There is a global consensus on the health intervention that should be made available to women and new born along a continuum of care

There is a global consensus on the health intervention that should be made available to women and new born along a continuum of care. Women centred service are not only aimed at preventing the leading causes of maternal and newborn death, but look to improve the overall health of women and infants by facilitating proper good nutrition, and preventing and treating maternal challenges, such as gestational diabetes, childbirth injuries, and managing blood pressure. Improved care for women during pregnancy plays a decisive role in reducing newborn and infant mortality rates as well as low birth weight and stillbirth. (Kathleen Schaffer, 2016)

An effective continuum of care includes quality care before, during and after pregnancy, and envisions care for normal pregnancy and childbirth as well as emergency obstetric care delivered by skilled health providers within a functioning health system for the continuum of care to have a significant impact on maternal and newborn health, it must also include access to the necessary facilities, medicines supplies, equipment and skilled providers. These health service must be available, accessible, acceptable and of quality and must be provided in a dignified and respectful manner, free from discrimination and abuse.
While the global community agrees on the clinical services needed to improve maternal and newborn health and nutrition, there are still gaps in services. This brief highlights four strategies that have potential to address these gaps.

? Ensure access to quality maternal and newborn care, including midwifery care
? Expand community-level strategies to reach the most vulnerable girls and women
? Provide maternal and newborn nutrition education, counselling, support and promote exclusive breastfeeding
? Address unintended pregnancy through modern contraception and increase access to safe abortion

2.2.2 Skilled attendants
The provision of affordable, quality maternal and newborn healthcare service must go hand in hand with access to skilled, knowledgeable and compassionate midwifery care throughout pre-pregnancy, pregnancy, birth, postnatal period and the first months of infant. This is one of the most important services a country can invest in to improve maternal and newborn health. The provision of full care, as recommended by the world health organization, for a pregnant women and newborn, combined with modern contraception for women who wanted to avoid pregnancy, would yield a drop in maternal death (Kathleen Schaffer,2016)

A skilled attendant has been defined as an accredited health professional such as a midwife, doctor or nurse who has been educated and trained for proficiency in the skills needed to manage normal uncomplicated pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and new-born (WHO, 2013).
Staff shortages characterize public hospitals and this makes it difficult to make maternal health service available as there is no one to deliver it. A study carried out in Madagascar, revealed that public health services were constrained by an inequitable distribution of human resources between urban and rural areas, and lack of essential goods and equipment to facilitate diagnosis and treatment (Honda et al., 2011). In addition to this, a study in Uganda showed that there were no skilled attendants to accompany the referred patient to another facility (Kahabuka, 2012). This shows that the poor, marginalized, and less privileged suffer whenever there are inadequacies in the health sector as they fail to receive the maternal health care needed for their survival.
Aiken et al. (2002) carried out a cross sectional study on association of staffing and patient outcomes in 168 hospital in Pennsylvania. The study used a sample of 10,184 registered nurses and 232,342 patients. Needleman et al (2002)carried out a cross sectional study in 43 hospital units in England. The study was to find out the association of nurse staffing and inpatient hospital mortality. The study investigated 197,961 patient and 176,676 nursing eight hour shifts. The two studies correlated high mortality rates to poor staffing ratio. Study by Fund (2008) in London on staffing levels and deployment to address challenges to safe delivery issue concluded that staffing was more critical during childbirth hours.

A qualitative study done in labour wards in seven hospitals in England indicated unreported near misses caused by shortages of midwives (Ashcrift et al, 2003). A near miss is a woman who survives life threatening condition arising from complications of pregnancy and childbirth and has many common aspects with those who die of such complications (2004). High level of obstetricians was associated with accurate interventions defined by higher level of caesarean sections and high positive outcome (Joyce et al, 2004). Inappropriate use of oxytocin and undiagnosed labour complications were common where there were no obstetricians (Ashcroft, 2008). There was continuity of care in hospital with regular obstetricians while hospitals that employed on call obstetricians reported third and fourth degree tears with more caesarean sections. This is because the complications in labour are sudden in most cases and require adequate and continuity of care (Abenhaim et al, 2007).

A study in United Kingdom on effects of staffing to care showed positive relationship between increase staffing levels and improved outcomes and also between reduced errors and reduced mortality (Currie et al 2005). In the United State of America twenty studies done to investigate increased staffing levels and their impact on patient outcomes indicated hours of direct contact care, improved safety, reduced errors and reduced mortality (Kane et al, 2007)

Essential components needed at a maternity facility can be measured to claim that it offers adequate services needed by women. Ameh et al., (2012) argue that the availability or presence of emergency obstetric care depends on the seven key components of key interventions referred to as the signal functions for basic obstetric care and nine interventions for comprehensive emergency obstetric care. Service availability is discussed below with reference to the availability of essential services, adequacy and equity of service.
Basic emergency obstetric care involves having antibiotics; oxytocic drugs; anticonvulsants; the use of a manual vacuum aspirator; assisted vaginal delivery or ventouse extraction; and resuscitation of the new-born baby using bag and mask. In order to offer comprehensive emergency obstetric care, a health facility should have all the above-mentioned items in addition to a caesarean section service and blood transfusion (Ameh et al., 2012). These features are the critical components needed for adequate availability of service at a maternity facility. The absence of these components will lead to questions about the kind of service women are receiving at a facility.
Not all maternity facilities have the essential or basic functions needed at a hospital. In a study carried out across six African countries, Ameh et al. (2012) discovered that 65-100% of health centres surveyed across Africa could not perform the seven signal functions of basic emergency obstetric care and 63-87% of the basic emergency obstetric care centres in South Asia were not fully functional. However, it has been argued that, for skilled attendance to have an impact on maternal death, it has to be in an enabling environment of a well-functioning health care system that provides access to comprehensive emergency obstetric care that includes caesarean sections, blood transfusion and other emergency services, as required (Silal et al., 2012).
2.3 Factors that affect maternal and newborn health services offered in public hospitals
2.3.1 Adequacy and Equity of service
It has been noted that maternity services, where available in least developed countries, are usually inadequate or inequitable (Gill &Carlough, 2008). Citizens have been seen to avoid and not use poorly-resourced public hospitals and seek medical attention at private hospitals. Failure by government hospitals to provide technical skills and adequate services to those in need of help has been identified as one crucial factor in developing countries (Stekelenburg et al., 2004).
Ameh et al. (2012) note that signal functions requiring little skill such as administration of antibiotics, anticonvulsants and oxytocic drugs are still not fully available at health facilities.Ameh et al. (2012) conclude by saying that the population is aware of non-availability of obstetric services and this affects their accessibility to obstetric care. One can say that the unavailability of essential and adequate services compromises the safe delivery of women in maternity facilities; this in turn, renders high maternal mortality.
Availability of maternal health services is seen to differ between private not-for-profit, private and public hospitals. In Brazil, for example, where the public health system is fully funded, disparities found in post natal care between private and public patients were due to transportation costs and distance. Higher maternal health service coverage was found in private hospitals than in public hospitals (Matijasevich et al., 2009). A study carried out in Tanzania revealed that government district hospitals were bypassed by women seeking health care because patients were not examined with the use of medical tools (Kahabuka, Moland, Kvale&Hinderaker, 2012). Women preferred church mission hospitals over government district hospitals. Even if government hospitals were fully funded, women would not access them because of transport cost and distance to the hospital, as well as their preference for the high level of maternity service coverage in private not-for-profit facilities.
Unavailability of drugs and midwives in public clinics resulted in women bypassing them. Frequent shortage of drugs and being asked to buy the required drugs in pharmacies were mentioned as factors in not using public hospitals in Tanzania (Kahabuka et al., 2012). A study carried out in Tanzania, revealed that the clinic closed at 4 p.m. and when women go into labour, there is no one at the hospital to help them, and most of the health professionals had their homes outside the community (Kahabuka et al., 2012). This indicates that unavailability and inadequacy of maternity services in government hospitals makes patients shun them.
Unavailability of maternal health services included lack of expertise; shortage of drugs; and inappropriateness of the birthing culture, which led to the service being unavailable or limited in public hospitals. Further literature also shows that only a minority of women in China reported for antenatal and post natal care; they failed to access maternal health services because of the cost of the service; the poor quality of hospitals in the villages and the inappropriateness of the culture of birthing practices that caused discomfort and embarrassment (Harris, Zhou, Liao, Barclay, Zeng, &Gao 2010).
Women from rural and mountainous areas without transport will not seek health facility delivery even when services are free (Wagle et al, 2004).AStudy done in Afghanistan, Bolivia, Ethiopia and Kenya reviewed geographical barriers where those in mountainous regions were not accessing health service adequately (Byrne et al, 2014).
A study done in Madya, India on twenty two casesof deceased women classified the causes using the three delays model (Ram, 2014). Eleven out of the 22 women died due to delay in deciding to seek care after becoming aware of complications. Twenty one women died of delay in reaching the facility as a result of poor transport with 12 dying in the health facility and 8 during referral from one health facility to another. Thirteen women out of the 22 reached the facility but shortage of drugs, blood and staff negligence caused delay in receiving adequate care (Ram, 2014). This was attributed to shortage of resources including skilled personal, supplies and inadequate infrastructure (Witter et al, 2013)
A study in Bangladesh concluded that inadequate facilities and lack of skilled care were the factors hindering quality maternal health care. Though there was reduction in Maternal Mortality Ratio (MMR) from 574 deaths per 100,000 live births to 194, more than 75 percent of deliveries took place at home (WHO, 2014).
A study carried out in rural Tanzania found that the working environment at government hospitals was not conducive to health professionals working at night because there was no electricity and lamps had to be used for lighting (Kahabuka et al., 2012). It is clear that basic infrastructure plays a crucial role in service delivery. In its absence hospitals become dysfunctional; this can result in women failing to receive even basic maternity services.
Turnçalp et al. (2012) conducted a study in Ghana that revealed that treatment at the facility was delayed and mostly involved emergency surgery; this was linked to a high load of cases and unavailability of operating rooms. Delays were also identified in a study carried out in Bolivia, where most of the women interviewed complained about insufficient resources, technical capacity, including ambulances and pharmaceuticals, insufficient beds, accommodation for family members and that the service was not culturally appropriate and accommodating (Otis & Brett, 2008). This shows how service unavailability takes different forms in government hospitals and lead to a limited maternal health service delivery that puts women at risk of maternal death.

2.3.3 Funding
In Mali waived fee was replaced by Medecins Sans Frontieres (MSF). The quality of care was maintained with consistency in drug supply (Ponsar et al, 2011). The outcome was decreased post caesarean maternal and neonatal death.
In Kenya there is delay in reimbursement of funds. The assessment study on implementation of free maternal health services showed that the reimbursed fee is not appropriately allocated to maternity services. This may impact negatively on quality of maternity services. Referral hospitals complained of inadequate reimbursement from the government as they were dealing with more complicated cases and some women took longer in the hospital (MOH, 2015).
2.3.4 Distance to the facility
It is a requirement of maternity facilities to have transport in the form of ambulances that fetch women from home to transport them to hospitals or from hospital to hospital in case the patient is referred to another hospital. A study by Deen (2012) found that women in Sierra Leone do not have transport to go to hospitals and cannot afford to use a taxi; hence women are forced to walk long distances or use a motor cycle. Again, in another study conducted in Brazil, it was noted that distances travelled to maternity hospitals were long, regardless of whether the hospital was private or public (Simões& Almeida, 2010).
2.3.5 Interpersonal aspect of care
Turncalp et al. (2012) further add that obstetric care does not exist in isolation with health care providers and patients only, but within the health systems environment where policy environment such as effectively allocation resources and financial policies allow access to affordable care. This supports other reasons why women fear government hospitals and shows that it is not only human and financial resources that affect access to maternal facilities. The way maternity patients are treated when they reach the maternity facility is important
Health professionals disrespect patients and the time they take to attend to them is long. It has been argued that from a health systems perspective, service delivery and interpersonal aspects of care play a crucial role and that poor quality health care services affect access and effectiveness (Turncalp et al., 2012). Unfriendliness and the lack of compassion of professional health workers in government hospitals were mentioned (Onah et al., 2006). A study carried out in Bolivia revealed that women were ridiculed by professional health workers because of their poverty, clothing, smell, and cries of pain. The way maternal patients are treated when they reach a facility determines whether they will seek help again at the same facility in the near future.
A study from Ghana highlighted women’s perception of care as including factors such as good communication, attitude, the presence of doctors, physical resources like beds at the facility and also information provided to women about their condition and treatment protocols (Turncalp et al., 2012). Positive interactions in terms of communication and attitude between patients and health care providers enhance quality of care as perceived by women and it improves the way women seek health in the future (Turncalp et al., 2012). This shows that it is of vital importance to listen to the needs of the maternity patients. Incorporating their beliefs and culture in trying to reduce maternal mortality will be helpful for both the maternity service provider and the patients.
In one evaluation of community satisfaction with primary health service in the morogoro region of Tanzania in 1992, the poor attitude of health providers were cited as major contributing factor to poor maternal health care. Poor staff attitude was perceived to exist in most health facilities including abusive language, denying women services, lacking compassion and refusing to assist (Wendy Holmes and Maya Goldstein).

2.4 Strategies that can be used to enhance maternal health in public service.
2.4.1 Increasing the budget for maternal and newborn health
Adequate, sustainable funding is critical to ensuring that mothers and new bornreceive high quality health care. In 2001, African Union member states including Zambia pledged to increase government spending for health to at least 15% of the national budget. Since then, Zambia’s annual health expenditure has fluctuated but in 2014, just 9.9% of the national budget was allocated to health (>publications.file )
To ensure that Zambia delivers on its commitment, Path and partners are advocating for robust government investment in maternal, newborn, and child health (MNCH). This can be done by generating evidence on the social and economic returns of health budget, as well as forging policy dialogue with decision-makers (>publications.file)
2.4.2 Human Resource for maternal, newborn and child health
It is a well-known fact that human resource for health is the backbone and limbs of the health care delivery system. Human resource crisis in health are prevalent, and for varying reasons, across the global even through policy often do not address health worker shortages until is it too late ( Ergo et al 2011)
(NHSP 2017-2021) In order to enhance quality maternal health care through human resource the GRZ has put strategies which will help in service delivery which are as follows:
? Enhance professionalism in nursing service.
? Strengthen respectful nursing care to all clients.
? Advocate for the provision of adequate and appropriate infrastructure and equipment.
? Strengthen human resource policies and system for nursing and midwifery

2.4.3 Logistics, equipment and supplies for maternal newborn and child health.
Integration of the delivery of health service cares the infrastructure and the timely availability of high quality drugs and supplies to facilities at all levels of the health sector. The health service delivery infrastructure constitutes the physical capacity and readiness of the building, equipment, communication system and the transport network. On the supplies side, the stocks of medical products and vaccines should be well managed, affordable to facilitate and clients, and appropriately distributed. The availability of pharmaceutical and medical supplies enables health workers to deliver appropriate care and build the community trust in the health system (Ergo, et al. 2011).
Although the Zambian government has made great strides in improving care delivery infrastructure, the country is still far away from meeting the policy objective of ensuring that the population has access to health facilities within a 5km radius.The government of the republic of Zambia through the Ministry of Health (MOH) has put in place strategies which will enhance quality maternal health through procurement of medical equipment using the GRZ funds, strengthen management and maintenance of medical equipment, integration of human resource, and infrastructure plan, (NHSP 2017-2021)
2.4.4 Health Care Financing
In order to improve quality maternal health care, the GRZ through the MOH has put in place a strategy of health care financing strategy to address issues of resource mobilization, allocation, reimbursement mechanisms, resource tracking, and fund holder management is nearing completion and will be implemented going forward. (NHSP 2017-2021)

2.5 Administrative and policy measures to enhance maternal health in public services.
In Zambia, most of the health related issues are governed by policies, programs, schemes and other approaches. Following independence in 1964 and prior to 1992, the Zambian government used successive national development plans as major policy instrument to guide the provisions of the health care service by the public health Act CAP 395 of 1930 of the laws of Zambia. In 2012, the government adopted a National Health Policy that set clear direction for the development of the health sector, with the objective to reduce the burden of disease, maternal and infant mortality and increase life expectancy through the provision of a continuum quality effective health care service as close to the family as possible in a competent, clean and caring manner.
The Zambian government has, however, shown commitment to the reduction of maternal, newborn and child mortality by ensuring that the necessary policies, strategic plan are in place and include: National health policy, National Reproductive Health Policy, National Food and Nutrition Policy (BuletiNsemukila, 2014).
Current the government is using the National Health Strategic Plan (2017-2021) which supports the National Vision 2030 which expresses the Zambian people’s aspiration to become a prosperous middle income nation by 2030. The aim NHSP on maternal health is to reduce the Maternal Mortality rate (MMR) FROM 398/100,000 birth in 2014 to 162/100,000 live birth by 2021. (NHSP 2017-2021)
Summary of the literature review
The findings of these study shows that there are various factors associated to quality maternal health care in the public service hospitals. The literature further revealed, shortages of specialized providers, poor attitudes of health professional, interpersonal aspects of care, inadequate funding, overcrowding and inadequate infrastructure which impedes quality maternal health care to women during pregnancy, childbirth and the postpartum period.

2.6 Theoretical framework
There are several theories in health care domain, however this section is anchored on the following theories, namely three delay models, theory of effective coverage, economic theory of demand for health care and health seeking behavior model.
2.6.1 Three Delay Model
Thaddeus and maine (1994) consider delay in seeking treatment to have adverse outcome on care. He talks of three types of delay which are decision to seek health care, reaching the facilities and receiving adequate and appropriate treatment. The factors that cause these delays are social culture, distance, cost and quality. Shortage of qualified staff, essential drugs and supplies is a major cause of delay in commencement of treatment after arriving in the facility. Financial cost is not a major determinant as women are more concerned with the quality of care (Thaddeus and maine, 1994).
2.6.2 Health Seeking Behaviours Model
The theory explains that health seeking behaviour is influenced by societal determinants, health services system and individual characteristic. Individual characteristics that influence decision to seek care are predisposing, enabling and need factor. Predisposing factors comprise of social demographic factors and past experience. Pregnant women mat fail to utilize service because of past mistreatment to them or fear of mistreatment as heard from others. Enabling factors include and access to service provider which include transport costs and availability of facilities within proximity (Ashcroft, 2008)

2.6.3 Theory of Effective Coverage
Theory of health coverage indicates that health services are a concept expressing interaction between the services and the people to whom it is intended. This interaction is a process from resource allocation to achievement of desired objective and defines utilization as a relationship between service capacity and service output. This interaction is made possible through availability of resources (manpower, facilities and drugs), accessibility, acceptability, contact and effective quality coverage (Tanahashi, 1978). Access is made available through these dimensions together with individual’s empowerment to use the health service following informed decision (Tanahashi, 1978). Frenz and Vega (2010) used the dimensions of Tanahashi’s model to assess to Universal Health Coverage especially to the marginalized and hard to reach area. Propose using Affordability Ladder Programs (ALPS) to assess social inequities in health care among different social groups. Women will utilize maternal health service when barriers in supply and demand side factors are removed (Dahlgren and Whitehead, 2007).
2.6.4 Economic Theory of the Demand for Health Care
Demand of the commodity is determined by the market price. When prices are lowered there is increase in quantity demanded and decreases when prices are high. This is the relation that has motivated user fee exemption policies with an aim of increasing deliveries by skilled birth attendants. The demand theory is adapted from grossman model which states that demand for health is derived from demand for health (Ensor and Cooper, 2004). Better health is investment as well as a consumption good produced through use of good nutrition and healthcare among other commodities. A pregnant woman who attend antenatal care and seeks delivery in a health facility by skilled attendant will have not only good health but also a health infant. However, there are determining factors that influence utilization of the healthcare services on both supply and demand sides.
Supply is determined by factor from health production function which interacts to produce effective healthcare services as follows (factor price/availability, technology and price management. Factors are items that require producing treatment like staff time, capital equipment and building, drugs, consumable and staff efficiency. These are combined with technology, in the case of maternal health the specialized personals. Price determines quality. The theory explains that the product may change in quality as the price drop. Delay of reimbursement fee or lack of funds in many countries that have introduced free maternity service led to lack of supplies and demotivated staffs. Scarcity of resources results in delay, long waiting time and compromised quality (Ensor and Cooper, 2004).
Grossman analyses individual investment and consumption decision to improve health and utilize health care. The model indicates that the individual, community and price of medical care and other goods determine the decision to seek health care. Demand is determined by quality, accessibility, price, waiting time and knowledge of health care needs (Ensor and Cooper, 2004). Reduction of direct financial barriers results in increased utilization of service, workload and consumption of supplies (Witter et al. 2013). Apart from direct hospital fees, there are other costs like transport cost and price of substitutes which will determine if a woman seeks to deliver in a health facility or at home. Addressing financial barriers is only one factor among many and maternal health programs require engaging government to address all factors that maternal health outcomes. Determining factors of demand and supply for maternal healthcare may generate barriers if not addressed(Witter et al. 2013).