The literature search initially identified 3747 papers published between January 2010 and January 2020. One thousand one hundred and eighty nine of these papers were found to be duplicates while 1192 papers were excluded by reading their titles only. One thousand two hundred and fifty four papers were excluded by reading their abstracts, as they were not related to the objectives of the study. Another 19 articles were excluded, as they were only abstract or poster presentations in conferences. Then the full texts were reviewed with 92 papers, which excluded 30, as they have not identified challenges and opportunities (Figure 1-PRISMA flow chart).
Among studies included in the review, a majority was from India (n=30, 48 %) (12-41). There were 11 studies from Nepal (42-52), 10 from Bangladesh (53-62), six from Indonesia (63-68) and two from Timor-Leste 69, 70. From Bhutan71, Thailand 72, and Myanmar 73 one from each was identified. Unfortunately, no study could be included from Sri Lanka, Maldives and Democratic Republic of Korea. When considering the publication year of the article, majority of selected articles were published in 2018 (n=16, 26%). In total, 21 quantitative, 33 qualitative, 07 mixed-methods and one field trial were found. Nine quantitative studies, 20 qualitative studies and five mix method studies found to be of high quality studies. The rest were found to be medium quality studies. A data table constructed for selected studies including important characteristics such as author, year of publication, country, study design, sample size, study objectives and quality assessment is attached as Additional file 4.
We found 62 articles related to the successes, challenges and opportunities for UHC with relation to MCH in WHO SEAR countries. We were able to categorize our findings in relation to access, coverage, equity and quality of maternal and childcare services. Summarized tables of extracted data are presented on Additional file 5. A narrative description of the successes and opportunities and the challenges are presented in the next section.
Successes and opportunities for UHC to MCH according to health system building blocks
- Service delivery
Successes and opportunities in access to MCH services were identified in the region. In Bhutan, antenatal clinics conducted in primary healthcare level are an important means of reaching the ANC services to women in rural areas with difficult geographical accessibility71. In a study conducted among Scheduled-Caste (SC) women in Bihar, India, revealed that the changes in the cultural acceptability of institutional delivery are facilitating the use of maternal health services by them27. Another study revealed that rural south Indian communities regularly use health care services during pregnancy and for delivery. New government programmes that increase availability of maternity services are supportive factors for the usage39. A study conducted among Nepal women has identified family support, transport availability and nearby birthing center as facilitators for institutional deliveries52. In Indonesia, a research revealed that all private and public hospitals in a province provide full coverage of Comprehensive Emergency Obstetric and New- born Care64. Support from friends, family and co-workers and male participation in accessing antenatal clinics are identified as enablers for early ANC booking in Bhutan 71.
As a success in equity, National Rural Health Mission, a community intervention in India, had Improved MCH outcomes for the poor in rural areas with reduction of geographical and socioeconomic inequalities17. There detected a marked reduction of inequity among rural and urban antenatal care in Bangladesh between 2001 and 201058.
Few opportunities have been identified in quality of MCH care service delivery in India. One study detected that there are quality enablers in health care institutions such as appreciation of public-private partnerships, availability of clinical guidelines in the form of wall posters in health facilities, efforts to translate knowledge and evidence through practice and enthusiasm towards value of guidelines22. Another study has spotted that improved skills and confidence among providers, inclusion of doctors in training, increased training frequency, administrative support, and nursing supervision and feedback as factors for facilitating obstetric and neonatal emergency care26. In Bangladesh, for the management of SAM in children, there are proper guidelines, cadres and inpatient management facilities as identified by a study carried out to assess preparedness 55.
- Healthcare Financing
To achieve UHC in MCH, under the national health mission of India, several cash schemes such as Janani Suraksha Yojana Janani Shishu Suraksha Karyakram and Chiranjeevanie Yojana have been introduced. These programmes provide improvements in maternal health care in India 14,18, 27,34,37,40. They further provide contracting in EmOC specialists in private sector as a measure to reduce maternal mortality29. In Nepal, Bangladesh and Indonesia, there are similar programmes to facilitate maternal care including institutional delivery42, 43, 52, 57, 59, 63, 64, 66, 67. For the improvement of access to needy mothers and children, government of India has provided accreditation of private sector health providers in government-led schemes for maternity services. Under those schemes, the private sector can potentially play an important complementary role to the public sector for maternity services34, 40, 41. As a positive factor that both government representatives and private practitioners have expressed enthusiasm in collaborating with each other with those programmes 41.
- Human resources
A success / opportunity with availability of adequate human resources for delivery care across most public health facilities has been identified only in one study in India 30. Accredited Social Health Activists (ASHAs) play a key role in facilitating the adoption of safe practices in postnatal care in India 36. Another study identified having 24 hour availability of midwives and friendly service providers in rural areas of Nepal52. Service providers are identified as motivated to deliver quality post-partum family planning services and transfer their knowledge to colleagues that lead to provision of high quality post-partum family planning services in Nepal51.Immunization staff and other health staff are aware of the evidence-based planning approach in immunization in Bangladesh 54.
- Health information management system (HIMS)
As a success with HIMS, records for MCH services at a state in India were detected as satisfactory31.
- Leadership and governance
Jat et. al. has noted that maternal health has become a political priority in India. There is a supportive policy environment with greater political will and better resources. This leads to several opportunities in terms of policies, guidelines and programmes for improving maternal health19. Regarding maternal nutrition, India has a better collection of programs and policies which can play a major role in improving MCH outcomes28. According to Maloney et al, supportive leadership and staff motivation facilitates the implementation of standards aimed at reducing common causes of maternal death in government hospitals in India 25.
Challenges for UHC to MCH according to health system building blocks
- Service delivery
Several common challenges were identified in the region in relation to access in MCH care services, which included clients’ factors as well as providers’. Lack of knowledge on local health system, misconceptions and mistrust about public health system and lack of time for attending clinics were among clients’ factors within vulnerable populations in India33. Feelings of shame and embarrassment, fear of repercussion for discussing their pregnancies with their doctors, and inadequate time with their doctors were identified as barriers for access in India15. Underestimation of the severity of the condition, especially in post-partum by family was a main challenge for looking timely postpartum care20. In a study conducted in India, it revealed that receiving postpartum care is rare for maternal problems. The main reason was the lack of recognition that a large proportion of maternal morbidity and mortality occurs in the postpartum period39. Another study revealed that cultural barriers include cultural norms such as preference over male infant and traditional clinical practices delays maternal care seeking among Indian women38.
In addition to that, lack of access to health care related information was detected as a challenge for decision to seek proper care in MCH15. The preference of pregnant women to deliver in their parents’ village and the use of traditional birth attendants were some obstacles in access in Indonesia63. Delayed first antenatal visit was common in Bhutan due to lack of gender insensitivity in providing care through male health workers and cost and time in clinic visits71. Several harmful cultural practices and beliefs are identified as barriers for institutional delivery in Nepal42, 45,46, 49,52. Perceived low-quality services are barriers for delivery and postpartum care access for rural Indian and Nepal women20, 39, 44, 45. Financial constrains due to poverty was detected as an overarching structural barrier for access38, 39, 46.
Male controlled family structures, intergenerational decision-making and cultural attitudes towards reproductive health information and service has reduced women’s access to reproductive health services in Timor-Leste69. Distance to health facilities, difficulty in geographical access, high transport costs, poor roads and lack of transportation facilities were identified as challenges for access to MCH care institutions throughout the region13,20, 33, 39, 42,44-46,49,52,63,69,70.
Several studies reported that the low quality of delivery and postpartum care provided by the institutions is a major challenge for health care access in the region44,49,69,70. The low quality is reflected with poor infrastructure, unfriendly health care providers, hospital policies and poor staff attitude. The restricted hours of opening, the lack of availability of medical resources and the lack of privacy are identified in maternity services in Timor-Leste69.
Regarding the service coverage, study done in child immunization revealed the challenges for low coverage of immunization in Bangladesh included lack of quantity and quality of supervision, lack of basic immunization supplies and some technical issues such as issues on doses, registration, and poor communication with communities 54. With regard to equity on access of maternal services, inequity was detected in service delivery to migrant women working in brick kilns33and SC women in India27. There are considerable socio-economic and geographic inequities in newborn care in Indonesia65. In Nepal, inequity persists in care seeking for childhood diarrhea and respiratory symptoms among poor, less educated mothers over 15 years 48.
When considering the quality of MCH care, facility readiness was detected as poor for emergency obstetric care and newborn care in public and private health facilities including primary care facilities both rural and urban areas in India, Nepal and Bangladesh21,31,47,56. Several studies detected inadequate infrastructure leads to poor quality in maternal and child care including family planning services in the region 12,22- 24,26,28,38,45,51,52,56,60,65,73. In addition to those problems, irregular supply of water and electricity, less-functioning of blood bank12, inadequate laboratory facilities12,56,61 were detected as challenges. Difficulty in maintaining privacy is another structural barrier12. Overcrowded health facilities and lack of health facility accreditation were detected as challenges for quality in maternal healthcare in Indonesia63. High volume of patients leads to suboptimal quality care in emergency obstetric care in rural Bangladesh56. The rural birthing centers in Nepal are not providing quality services due to unavailability of 24-hour services as identified by Khatri45.
In two rural districts of Uttar Pradesh, India, process gaps are observed during delivery and post-delivery stages compromising mothers’ safety and quality care 30. Few other studies pointed out the problems with referral system for the contribution of poor quality12, 36, 38, 65. According to Puett et al, referrals by community health worker of childhood conditions are treated with low quality in Southern Bangladesh institutions60. It acts as a challenge for community management of them. Health service responses for postpartum care are identified as poor and non-patient-centered in a study done in Indonesia 64. Postnatal care at village level is identified as non-patient-centered care practices in Klaten district, central Java Province, Indonesia 68.
Few other challenges were identified in quality service delivery with regard to providers’. Unwillingness of provider to apply new techniques also acts as barriers for quality care 65. In Myanmar, poor quality of maternal and perinatal health care detected due to inadequate relationships between health cadres73. Interpersonal behavior among staff as well as patient’s relatives which leads to less information sharing is another barrier for quality care12. Hierarchy in healthcare workers is a challenge to care provision of obstetric and neonatal emergency care in primary care facilities in Bihar, India26. Inadequate or lack of training of health staff is another problem in quality services23, 56, 73. Antenatal care is typically delivered at the periphery by non-specialized providers in rural Karnataka State 39. Following providers’ behaviors were identified as challenges for quality maternal and childcare in few institutions; Negligence by health staff 20, rudeness of staff against clients 25, abuse and demand for informal payments 30. Cultural norms and practices also play a role in quality care as identified by few studies in the region26, 36, 73. Few studies have identified that high out of pocket expenditure is a challenge for quality maternal and child care12, 62.
- Healthcare financing
Even though there are government funded health beneficiary programmes in India, challenges for the proper implementation exist. The health facilities are in poor quality and provide suboptimal benefits due to lack of resources and various interactions, which lead to poor utilization of facilities18. Identified challenges for low participation of private practitioners in government-funded programmes are low and delayed reimbursements, poor infrastructure and administrative issues29,41. Despite the government’s efforts at increasing access to delivery services for poor women in the private sector with programmes, uptake was low34. Partial health insurance cover for migrant women working in brick kilns in district Faridabad, Haryana, India, is an access barrier for them to maternal health utilization33. Lack of proper documentation for health insurance registration is a perceived barrier for Jamkesmas health insurance membership in Indonesia63. High out of pocket expenditure is a major barrier to access to appropriate medicine in children in rural Bangladesh62.
Challenge in equity was detected with low receipt of JSY benefits among mothers in Odisha and Jharkhand area, India37. Receipt of the benefits is highly variable, not equally distributed, favoring wealthier groups. The JSY scheme is currently not sufficient to close the poor-rich gap in institutional delivery rate37. Shortage of human resources was a major health system barrier for implementation of National Rural Health Mission which implemented in India from 2005 to 2012 to reduce MCH inequalities 17.
- Human resources
Inadequate healthcare workers including specialists was identified as a challenge for provision of better maternal and neonatal care in India, Nepal, Bangladesh, Indonesia, Timor-Leste and Myanmar 12,22,24,26,29,8,45,47,49,51,56,61,63,69,73. Shortage of staff is widespread in rural areas. Provider incompetence in emergency obstetric care and neonatal care are another problem detected by many researchers over the region21, 52. Lack of skills for post-delivery counseling is a challenge for provision of quality maternity care12. Suboptimal knowledge and skills among workers in the field leads to poor quality MCH 22,35,47,65, 68. Few social, professional and economic barriers are identified with midwifery personnel in Bangladesh which preventing quality maternity care53. Staff nurses involving maternal, newborn, and child healthcare in government public health facilities in Uttar Pradesh, India, are working in stressful environment which may lead to low quality of services 16.
- Medical products
Several studies detected that lack of adequate supplies and drugs affects the quality in maternal and child care including family planning services in the region 12,22,38,51,56,60. Unavailability of medicines and therapeutic diet in facilities was detected as a challenge for management of SAM in Bangladesh 55.
- Governance and leadership
Poor governance in birthing centers 45, lack of support from hospital administration 51 and less priority given on primary health care50 are the barriers identified in Nepal for good quality delivery and postpartum care. In Indonesia, decentralization of the health sector which created confusion regarding roles and responsibilities as well as complex administration process were identified as important factors which impede the quality care 64, 65. Vogel et al has identified that the deficiencies in policies and political context and deficiencies with accountability and monitoring as the barriers to implement WHO Maternal and perinatal health recommendations in Myanmar73. Health policy on maternal care are not focusing on adolescent pregnancy in Thailand. It is recognized as a challenge in provision of quality care for pregnant adolescent women 72. Pertaining to management of SAM in children in Bangladesh, there detected a conflict situation among nutrition stakeholders and problems in nutrition coordination 55.
Risk of bias assessment
The quality appraisal checklists developed by JBI cover the appropriateness of the research design and standard conceptions for assessing risk of bias and overall quality. The quality assessment helped to collect the strengths and weakness of the evidence summarized by the whole review. All quantitative studies included here are medium in quality due only to failure to identify and mention how they dealing with confounding factors. Twenty one out of 33 qualitative studies are medium due to lack of a statement on locating and influence of the researcher. However, research objectives, data collection and analysis and ethical aspects are presented nicely. Only one qualitative study failed to mention specifically in ethical approval even though other ethical aspects were mentioned 27. Nine quantitative studies out of 21(43%), 20 qualitative studies out of 33 (61%) and five mix method studies out of seven (71%) found to be of high quality studies. Altogether 34 (55%) studies had high quality. The rest of them were found to be medium quality studies. No study was excluded nor weighted due to quality assessment, but the quality is used to inform data interpretation.