Project Details
Description
Progress in reducing mortality has stagnated in the first five years of the Sustainable Development Goals (2016-2020), in contrast to the Millennium Development Goals which achieved a 33% reduction in maternal mortality globally over 15 years (2000-2015) [1]. Approximately 287,000 women and nearly 5 million babies (including stillbirths and neonatal deaths) die each year worldwide. More than 98% of these maternal deaths occur in low- and middle-income countries (LMICs) with 70% being located in Sub-Saharan Africa [2,3]. Studies indicate that the highest risk of maternal and perinatal death occurs during childbirth and within the first 24 hours afterward. Direct obstetric causes such as severe haemorrhage, hypertensive disorders, and sepsis account for more than half of all cases. Therefore, timely access to skilled healthcare providers within an enabling environment is essential for reducing adverse pregnancy outcomes for both the mother and the newborn. Most maternal and neonatal deaths can be prevented if women receive adequate antenatal care and give birth in wellequipped healthcare facilities with skilled providers to manage complications. Alternatively, if functional referral systems are in place, women can be promptly directed to appropriate healthcare services in case of obstetric complications [4,5].
Most women in LMICs receive antenatal care, and over half give birth in healthcare facilities. However, research consistently shows that antenatal, intrapartum, and postpartum care often fall short of evidence-based quality standards and lack respect, dignity, and autonomy for women. More maternal deaths today are attributable to both poor quality of care and delays in accessing health healthcare facilities when complications occur, particularly in urban settings where despite short physical distances, travel time can be long due to poor road infrastructure and heavy traffic [6]. For instance, in Guinea, the latest Demographic and Health Survey of 2018 (DHS 2018) indicates that 81% of pregnant women receive at least one antenatal visit. The coverage of facility-based childbirths increased from 29% to 53% between 1999 and 2018 [7]. Despite, the country still has one of the highest maternal mortality ratios (MMR) globally, with 553 maternal deaths per 100,000 live births in 2020. The MMR in urban areas of Guinea remains unknown, however, a study estimated it to be 1,141 deaths per 100,000 live births at the Hôpital National de Ignace Deen in Conakry [8]. Some studies have provided evidence of mistreatment during facility-based childbirth in urban settings. For example, a study conducted by Baldé et al. in 2017 in the Mamou region highlighted instances of mistreatment at the referral hospital, including slapping, verbal abuse for non-compliance with providers' instructions, giving birth on the floor, and a lack of skilled provider present at the health facility during admission [9]. In addition, an analysis of the continuum of maternal care demonstrated a loss of women along the continuum between antenatal, childbirth, and postpartum care, highlighting issues related to the quality and accessibility of care [10].
The gap between knowledge and practice in maternal and perinatal care in LMICs is wide, particularly in urban areas, where two-thirds of the world's population will live by 2050 [11]. Nearly 90% of these additional 2.5 billion urban residents will be concentrated in Africa and Asia [12]. Urban health systems have received little research attention[13]. They struggle to meet the needs of women in various states of vulnerability [14], including low education, living in informal settlements (slums), recent migration, or adolescence [15,16]. Currently, urban health systems do not comprehensively address the needs of women and newborns. Challenges identified in cities include: 1) clustering of urban poverty and marginalization of migrants from the health system [17]; 2) a wide range of private providers contributing to over-medicalization [18] and high out-of-pocket expenses [19]; 3) suboptimal quality of care in health facilities [19,20]; 4) relatively short distances to health facilities masking longer travel times due to spatial accessibility issues [21] - e.g., traffic leading to delays; inability to travel at night due to insecurity [22,23]; and 5) lack of trust in lower-level facilities that leads to bypassing the nearest facility, even in emergencies, and overcrowding in hospitals [13,24]; 6) inefficient referral and counter-referral systems [25], communication channels, and insufficient functional ambulances [26,27]; and 7) incomplete or poor quality routine data to inform decisionmakers [28]. Other very specific local factors exist in each city; many are not identified or well described [29]. However, urbanization is not just a matter of scale - that is, meeting the demand for care with sufficient supply. Urban areas harbor complexities and interactions, which can exacerbate pre-existing weaknesses in health systems during health emergencies such as infectious disease outbreaks [30]. A recent study in Tanzania showed that neonatal mortality rates are twice as high in core urban areas as in rural areas [31]. Although the authors could not conclusively identify key factors contributing to this phenomenon, they speculated that a combination of environmental hazards, poor quality of care, poverty, and information bias is at play.
In Guinea, we have a limited understanding of the effect of the complexity of urban living and urban health service provision of maternal and child health. In 2017, Diallo et al. showed that maternal deaths at the Hôpital National Ignace Deen (HNID) were about 25 times more frequent among referrals for childbirth than direct admissions [8]. However, the authors did not report on the extent to which the context of advanced urbanization and the profile of the referring facilities contributed to this. Nor did the study explore the question of the quality of care offered to women.
Most women in LMICs receive antenatal care, and over half give birth in healthcare facilities. However, research consistently shows that antenatal, intrapartum, and postpartum care often fall short of evidence-based quality standards and lack respect, dignity, and autonomy for women. More maternal deaths today are attributable to both poor quality of care and delays in accessing health healthcare facilities when complications occur, particularly in urban settings where despite short physical distances, travel time can be long due to poor road infrastructure and heavy traffic [6]. For instance, in Guinea, the latest Demographic and Health Survey of 2018 (DHS 2018) indicates that 81% of pregnant women receive at least one antenatal visit. The coverage of facility-based childbirths increased from 29% to 53% between 1999 and 2018 [7]. Despite, the country still has one of the highest maternal mortality ratios (MMR) globally, with 553 maternal deaths per 100,000 live births in 2020. The MMR in urban areas of Guinea remains unknown, however, a study estimated it to be 1,141 deaths per 100,000 live births at the Hôpital National de Ignace Deen in Conakry [8]. Some studies have provided evidence of mistreatment during facility-based childbirth in urban settings. For example, a study conducted by Baldé et al. in 2017 in the Mamou region highlighted instances of mistreatment at the referral hospital, including slapping, verbal abuse for non-compliance with providers' instructions, giving birth on the floor, and a lack of skilled provider present at the health facility during admission [9]. In addition, an analysis of the continuum of maternal care demonstrated a loss of women along the continuum between antenatal, childbirth, and postpartum care, highlighting issues related to the quality and accessibility of care [10].
The gap between knowledge and practice in maternal and perinatal care in LMICs is wide, particularly in urban areas, where two-thirds of the world's population will live by 2050 [11]. Nearly 90% of these additional 2.5 billion urban residents will be concentrated in Africa and Asia [12]. Urban health systems have received little research attention[13]. They struggle to meet the needs of women in various states of vulnerability [14], including low education, living in informal settlements (slums), recent migration, or adolescence [15,16]. Currently, urban health systems do not comprehensively address the needs of women and newborns. Challenges identified in cities include: 1) clustering of urban poverty and marginalization of migrants from the health system [17]; 2) a wide range of private providers contributing to over-medicalization [18] and high out-of-pocket expenses [19]; 3) suboptimal quality of care in health facilities [19,20]; 4) relatively short distances to health facilities masking longer travel times due to spatial accessibility issues [21] - e.g., traffic leading to delays; inability to travel at night due to insecurity [22,23]; and 5) lack of trust in lower-level facilities that leads to bypassing the nearest facility, even in emergencies, and overcrowding in hospitals [13,24]; 6) inefficient referral and counter-referral systems [25], communication channels, and insufficient functional ambulances [26,27]; and 7) incomplete or poor quality routine data to inform decisionmakers [28]. Other very specific local factors exist in each city; many are not identified or well described [29]. However, urbanization is not just a matter of scale - that is, meeting the demand for care with sufficient supply. Urban areas harbor complexities and interactions, which can exacerbate pre-existing weaknesses in health systems during health emergencies such as infectious disease outbreaks [30]. A recent study in Tanzania showed that neonatal mortality rates are twice as high in core urban areas as in rural areas [31]. Although the authors could not conclusively identify key factors contributing to this phenomenon, they speculated that a combination of environmental hazards, poor quality of care, poverty, and information bias is at play.
In Guinea, we have a limited understanding of the effect of the complexity of urban living and urban health service provision of maternal and child health. In 2017, Diallo et al. showed that maternal deaths at the Hôpital National Ignace Deen (HNID) were about 25 times more frequent among referrals for childbirth than direct admissions [8]. However, the authors did not report on the extent to which the context of advanced urbanization and the profile of the referring facilities contributed to this. Nor did the study explore the question of the quality of care offered to women.
| Status | Active |
|---|---|
| Effective start/end date | 1/01/25 → … |