Implementation and aspiration gaps: whose view counts?
2068 www.thelancet.com Vol 388 October 29, 2016 The Lancet's Maternal Health Series paints a sobering picture of the state of maternal health today. The Series focuses on the "mismatch between burden and coverage" which "exposes a crucial gap in quality of care" and spotlights the millions of pregnant women and adolescents who never get access to services at all. But 30 years after the start of the safe motherhood initiative, this mismatch exposes something else as well: a dangerous disconnect between the way the global health community has framed problems, proposed strategies, and pushed solutions, and the lived experience of people and providers. Thus the quality and access gaps defi ned in the Lancet Series through epidemiological analysis and quantitative data could also be framed as implementation and aspiration gaps, drawing on a wider range of empirical data to speak a diff erent truth to power. Take the example of facility based delivery care. The central aim of global skilled birth attendance strategies has been to ensure that routine births are managed in accordance with evidence based practices and that obstetric complications are treated in facilities where emergency obstetric care (EmOC) is delivered. Whether women are driven to deliver in facilities by their own desires, by fi nancial incentives, or even by government compulsion is often unclear and rarely considered to matter. Seemingly, what counts is that facility based delivery has increased, sometimes dramatically. What do women experience when they arrive at facilities ready to give birth? Suellen Miller and colleagues identify 51 high quality global and national clinical practice guidelines issued since 2010 for routine maternity care in facilities. Focusing on middle income countries to determine what actually transpires, they document pervasive, health threatening deviations from those guidelines, characterised by too little, too late (insuffi cient appropriate care) and too much, too soon (excessive medicalisation) Other recent reviews round out the picture by exposing a startling range and level of disrespectful and abusive treatment, in countries both rich and poor. Implementation gaps are not limited to the four walls of the health facility. Oona Campbell and colleagues show that the indicators we in the global health community have so confi dently promoted for coverage measurement at the population level often serve only to hide catastrophic failures. They say that "governments and policy makers can no longer pretend to provide life saving care, using phrases such as skilled birth attendant and EmOC to mask poor quality" Pretend is perhaps a good choice of verb. Campbell and colleagues show that standardised, globally formulated strategies pressed upon countries in an attempt to make services widely available and accessible ultimately ignore the varied topographies, health system confi gurations, and demographic characteristics of diff erent countries which makes achievement of globally determined norms at a globally determined pace manifestly unrealistic. A view from the ground would show globally formulated strategies ignore many other things as well: diff erent histories, governance styles, and social dynamics; minimal state capability to infl uence the dynamics at the periphery of the system; and corrosive distrust of health systems by both the people who work for them and the people meant to benefi t from them. A view from the ground would show that people's interactions with maternal health services are never only about attaining health outcomes. These interactions are also about aspirations to have some control over their birth experience, to be treated with dignity and respect, and to use their choices around childbirth to signal who they are and who they want to be. Implementation and aspiration gaps: whose view counts? 12 Stenberg K, Axelson H, Sheehan P, et al, on behalf of the Study Group for the Global Investment Framework for Women's Children's Health. Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework. Lancet 2014; 383: 1333 54. 13 ten Hoope Bender P, de Bernis L, Campbell J, et al. Improvement of maternal and newborn health through midwifery. Lancet 2014; 384: 1226 35. 14 Mason E, McDougall L, Lawn JE, et al. From evidence to action to deliver a healthy start for the next generation. Lancet 2014; 384: 455 67.
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