Service Delivery Redesign

Maternal and Newborn Health Service delivery redesign is an intervention that seeks to restructure health systems so that all women and their newborns, no matter where they live or their economic circumstances, have ready access to advanced obstetric and neonatal care if a complication is to arise. The core tenets of MNH SDR​ are:

• Ensure all mothers give birth in or close to higher-level facilities that can provide definitive care for complications (i.e., capacity for cesarean section, blood transfusion, care for sick mothers and newborns).
• Strengthen primary care for coordination of care and provision of quality antenatal, postnatal and newborn care
• Implement intersectoral interventions to ensure quality, access, equity and financial protection for all mothers and their newborns.

Current evidence shows that maternal and newborn mortality are lowest in high- and upper-middle-income countries, where nearly all deliveries occur in higher-level facilities. Conversely, in many low- and lower middle-income countries which have the highest burden of maternal and newborn mortality, more than a third of deliveries occur at the primary care level.

Evidence from the BetterBirth Trial, the largest primary care quality improvement trial of intrapartum care, showed that even when processes of care are significantly improved at the primary care level, mortality gains are low when there is no ready access to definitive care for complications. This is  because the prevailing residual mortality is more difficult to manage, thus women who develop complications today will require more complex care to be effectively managed. Additionally, risk stratification and referral, two important primary care strategies to manage complications, are currently inadequate to ensure survival for all mothers and newborns; risk stratification is not sufficiently sensitive to clearly distinguish who will go on to develop complications, and referral is often slow and not an effective way to deal with emergencies.

The government of Kakamega County, in western Kenya, is in the process of implementing Maternal and Newborn Health Service Delivery Redesign. An accompanying rigorous process and outcome evaluation of the program will provide evidence on the comparative benefits of this concept in relation to the prevailing model of care.

The primary intention of SDR is to improve the survival and health of mothers and newborns. This would happen through timely identification of complications, immediate provision of lifesaving care, and proper management of ANC, PNC and newborn care. Another important benefit is that concentrating deliveries in fewer facilities would increase health system efficiency; scarce funds, health personnel, equipment and supplies would be more efficiently used and improvement efforts would be limited to only a few facilities. The larger delivery volumes that facilities would manage under MNH SDR also makes it possible for multi-disciplinary care teams to be formed, which is a hallmark of high quality systems. These larger volumes would also help health care workers maintain their skills for managing complications. Lastly, there is likely to be increased job satisfaction and motivation since providers would be working in clinical environments that encourage teamwork and emphasize strong performance.

Implementing redesign when the health system is not ready could lead to negative outcomes. If the receiving hospitals are of insufficient quality, survival and health gains will not be achieved. Current evidence shows that in many lower income countries surgical, anesthetic and sick newborn care capacity and quality are low. Without adequate preparation, such deficits could lead to iatrogenic complications. Increasing hospital deliveries may also lead to inappropriately high rates of cesarean sections or increased use of unnecessary medical interventions. Delivery hospitals may also become overcrowded if adequate expansion does not accompany the implementation of the MNH SDR program; such overcrowded facilities increase risk for nosocomial infections and do not engender patient-centered, dignified care. Healthcare workers in such facilities would also be overburdened and demotivated. Moving deliveries to higher-level facilities also increases distance to delivery care for rural women; this can limit access if adequate mitigating measures, e.g., transportation schemes, voucher programs and maternity waiting options, are not implemented as part of MNH SDR.

No. MNH SDR strongly recommends a midwife-led model of service provision for births if this cadre is available in the context. Midwife-led models of intrapartum care are known to advance physiological birth and patient-centered care. Other cadres of health workers like general physicians can provide support as available, and obstetricians should be involved in birth care for complications and for high-risk pregnancies.

Primary care is the bedrock of any health system, and it is the same with MNH SDR. In MNH SDR, the key role of the primary care level is to coordinate care for mothers throughout their journey through pregnancy, delivery and the postnatal period, and to provide high quality, patient-centered antenatal and postnatal care for the mother and newborn care for the baby. The primary care level thus needs to be strengthened to be able to deliver these important services.

Birth care on the other hand is best provided at a facility that can immediately manage complications if they should arise, since the birthing process can become rapidly fatal through unforeseen complications. MNH SDR therefore proposes that all deliveries occur in or close to higher-level facilities that can guarantee care for maternal and newborn complications.

Freeing up primary care facilities of the responsibility of birth care would also open up room for critical primary care services, such as the management of uncomplicated chronic diseases, to be provided at the primary care level.

Thus, SDR is not a call to side-step primary care, but rather a proposal to organize care to maximize outcomes and to strengthen the primary care level to provide care that it is at the core of its competence.

Given that MNH SDR intends to maximize survival and health, this should be the desired road of travel in all contexts. Relocation of deliveries to specific facilities however requires that there are adequate facilities that can provide the service in an equitable manner and in a way that reduces the risks of redesign to a minimum. This suggests that health systems which have some basal assets, e.g., adequate spread of hospitals, well-trained and adequate numbers of health providers and short distances to care for the population, have an easier path to instituting MNH SDR than settings that lack these. The ease of implementation can be determined by performing a feasibility assessment of MNH SDR in the setting in consideration. A guide to perform such a feasibility assessment can be found here. MNH SDR is a largescale health system reform and therefore beyond the feasibility assessment, the level of political buy-in is an important determinant of whether the program will be implemented and sustained. In all cases, MNH SDR should be done deliberately and thoughtfully. 

In places where women are already giving birth in hospitals at very high rates, the focus of SDR would be to ensure that quality care is provided at all points in the continuum of care. This may mean that strategies would need to be implemented to curb overmedicalization of births if it exists, e.g., employing onsite midwife-led care as the primary model of intrapartum care for all low-risk mothers. Another consideration in such a situation is to ensure that primary care facilities are staffed and equipped to perform their coordination function and provide high quality antenatal, postnatal and newborn care, and that such care is appropriately shifted from hospitals to the primary care level.

The cost to implement MNH SDR will depend on the context, specifically on the prevailing health system gaps (e.g., human resource numbers and competence, quality and coverage of hospital care and ease of geographic and financial access to care) and the strategies chosen by the government to fill those identified gaps and to achieve the tenets of MNH SDR. It is thus safe to say that SDR would cost more in places with larger health system gaps. Independent of the start-up cost, the potential long-run impacts of MNH SDR on maternal and newborn health outcomes and on health system efficiency likely makes it more cost-effective than a highly decentralized alternative.

Service Delivery Redesign can be applied to any condition/disease area. For each condition, SDR recommends a rethink of the system to ensure that different patient segments can receive high-quality and appropriate care at the right level of the health system, i.e., at a hospital, primary care clinic or using community/non-visit interventions as appropriate. For each disease or condition, complex presentations which require significant expertise, or activities/procedures for which there is a reasonable possibility of rapidly fatal complications arising are best managed in hospitals, while stable presentations and preventive/promotive services should be managed lower down the health system. For example, for mental health, patients experiencing debilitating symptoms and those with multi-morbidities would be managed in specialized centers, patients who have recently become stable would be managed with regular in-person primary care visits, while those who have been stable for a long time could be managed with non-visit care through telemedicine. For Tuberculosis, care for uncomplicated cases would be managed in community clinics, while multidrug resistant cases with complications would be managed in centralized specialist centers.

There are five broad areas that need to be deliberately considered in implementing Service Delivery Redesign for any condition 1) improve hospitals 2) boost primary care 3) enable access 4) build demand. The level of emphasis for each area will depend on the condition and the health system deficits present.