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Redesigning maternal health services: is centralisation the answer in low-resource settings?
  1. Claudia Hanson1,2,
  2. Joanna Schellenberg2
  1. 1Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
  2. 2Disease Control, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Claudia Hanson; claudia.hanson{at}ki.se

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Summary box

  • One key recommendation of the Lancet Commission on High-Quality Health Systems in the Sustainable Development Goal Era published in September 2018 is the redesign of childbirth services.

  • The plea for the childbirth service redesign is underpinned by the assumption that the centralisation of childbirth services to hospitals will result in (1) more efficient delivery care, (2) more skillful maternity providers and (3) more timely emergency care interventions including blood transfusion and caesarean section.

  • We call for research to develop and test context-specific redesign strategies for improved childbirth care based on the two continuums of care: from pregnancy, through to childbirth and postnatal care, and from community to specialised referral care.

  • Strategies need to take into account specific aspects of access, safety and quality of care in the respective setting in order for safe and respectful childbirth care to reach all women.

Introduction

A strategy of childbirth in facilities close to home has been in place for almost two decades,1 but given numerous reports of low quality of care,2 3 the recent review of the strategy is timely.2 4 The Lancet Commission on High-Quality Health Systems in the Sustainable Development Goal Era suggests that childbirth services should be centralised to hospitals under the premise that larger volumes will result in (1) more efficient delivery care, (2) more skillful maternity providers and (3) more timely emergency care interventions including blood transfusion and caesarean section.

There is no doubt that the present strategy of childbirth care is not fulfilling expectations: maternal mortality is not reducing at the expected pace of 5% per year, but only 2.4% in low-income and middle-income countries5—except in a few settings such as Cambodia, where dedicated midwives offer childbirth care in health centres, and maternal mortality has reduced with an annual decline of 7.4% from …

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