Healthy Mothers and Babies: Supporting Skilled Attendance at Birth

Challenge

Pregnancy and childbirth are often the most vulnerable time for women, especially in countries with limited access to reproductive and maternal healthcare. While healthy pregnancies, and maternal and child survival depend on the entire continuum of reproductive and maternal healthcare, skilled birth attendance, whether at home or in a healthcare facility, is of particular importance for reducing the risk of maternal and neonatal mortality. Yet, women often lack access to these services due to barriers such as cost (including hidden costs e.g., transportation or out-of-pocket payments for medicines), mobility, availability of quality services, and social norms (e.g., not being able to travel without a companion, preference for traditional practitioners and methods that may not be sufficient, especially in obstetric emergencies). Disruptive events such as the COVID-19 pandemic, disasters, and conflict create further barriers to service delivery and access.

Approach

The World Bank has been actively involved for over a decade in efforts to ensure skilled birth attendance as part of the reproductive and maternal health continuum of care. Starting with the World Bank's 2010-2015 Reproductive Health Action Plan, the World Bank sharpened its focus on supporting reproductive and maternal health through project lending. By 2015, the World Bank, along with other partners, had established the Global Financing Facility to leverage grants for IDA countries. These grants have been very successful in improving availability and quality of these services in areas with the highest burden of poor maternal and child health outcomes. Currently, the World Bank's support to reproductive and maternal health comprises both direct lending and grants.

To support availability and access to skilled attendance at birth, the World Bank has implemented various approaches, including:

• Improving Service Delivery: The World Bank has focused on service delivery as part of health systems strengthening (e.g., refurbishing maternity wards, strengthening referral and ambulatory systems to connect women to better quality and timely skilled birth attendance). It includes improving access to quality emergency obstetric and neonatal care services.
• Training Programs: The World Bank has invested in hiring, training, and deploying skilled birth attendants, female community health workers, and midwives, to scale up service delivery, and improve the quality of birth attendance.
• Results-Based Financing: The World Bank uses results-based financing, particularly through its partnership with GFF, such as performance incentives for skilled birth attendants and doctors to meet agreed upon targets for service delivery. For example, a results-based incentive may be linked to the successful delivery of healthy babies, or to providing ante- or post-natal care that meets specific medical guidelines or protocols.
• Demand-Generation Strategies: The World Bank supports strategies such as information and education campaigns, social and behavior change communication, cash transfers, and coverage via universal health coverage programs to improve utilization of skilled attendance at birth. For example, pregnant women may be given vouchers to receive free or low-cost pregnancy related healthcare and/or free transport to and from healthcare facilities to reduce the financial barriers to healthcare, and to incentivize them to seek such care.

Results

Between FY18 and FY23, the World Bank supported nearly 95 million women to receive skilled attendance at birth though project investments in 47 low- and middle-income countries. Notable examples below show the range of interventions that the World Bank has deployed to address varied needs across contexts.

• Indonesia has a high maternal mortality rate, 173 deaths per 100,000 live births in 2020 (4^th highest in the ASEAN region), with several provinces reporting rates exceeding 250 deaths per 100,000 live births. To tackle this, the World Bank is addressing key causes of avoidable maternal deaths such as post-partum hemorrhage, eclampsia and infections, that require skilled and timely intervention through the availability of maternal and neonatal health care. Interventions include: Emergency Obstetric and Newborn Care, supporting regular pre and post-natal care visits, and raising awareness; World Bank projects use a results-based financing mechanism to facilitate performance based payments for primary care services and provide financial and technical assistance to improve demand for, access to, and quality of services e.g., increasing demand for skilled delivery through cash transfers and community-based education and improving coverage and quality of maternal and child health services through the development and implementation of standard clinical decision support tools. These investments have facilitated over 26.5 million women to receive skilled attendance at birth between 2018 and 2023, especially reaching communities with the poorest reproductive and maternal health outcomes.
• The World Bank's support to the Mozambique Primary Health Care Strengthening Program aimed to improve the utilization and quality of reproductive, maternal, child and adolescent health and nutrition services, particularly for the poorest women in rural areas. Some of the key challenges the country faced were a high and rising adolescent fertility, which is often associated with higher risk of maternal death, and a weak health system. Only 40 percent of maternal deaths were taking place in district hospitals when the program was initiated in 2017, highlighting the need for better quality of care, training of skilled birth attendants, and strengthening referrals to higher tier facilities. Using a results-based approach, the program supported health systems strengthening, including enhancing access to and delivery and quality of primary care services, which facilitated almost six million skilled deliveries at birth between December 2017 and December 2022.
• In Kenya, the World Bank's investment in the Transforming Health Systems for Universal Care Projectsupported the country's efforts to increase skilled birth attendance. This investment complemented the government of Kenya's free maternal health program Linda Mama, which seeks to address the main barriers for better maternal, newborn, and child health-as well as other interventions supported by development partners. Overall, the project supported an increase in skilled attendance at birth from 57 percent to 75 percent in targeted facilities. This translates to over seven million deliveries between FY17 and FY23.

Data Highlights

Between FY18 and FY23, the World Bank supported 94.7 million women to receive skilled attendance at birth though its project investments. The majority of this support was directed toward the most vulnerable communities in the Africa region followed by East Asia (see Figure 1). The top 10 countries where the Bank has supported the largest number of new beneficiaries of skilled attendance at birth include: Indonesia, Tanzania, Nigeria, Kenya, Mozambique, Myanmar, Burundi, Afghanistan, Ghana, and Niger.

World Bank Group Contribution

Between FY18-FY23 the World Bank approved over $3.5 billion in new lending for reproductive, maternal, newborn, child, and adolescent health, which encompasses skilled birth attendance as a core intervention. The majority of this lending was directed to the Africa Region, which bears some of the highest burden of poor reproductive and maternal health outcomes.

Partnerships

• Global Financing Facility (GFF): is a key partner in delivering on reproductive, maternal and child health. Hosted at the World Bank, the GFF leverages IDA funds through grants for results-based reproductive and maternal health interventions.
• The Human Reproduction Programme: is the UN system's main instrument for research on reproductive health. The World Bank is a permanent member of its governance structure.
• The World Bank is also a member of the Partnership for Maternal, Newborn, and Child Health (which focuses on evidence-based policy advocacy), and the H6 (a partnership of UN agencies to harmonize maternal and child health activities within countries).

Looking Ahead

The World Bank is strongly committed to improving maternal and newborn health outcomes through supporting the continuum of reproductive, maternal, newborn, child, and adolescent health care, which includes skilled attendance at birth. Key to this is ensuring availability of timely and appropriate care. Through continued investments in service delivery and health systems strengthening, as well as supporting countries to implement Universal Health Coverage (allowing affordable access to care) and using mechanisms such as results-based financing to improve quality of services, the World Bank will continue to support investment in this area. For example, our Sahel Women's Empowerment and Demographic Dividend program which continues to support women and girls' access to reproductive health, and the continued support to GFF which leverages IDA projects to deliver on sexual and reproductive health.

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