Trying working environments strain quality of health care

Cape Town | A new Cochrane qualitative evidence synthesis describing the factors that influence the quality of maternity care in low-and middle- income countries  has shown that birth attendants who experience difficult working environments are likely to provide poor maternal care to mothers and their babies.  

Thirty-one qualitative studies that explored the views, experiences, and behaviours of skilled birth attendants in Africa, Asia, and Latin America found that access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport are just some of the contributing factors to the poor quality of the health care offered to women. 

“This qualitative evidence synthesis looks at the issues influencing the quality of maternity care from the perspective of health care providers, and helps explain why they are not always able to deliver good quality care during pregnancy and childbirth,” says review author and SAMRC Senior Specialist Scientist Dr Simon Lewin.

In many low- and middle-income countries, many mothers still die during childbirth. Women are encouraged to give birth in health facilities rather than at home so that they can receive care from skilled birth attendants. However, the skills, attitudes and behaviour of skilled birth attendants, and the extent to which they work in an enabling working environment, impact on the quality of care provided.

“More needs to be done to address the human resource and infrastructural challenges that prevent health workers in low- and middle- income country settings from providing good quality maternity care,” says lead author of the synthesis Dr Susan Munabi-Babigumira who is based at the Norwegian Institute of Public Health. “We have provided a set of questions that will hopefully guide programme managers who are seeking to improve health services.”

In efforts to help health service managers explore ways of improving maternity care, the reviewers have developed a set of questions to be considered when implementing or planning for obstetric health services. These questions include the staffing situation in relation to the workload, how health workers at facilities perceive their working and living conditions, and the opportunities available at health facility level to foster good inter-professional relations. (see notes to the editor)

“This set of questions that we have provided could act as prompts for programme managers to think through the areas where they could make improvements to the health service,” says Dr Lewin.

Dr Harriet Nabudere, one of the review authors based at the Uganda National Health Research Organisation reiterates that the findings from this synthesis provide research evidence to support decisions by health managers, practitioners and policymakers when addressing barriers faced by some health systems in low and middle-income countries. She adds that international actors can also use this evidence to support countries to strengthen health systems to improve health outcomes.


1 At your facility, what is the staffing situation in relation to the workload, for instance for providing 24-hour care? Where task-shifting strategies or increasing health workers' scope of practice are suggested as options to improve the staffing situation, how will this impact on health workers' workload and on the overall quality of care? Would recruiting more health workers be a better option instead of moving people around?
2 For facilities that deliver emergency obstetric care, are specialists available when needed? If no specialists are available and tasks have been transferred to non-specialist health workers, have these health workers been provided with training, supervision, and linkages to other centres, for instance for referral or support by telephone?
3 How do health workers at your facility perceive their working and living conditions? Could these be the underlying reasons for absenteeism, decreased morale, poor retention, and recruitment of health workers?
4 For managers at district or higher programme levels, are sufficient funds available for the recruitment of health workers? Is the recruitment process responsive to the local needs with minimal bureaucracy? Recruitment arrangements need to take into account facility arrangements, e.g. 24-hour opening.
5 Do health workers' salaries reflect their training, experience, actual workload and responsibilities, and the need for reasonable living conditions?
6 What are health facility managers' training needs and how can they be supported to attain this training?
7 What are the pre- and/or in-service training needs for the health workers at your facility? Consider if the health workers can manage complicated pregnancies, alternative delivery positions (practice), among others. When planning for in-service training, consider how this training is organised, e.g. scheduling of classes, availability of tutors for upgrading courses, selection of trainees according to health facility, or individual training needs, etc.
8 What are the reasons why women may be reluctant to accept referral to higher levels of care? When exploring how to improve the referral process, health system managers may need to consider these issues in order to make the referral system more responsive to women's needs, e.g. their need of financial support or the need to manage their fears
9  Does your health facility have a regular and reliable supply of electricity and water all year round? Consider how intersectoral collaboration could help resolve problems with electricity and water supply.
10 Does your health facility have the necessary equipment such as cord clamps, complete delivery kits, as well as sterilising equipment required for good-quality maternity care? In order to deliver quality care, attention needs to be given to ensure necessary equipment is available and sufficient in number to meet the demands for maternity care.
11 In case your health facility occasionally runs out of supplies, drugs, and blood that are necessary to provide maternity care, what are the underlying reasons for stock-outs of these items and how can these problems be addressed?
12 Is the physical environment at your health facility optimally organised to facilitate health workers' delivery of good-quality care? For instance, what is the location of the postnatal ward in relation to the labour ward for health workers who need to monitor mothers in labour as well as mothers in postpartum and their newborns? Consider collaborating with health workers to organise the available space in view of the number of mothers served.
13 What opportunities are available at the health facility level to foster good interprofessional relations, e.g. opportunities for collaborations, team building, and appreciating each others' competencies?

For more information, please contact Susan Munabi-Babigumira:

Read the review at:

Release date: 
Monday, November 27, 2017 - 08:00
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