More than 4.5 million women and babies die annually during or immediately after childbirth, according to a recent United Nations report. Most of these deaths are preventable with access to quality care. The Bay Area Global Health Alliance, together with Merck for Mothers, convened a small group of members in April 2023 to discuss the challenges and opportunities of ensuring safe delivery in both urban and rural impoverished communities.

The cross-sectoral Alliance members that were engaged in discussing possible options to reduce those abysmal statistics included CCBRT in Tanzania and Chidamoyo Hospital in Zimbabwe, and representatives from Antara International, Maya Health Alliance, Simprints, UCSF Bixby Center for Global Reproductive Health, and the World Telehealth Initiative.

Identifying Challenges

Delivering quality care in low-resourced areas requires healthcare providers to surmount a host of unique challenges. CCBRT and Chidamoyo presented three common issues they face in providing quality maternal care in their respective countries:

• Workforce turnover and burnout; the frequent attrition of skilled nurses, doctors, and other medical staff
• Lack of diagnostics and/or technology to support safe delivery
• Limited access to maternal health information for patients and information and communications technology (ICT) for providers

Low- and middle-income countries (LMICs)—as well as some regions and settings in high-income countries—suffer from low doctor-patient ratios. Staffing is a primary concern. There are simply not enough medical personnel to treat the volume of mothers needing care during and after their pregnancies. Low wages, lack of ongoing training, and difficult and uncomfortable working conditions foster an environment in which healthcare workers seek better salaries, less stressful working conditions, and more prestige in other countries or with other for-profit businesses.

In LMIC settings, many hospitals lack essential and newer technologies and equipment (e.g., ultrasounds, fetal heart rate monitors, infusion pumps) that make it possible to provide quality care to a high volume of patients. In both rural and urban settings, if they do have access to adequate equipment, its regular and sustained application can be challenged by intermittent (or no) internet access and power grid failures.

Further complicating the picture is that expectant mothers in low-resource settings frequently have little knowledge of, or access to, information about their pregnancies. Especially in rural areas, mothers may advance through their pregnancies without seeking maternal care. For instance, without knowing how much weight they should gain, they can’t know if the pregnancy is progressing normally. The difficulties in sharing important information with expectant mothers—many of whom live long distances from any healthcare provider—are compounded by the providers’ need for better information and communications technology (ICT). Without up-to-date and efficient ICT systems (e.g., electronic health records), healthcare professionals have a more difficult time making diagnoses and providing the range of support needed, including treatment, monitoring, medication prescriptions, referrals, information retrieval, and communication.

Providing Solutions

The thoughtful dialogue resulted in several recommendations to improve the delivery of quality maternal healthcare in LMICs. They include the following:

Bi-directional exchange programs in which healthcare workers from high-income countries work onsite for limited periods in LMICs could provide resources and training, free of charge – and vice versa. Exchanges would provide a much-needed avenue for continuous learning and professional development, assist with staffing management concerns, motivate local healthcare workers, and offer access to research possibilities. Additionally, exchange programs create a pipeline of willing ambassadors—healthcare workers who’ve returned to their home countries and are motivated to serve as champions of the organization.

Telehealth could further support a long-term bidirectional relationship and capacity-building once an exchange has been completed. Telehealth also offers opportunities to provide essential skills and maintenance training on new technology as well as oversight for direct patient care.

Provide training / capacity strengthening opportunities and empower the “next-in-line” when doctors aren’t available. This can mitigate care paralysis from understaffing and allows systems to build their own capacity, eliminating the need for healthcare workers to rely on external support. It can also serve to reduce burnout. Building capacity through training and support from online modules and apps can help to build the confidence and clinical skills of healthcare workers in rural areas (e.g., Safe Delivery App, iDeliver, Respectful Maternity Care Training Module, etc.).

Embrace emerging technology that performs in regions with fragile infrastructures. Technology designed in low-resource regions is especially valuable. New tools like AI for ultrasounds and less expensive ultrasounds developed in LMICs could better serve hospitals in rural and urban settings (e.g., Butterfly Network, Vave, etc.). Technology innovations can also be used to attract young people and others who haven’t traditionally considered work in the health system to increase staffing, particularly for administrative positions.

Surface opportunities to educate women regarding their health. Health applications and digital technologies can play an important role in promoting greater awareness of a woman’s health  (e.g., Together for Her Health).

Give communities agency to advocate for improving health systems. Raising awareness about women’s rights to kind, respectful, competent care, regardless of economic background, can help create a “pull” from women in communities, resulting in pressure on governments to invest in healthcare (for example, the What Women Want campaign results have been used to drive policy).

* CCBRT is a Tanzanian NGO, where 90% of urban women choose to give birth in a facility. Yet, only three public health facilities provide comprehensive care—leading to many maternal deaths. Using evidence-based interventions, the group has achieved a 47% reduction in maternal mortality and an 80% improvement in the quality of care. CCBRT opened a new 160-bed maternity and newborn wing in 2022 to further reduce congestion in the public healthcare system, with a focus on high-risk pregnancies and the vulnerable poor. newsite.ccbrt.org/

Chidamoyo is a 100-bed hospital in rural northwest Zimbabwe. It serves a population of 70,000 patients through its hospital and 18 mobile outreach clinics, sees ~250 patients each day, and delivers 1,500 babies each year. Nine of its mobile clinics focus on antiretroviral therapy—and those efforts have resulted in a 90% reduction in HIV transmission in utero and a 90% reduction in the AIDS rate at the hospital. In 2016, Chidamoyo opened a new Mother’s Waiting Shelter, which can host 80–90 women in their last trimester, helping improve maternal outcomes by reducing delays in reaching a healthcare facility. chidamoyohospital.org/