Mainstreaming a health systems approach to maternal health programming: transdisciplinary research in Rwanda and South Africa

In this WOTRO funded project, which runs from July 2012 to July 2016, NICHE collaborates with the Ministry of Health in Rwanda, the Centre for Health Policy at the University of the Witwatersrand in South Africa and the Public Health department at the University of the Western Cape, South Africa.

Too many women in low- and middle-income countries still die as a direct result of pregnancy and childbirth. We know from experiences in high-income countries that the vast majority of these deaths are preventable. Most experts argue that strengthening various aspects of the health system (as conceptualized in the WHO building blocks) is the solution, but it is not clear how these building blocks interact and mutually reinforce each other. There is uncertainty about the type of health system interventions that have been most successful and are best value for money. Demand-side interventions also appear critical for improving maternal health.

We postulate that the key steps needed to improve services in pregnancy include holding maternal health managers accountable for these services and encouraging community participation to thus increase patient demand. Much more may be needed to improve the skills of public-sector managers and enhance team-work, for instance in the use of routinely detection of women with high-risk pregnancies, the timely referral of women in labour for emergency obstetric care and drawing lessons from a systematic analysis of near-misses and instances of maternal or neonatal death.

Objectives of the research project
The research project aims to generate knowledge on how health systems strengthening can improve maternal health, and which health system supply and demand initiatives have the largest impact. Using a combination of systematic and realist reviews, secondary data analysis and primary data collection and analysis, the key components of health systems that countries currently prioritise in their efforts to improve maternal health will be identified and tested in four sub-projects. These four sub-projects are related to the two main objectives of the research project, as follows.

Objective 1: Define the evidence base for the synergies between health (support) systems and maternal health
1a. Systematic review of peer-reviewed literature (primary studies and previous reviews);
1b. Realist and desk review, involving Rwanda, South Africa and three other purposively
selected low-and middle-income countries.

Objective 2: Improving maternal health policy and practice in Rwanda and selected provinces in South Africa.

2a. Primary descriptive research through qualitative interviews, case studies and health system
2b. Intervention research: action research, active dissemination of study findings and policy

Ongoing sub-projects include: a systematic review entitled “Health system and community-based interventions for improving maternal health and reducing maternal health inequalities in low- and middle-income countries: a two-stage mixed-methods research synthesis”; and a ”Realist review delineating the contribution of health system building blocks and demand initiatives to improving maternal health in Sub-Saharan Africa”.

Through a case study approach in Rwanda and two sites in South Africa, illustrative successes and failures in efforts to improve maternal health services will be documented, with a particular focus on emergency obstetric care, and issues of health worker motivation and leadership:
- Eastern Cape case study: A comprehensive approach to access to high quality maternity services in rural areas: describing and strengthening an integrated comprehensive maternity services package in OR Tambo District;
- Gauteng case study: An assessment of emergency obstetric care in a South African district: a health systems lens;
- Rwanda case study: Exploring opportunities to improve emergency obstetric care in Rwanda.

The WOTRO grant covers the cost of training two PhD candidates (one from Rwanda, one from South Africa), to conduct their PhD studies at Radboudumc and UWC, respectively, in the field of policy and health systems research.
Principal investigator : Dr Duane Blaauw, Senior researcher, Faculty of Health Sciences / CHP, University of the Witwatersrand, Johannesburg, South Africa.

Staff Members involved:
Related publications: