Problem: High rates of maternal and infant mortality; inadequate provision of prenatal care and high rates of unattended births; weak capacity for delivery of prenatal and obstetric services in appropriate care settings; geographic disparities in access to prenatal and obstetric services.
Solution highlights: Improving maternal and child health was established as a key government priority. Strong top-down support for change reinforced by legislation provided a guiding framework for transformations; Investigation into key challenges leading to a strong understanding of root causes ensured health reforms responded to needs; prenatal screening recommendations were developed and changes to resource distribution, provider training and incentives were implemented to promote uptake and adherence to new guidelines; financial incentives for patients helped encourage desired participation in prenatal care by women; service delivery reforms took time and adoption of a long-term vision was needed.
Description of practice
In 1991, high rates of infant mortality (12 per 1000 live births) and maternal mortality (31 per 100 000 live births) established improvement of maternal and child health as a key priority for the Ministry of Health. Close examination of mortality trends by the Ministry specifically identified a lack of prenatal screening and high rates of unattended births as root causes of observed problems. Capacity to provide adequate prenatal and obstetric services was weak across all care levels, hindered by a lack of necessary equipment and appropriate training. Geographic disparities in access to prenatal and obstetric services were also observed and population uptake of available services was suboptimal.
When the Government of Belarus identified maternal and child health as a priority in the early 2000s, improving maternal and child health became a main focus for several government programmes, including the National Demographic Security Programme 2006–2010 and the Children of Belarus Programme. Strong government backing and funding for activities were key enablers for change in the delivery of prenatal and obstetric care. Guided by supportive government policy, legislation and incentives, changes in the organization of prenatal and obstetric services have been made to support improvements in maternal and child health. New prenatal screening recommendations have been developed, with providers receiving the necessary training and equipment (including ultrasound machines) to implement these. Basic prenatal services have expanded to include a minimum of three prenatal screenings. New regulations specify the order and timing of screenings and care pathways are now adapted based on screening results, pregnancy risk-level and individual needs. Increased emphasis has been placed on care delivery in lower-level settings and home-care visits have been made available. Resources have been redistributed between health facilities, with specialized equipment and providers pooled at higher care levels. Additionally, Republican Scientific and Practical Centres have been introduced to lead highly-specialized care delivery for high-risk pregnancies. Recognizing also the importance of encouraging population uptake of recommended services, pregnant women are financially incentivized to enrol in prenatal care early and follow guidance issued by providers.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
A strong government-led effort by the Ministry of Health through a top-down approach was the main driver of change. However, a number of government departments and national agencies played a role in improving maternal and child health. The commitment of specialists and providers in learning the new techniques required by the initiative was essential and a cascade training model ensured diffusion of knowledge across care levels.
The National Statistics Committee conducts ongoing data collection and monitoring of the initiative. Reports produced by the Committee allow maternal and child health outcomes to be tracked by the Ministry of Health. While changes took time to observe given the gradual introduction and long preparatory stage of the initiative, substantial improvements in maternal and child health have now been achieved. Over time, improvements in key indicators have been recorded, with infant mortality rates falling from 11.4 to 3.7 per 1000 births between 2000 and 2013 and maternal mortality falling from 32 to 1 per 100 000 births. Access to prenatal and obstetric services is reported to have increased and 98% of women now receive standardized, free prenatal care. Today, the infrastructure, regulations and incentives put in place by the initiative continue to support improved maternal and child health outcomes.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
Please click on the link below for more information about this practice.
- Elena Bogdan
- Ministry of Health