by modeling the
stricter scenario of one-hour access, which in
effect doubled the transport time assumptions
for rural women.
Third, the quality-of-care analysis was limited
to an assessment of basic maternal care func-
tions because of the lack of data on critical com-
ponents of quality such as patient outcomes and
competence in treating obstetric emergencies.
It therefore represents a minimum quality score
that reflects necessary, but not sufficient, ele-
ments of quality.
Finally, this study measured only the geo-
graphic feasibility of redesign. Additional re-
search is required to assess the financial, social,
and cultural barriers to hospital delivery in ur-
ban and rural areas.
Study Results
Characteristics of the study countries are pre-
sented in exhibit 1. The countries range from
low-income (Haiti, Malawi, and Nepal) to up-
per-middle-income (Namibia) and from 40 per-
cent rural (Haiti) to 85 percent rural (Kenya).
Namibia and Nepal have the lowest neonatal and
maternal mortality rates. Malawi has the highest
maternal mortality rate, while Haiti has the high-
est neonatal mortality rate.
On average across the study countries, 32 per-
cent of facility deliveries occur in nonhospital
facilities (data derived from exhibit 1). The share
of nonhospital facility deliveries ranges from
5 percent in Namibia to 56 percent in Malawi.
Sixty percent of births in Haiti still occur outside
of facilities. Basic maternal care functions such
as the availability of safe water and provision of
neonatal resuscitation in the past three months
were more available in hospitals than in all de-
livery facilities collectively in all countries, with
the difference in scores on the index ranging
from 18 percentage points in Malawi to 41 per-
centage points in Tanzania. Maternal care func-
tion scores were much higher in hospitals than in
all delivery facilities, but they were still below
100 percent, ranging from 66 percent in Haiti
to 83 percent in Malawi (see the appendix).22
Over 90 percent of pregnant women are cur-
rently within two hours of a delivery facility in
Haiti, Kenya, Malawi, and Namibia. Access to
hospitals is also high in these countries: At least
89 percent of pregnant women are within two
hours of a hospital (exhibit 2). In all of the study
countries, moving deliveries from the nearest
facility to hospitals would result in fewer than
10 percent of women losing two-hour access to
delivery care. In Haiti, Kenya, and Malawi fewer
than 2 percent of pregnant women would no
longer be within two hours of a delivery facility,
while in Tanzania 9.9 percent more pregnant
women would be farther than two hours from
a delivery facility.
Average travel time would increase most in
Tanzania and Nepal under service redesign,
where the average woman would need to travel
an additional forty-six and forty minutes, respec-
tively, to reach the nearest delivery facility.
Kenya had the smallest increase in average travel
times, with the average woman traveling only an
additional seven minutes. Maps of one- and two-
hour access to current delivery facilities and hos-

Exhibit 1

Selected characteristics of six low- and middle-income countries, 2008–18

Haiti Kenya Malawi Namibia Nepal Tanzania

Demographic characteristics
Annual GDP per capita (US$) 740 1,455 301 4,140 730 879
Annual health expenditure per capita (US$) 62 78 29 499 40 52
Female literacy rate (%) 57 74 55 88 49 73
Women’s decision makinga (%) 61 59 47 75 46 35
Rural population (%) 40 85 84 52 81 68
Land area (1,000 square km) 28 569 94 823 143 886
Health system characteristics
Pregnancies per year 106,192 2,387,171 1,006,889 86,151 940,322 2,657,685
Doctors per 100,000 population 25 20 2 37 21 12
Nurses or midwives per 100,000 population —b 87 28 278 47 43
Maternal mortality ratio per 100,000 live births 359 510 634 265 258 398
Neonatal mortality rate per 1,000 live births 24.6 22.6 23.1 17.8 21.1 21.7
Place of delivery (%)
Not at a facility 60 34 8 11 41 34
Nonhospital facility 9 18 56 5 15 31
Hospital 31 48 36 84 44 35
Nonhospital deliveries as % of all facility deliveries 23 27 61 5 26 47
Basic maternal care functions indexc
All delivery facilities 0.43 0.49 0.65 0.37 0.49 0.38
Hospitals 0.66 0.72 0.83 0.71 0.73 0.79

SOURCES Authors’ analysis of the most recent data available from the World Bank’s World Development Indicators for all demographic and health systems indicators
except pregnancies, and of data on pregnancies from WorldPop (see note 26 in text). Place of delivery and basic maternal care functions index are from authors’ analysis of
Demographic and Health Surveys and Service Provision Assessments. NOTES Percentages might not sum to 100 because of rounding. GDP is gross domestic product.
a
Women who participate in decisions about their own health care, major household purchases, and visiting family members. bNot available from Haiti in the past ten years.
c
The index, which is explained in the text, uses a score of 0 to 1. Higher values indicate better care.

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 Global Health Policy

Exhibit 2

Access to delivery facilities and hospitals under current and redesign scenarios in six low- and middle-income countries

Haiti Kenya Malawi Namibia Nepal Tanzania

Current scenario: delivery in nonhospital facilities and hospitals
Number of delivery facilities 395 1,209 540 256 2,309 5,729
Pregnant women within 2 hours of a delivery facility
Number 106,002 2,174,107 959,468 81,898 795,057 2,199,494
Percent 99.8 91.1 95.3 95.1 84.6 82.8
Travel time to delivery facility (minutes)
Average 13 23 20 31 35 36
Standard deviation 17 45 20 49 90 75
Redesign scenario: delivery in hospitals only
Number of delivery facilities 95 436 98 43 82 272
Pregnant women within 2 hours of a delivery facility
Number 104,426 2,139,871 104,269 77,321 732,786 1,937,029
Percent 98.3 89.6 94.7 89.8 77.9 72.9
Travel time to delivery facility (minutes)
Average 22 30 30 47 75 82
Standard deviation 28 45 25 64 150 173
Difference between current and redesign scenarios
Pregnant women within 2 hours of a delivery facility (%) 1.5 1.5 0.6 5.4 6.7 9.9
Average travel time (minutes) 9 7 10 16 40 46

SOURCE Authors’ geographic feasibility assessment in six countries.

pitals are shown for Tanzania (exhibits 3 and 4,
respectively), which has the largest annual num-
ber of pregnancies. Maps for the other countries
are in the appendix, as are estimates for the
percentage of women within one hour and for
public facilities only.22 Under both scenarios,
fewer women live within one hour of a facility
within two hours (see the appendix).22 Under
service redesign in Kenya, 4 percent of women
would lose one-hour access to delivery facilities,
while in Tanzania the share would be 20 percent.
Given the predominance of public facilities in
these countries, particularly in rural areas, geo-
graphic access did not change when we excluded
private facilities.
Discussion
In the six countries studied, all of which have
high maternal and newborn mortality, nearly
one in three women who deliver in the health
system deliver at nonhospital facilities (calculat-
ed from exhibit 1)—a proportion of women de-
livering in such facilities that is far higher than in
high-income countries.14 We found that a policy
to provide obstetric services in hospitals would
not unduly compromise access, defined as a trav-
el time of two hours or less to a delivery facility.
Under this policy, in the study countries 1–10 per-
cent more pregnant women than today would
live farther than two hours from a delivery facili-
ty. Travel time to the nearest facility would range
from twenty-two minutes in Haiti to eighty-two
minutes in Tanzania, although this would differ
by region. Redesign could also result in improve-
ments of 18–41 percentage points in basic mater-
nal care functions, which suggests the potential
for large quality gains. More precise estimates of
the extent of quality improvement will need to be
conducted using detailed local measures.
Our analysis assumed that women would walk
to the nearest road and then take motorized
transport to the facility. Because transportation
might not be readily available to women, we also
modeled a more demanding scenario of one-
hour access, which could be interpreted as dou-
bling transport times for women. Because this
affected both current and redesign scenarios,
the relative difference in loss of access was not
greatly affected.We found that between 4 percent
and 20 percent of women would lose one-hour
access to care. Irrespective of the travel time as-
sumptions, redesign would present the greatest
travel challenges for women living in remote
rural areas. Improving access to care for these
women should therefore be a key component of
any implementation strategy, as discussed be-
low. It is important to note that women in remote
areas may have the most gain from redesign,
given that today many of them now deliver at
home or in remote clinics with little practical
recourse to access transportation if complica-
tions arise. Future research should incorporate
information about the range of local transporta-
tion options as well as weather-related obstacles.
Policy makers in each country will need to decide

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on the locally acceptable travel time and review Exhibit 3
options for women in remote areas, such as hav-
Areas of Tanzania within one hour and two hours of delivery facilities
ing women approaching the end of their preg-
nancy stay near delivery facilities.
The study demonstrated that access under re-
design differed between countries. While Tanza-
nia had the largest reduction in two-hour access
among the study countries, this may be due to
its larger land area, an overestimation of current
delivery care availability—because not all of the
public dispensaries that we classified as delivery
facilities provide delivery today—or both. In
Haiti and Malawi hospitals are very accessible
in part because of the countries’ small land areas
and good hospital networks. In contrast, Nami-
bia has a large land area but very concentrated
population centers.While the majority of women
in Namibia already deliver in hospitals, this anal-
ysis suggests that 10 percent of women have re-
sidual access challenges. The large increases in
average travel times in Nepal are expected, given
its very remote mountainous regions—which
would require special considerations for imple-
mentation.
While ours is the largest study of delivery care
redesign, our findings are consistent with those
of previous research. Fogliati and coauthors con-
ducted a detailed modeling of two districts in
Tanzania and found that consolidating delivery
services in higher-level facilities could have large
benefits to quality with only minor trade-offs in
terms of access.20 A WHO analysis of Malawi also
found that 95 percent of births occurred within
two hours of a facility classified as providing
SOURCE Authors’ geographic feasibility assessment.
basic emergency obstetric care, but only 30 per-
cent of births were within two hours of a facility
with enough capacity to provide truly skilled
birth attendance.27 Finally, the results of our First, policy change may be required to define
analysis of two-hour access to hospitals are which facilities can offer delivery.While our anal-
broadly similar to those of Paul Ouma and col- ysis modeled shifting deliveries to hospitals,
leagues’ assessment of access to emergency care the results would be very similar for delivery in
in public hospitals, though our inclusion of midwife-led birth centers, freestanding materni-
private facilities led to higher percentages of ty units, or other settings very close to hospitals.
hospitals within two hours, particularly in The use of such settings could help strike the
Namibia.28 Our estimates of quality using an in- right balance between providing rapid access
dex of basic maternal care functions in the study to emergency maternal and newborn services
countries also align with the results of earlier and maintaining a supportive and patient-
studies that demonstrated much higher quality centered birthing environment that reduces
of maternal and newborn care in secondary or overmedicalization.17,29 Countries should involve
tertiary care facilities.9,18 faith-based and private hospitals in redesign
plans to ensure access in remote areas and pro-
mote shared standards and learnings.
Policy Implications Second, even if the average quality of care rises
Redesigning service delivery for obstetric care through redesign, many hospitals will require
will require thoughtful planning, community substantial improvement in the quality of their
involvement, and a multisectoral approach. We obstetric services to consistently save lives. Peri-
outline here five essential considerations for natal mortality rates are higher in low-income
such a reform, which should be complemented countries than expected, despite the availability
with locally identified needs. of basic drugs and equipment—which suggests

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 Global Health Policy
Exhibit 4
Areas of Tanzania within one hour and two hours of hospitals
Hospital
Regional boundary
1-hour access
2-hour access
0 km 250 km
SOURCE Authors’ geographic feasibility assessment.
gaps in clinical competence or know-do gaps.5
Competence, particularly in emergencies and pa-
tient monitoring, needs to be improved through
better preservice education, strong health sys-
tem leadership and hospital management, stron-
ger accountability systems, and ongoing mainte-
nance of skills. Given the documented instances
of disrespect and abuse in maternal care in low-
and middle-income countries,30 emphasizing
patient-centered care and ensuring privacy in
hospitals is critical to the success of delivery ser-
vice redesign. A key concern is avoiding the over-
crowding and understaffing that occur today in
some referral hospitals through the expansion of
delivery wards or addition of birth centers or
other proximal units.31
Third, the quality of primary care should be
improved for the services it is best suited to pro-
vide, particularly antenatal and postnatal care.
Strengthening referral systems, including the
transfer of client records between facilities, is
an essential component of redesign.32 With the
removal of delivery services, primary care facili-
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ties would also have more scope for expanding
and improving other services, such as care for
noncommunicable diseases. These are growing
as a fraction of the disease burden and require
coordinated and continuous care that is well
suited to the primary care setting.33 Primary care
providers may also benefit from redesign. Re-
search shows that birth attendants who are asked
to perform tasks that are beyond their expertise
and scope of practice experience stress and poor
morale.10,34
Fourth, health system leaders will need to
identify options to enable access to high-quality
delivery care for women living far from hospitals.
Intersectoral solutions—such as improving key
roads and bridges, introducing transportation
vouchers or public-private partnerships for mo-
torized transport, upgrading rural health cen-
ters with surgical services, and providing mater-
nal waiting home options by large centers for
women near the end of pregnancy—may be need-
ed.35,36 Strategies to enable access should also
consider nongeographic barriers to care, includ-
ing financial, social, and cultural constraints.
Although there are challenges in improving ac-
cess to care for rural women, evidence suggests
that these are not insurmountable. Many rural
women already bypass their local facility for one
farther away, which suggests that transportation
is not always the limiting factor.31,37 As many low-
income countries continue to urbanize and ex-
500 km pand their transportation infrastructure, dis-
tance to care will also become less of a constraint.
The final consideration for implementing re-
design is to work with communities to raise
awareness of and demand for high-quality care,
through education and community outreach to
seek women’s preferences and ideas. Redesign
may be consistent with many women’s prefer-
ences: Research finds that many women are
willing to travel farther for care, and that those
who do are more satisfied with their care.37 Given
the persistent large numbers of home deliveries,
particularly in Haiti and Nepal, this reform
would need to be accompanied by ongoing work
to build demand for facility delivery. Fifty-six
percent of women delivering at home in Nepal
said that it was not necessary to deliver in a
facility, but evidence shows that improving the
quality of care can raise demand for facility de-
livery.38,39
Conclusion
Though implementing redesign would be com-
plex, the counterfactual of improving quality
at all delivery facilities could be even more
challenging—given the large number of primary
care facilities and the weak results of current
efforts to improve them. Two randomized trials
in India have found that extensive quality im-
provement programs in primary care facilities
had no effect on newborn and maternal health
outcomes.40,41 These null results were likely due
to low health worker competence and lack of
support systems for complex obstetric and new-
born care. Redesign should be tested and rigor-
ously evaluated in a variety of contexts to deter-
mine the costs of implementation and its effects
on health, user experience and costs, and equity.
New thinking will be required to achieve the
ambitious Sustainable Development Goal tar-
gets for maternal and newborn mortality. Service
delivery redesign is one such idea. The current
close-to-client childbirth model has resulted in
many women in low-income countries delivering
in primary care facilities that are not able to
consistently provide lifesaving care. This policy
is opposite to that pursued by high-income coun-
tries, which highlights a global health inequity.
It is time to reconsider how health systems in all
countries can be organized to produce better
outcomes for mothers and newborns. ▪

An earlier version of this article was
presented at the Fifth Global
Symposium on Health Systems Research
in Liverpool, UK, October 10, 2018. This
study was funded by the Bill & Melinda
Gates Foundation (Grant
No. OPP1161450 to Margaret Kruk). The
funders had no role in study design,
data collection and analysis, decision to
publish, or preparation of the
manuscript. The authors thank Dennis
Lee for providing data management
support. This is an open access article
distributed in accordance with the terms
of the Creative Commons Attribution
(CC BY 4.0) license, which permits
others to distribute, remix, adapt, and
build upon this work, for commercial
use, provided the original work is
properly cited. See https://
creativecommons.org/licenses/by/4.0/.

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