A U.S.-based group, Centering Healthcare Institute, is bringing an alternative form of prenatal care to areas where even traveling to appointments is a hardship.
As a standard of care, the World Health Organization suggests all women attend a minimum of four antenatal -- or prenatal -- care visits during various stages of their pregnancy.
"Antenatal care is an intense, complex period. It's a period where we have to do health promotion activities, but also it's about birth preparedness and complication readiness," said A. Metin Gulmezoglu, coordinator of maternal health at the World Health Organization.
In developing nations this period in a woman's life is even more complex. Even the minimum number of prenatal visits is difficult to achieve. And when women do seek care, the quality is often sub-standard.
"Access to safe maternity care is low," said Faith Muigai, director of clinical operations at Jacaranda Health, which is a network of private maternity clinics in Kenya.
Despite a mandate in Kenya that the public facilities provide free maternal care, the maternal mortality ratio in 2013 was 400 for every 100,000, according to a World Bank report. That is nearly 14 times as high as it was in the United States the same year.
"It's not because of lack of facilities but more so the quality of care in these facilities is poor," Muigai said.
Muigai and Gulmezoglu were part of a panel Tuesday at The Woodrow Wilson Center in Washington to discuss ways to improve quality and access to prenatal health care in developing nations.
"Pregnancy is a universal experience. We are all meant to be in [a] conversation and that's what's missing. We need to be talking to each other," said Carrie Klima, a clinical associate professor at University of Illinois in Chicago who focuses her research on group-based prenatal care, called CenteringPregnancy.
The Centering Healthcare Institute -- which has locations nationwide, in addition to international locations -- uses the group-based model of women receiving care from providers, while also learning from their peers, Klima said. In a group model, for instance, pregnant women or recent mothers can provide advice and peer support to other women, rather than patients sitting in waiting rooms idly before an appointment.
In America, the model is 10 visits for prenatal care. Klima and the other members of the research group cut that to four visits to adapt it for life in two African nations, Tanzania and Malaw. In Tanzania the maternal mortality rate is 410 per 100,000, in Malawi it is even higher, 510 per 100,000. Centering Healthcare workers provided information to the the women about health issues in their native languages. Language issues can be barriers that may deter women from seeking care, Gulmezoglu said.
Klima shared a story of one patient who didn't understand blood pressure until it was explained to her.
"She didn't know what that meant, and yet she had it written on her card numbers of times," she said.
Muigai says the problem isn't just education. The system itself needs to change, starting in communities. "I've seen [expectant] mothers wait to take action when things go wrong -- that's when community outreach becomes important," Muigai said.
Pre-natal health-care issues in the U.S. don't come close to the problems in Africa, Klima said.
"Even our worst low-income centers in the United States have higher levels of care than in Malawi," Klima said. "We have 9-1-1. They don't necessarily even have that."
Muigai is working to educate the public health sector in Kenya and increase efficiency and effectiveness. Aspects of care aren't integrated, so improving efficiency will hopefully lead to one day women not having to walk for hours to one facility -- just to turn around and walk elsewhere for another appointment, Klima said.
"We are hoping to influence areas to encourage the public services to adopt better quality standards." Muigai said. "It's all about playing nice in the sandbox."
The panelists agreed that understanding what drives women's decision making about their pregnancies and communicating quality standards is vital to improving the system in developing countries.
"It's a complex issue and solutions need to be developed locally," Gulmezoglu said.
The World Health Organization began taking steps in April to reduce inequities and improve outcomes by studying various research methods and approaches, such as examining reasons women had for choosing whether to get care, he said.
Klima plans to make another trip to Africa with the Centering Healthcare Institute next month to do another pilot research program in Dar es Salaam, Tanzania. She hopes this trip will help her better understand the barriers that pregnant women face in getting adequate care.