Improving Access to Quality Maternal Health Care – Is Social Franchising A Solution?
A Special Pre-Conference Session
2014 Global Conference on Social Franchising for Health
Cebu, Philippines
Overview
This year’s Global Conference on Social Franchising for Health brought together representatives from franchise
programs operating in 36 countries along with technical experts, researchers, and donors. MSD for Mothers
and the University of California at San Francisco’s Global Health Group co-hosted a special pre-conference
session to explore social franchising’s potential for improving access to quality, maternal health services.
The session provided a forum for social franchises working in maternal health, particularly the few that are
franchising labor and delivery services, to share their experiences. By sharing strategies and lessons learned
from a variety of settings, MSD for Mothers and UCSF aimed to highlight the opportunity for social franchises
to increase women’s access to quality maternal health services while examining critical questions about the
feasibility of implementing social franchising for labor and delivery services and approaches to quality
assurance.
The following document highlights key points from the session discussion, outlining a collective vision for
franchising quality maternal health services, challenges implementing maternal health services, and quality
assurance approaches.
Highlights

Social franchising may provide an opportunity to expand the availability of private maternal health care
and assure its quality. Its standardization of service provision and focus on quality makes it well-suited to
overcoming the challenges with assuring the quality of private maternal health care.

Franchising of maternal health care, especially labor and delivery services, entails a more complex set of
requirements than what is required of other services typically offered by social franchises, including
infrastructure, human resource capacity and referral systems.

Given that the link between quality of care and outcomes in maternal health is not straight-forward (i.e.
bad care can result in good outcomes and vice versa), it is important to focus on measuring the content
of care (providers actions), as well as the structure of care and the experience of care.

It can be difficult for franchisors to observe providers actions during labor and delivery for lower volume
facilities, so they must develop other methods of assessing provider skills (e.g. drills, use of models,
vignette, and case studies).
Social Franchising As an Opportunity to Improve Access to Quality Maternal Health Services
A surprisingly large proportion of women – from all income levels – seek maternal health services from the
local private health sector. Private providers are an often overlooked part of the healthcare system, and have
the potential to make a contribution to efforts to reduce maternal mortality. However, there are outstanding
questions about how well or how consistently private providers are able to provide quality, affordable,
accessible and equitable care. While ensuring quality care is important for any health service, it is critical for
maternal health because childbirth complications can be life-threatening and unpredictable, requiring timely,
skilled management in a health facility.
Social franchising may provide an opportunity to expand the availability of private maternal health care, and
assure its quality. Social franchising has had success in expanding access to affordable family planning and
primary health services, but relatively few social franchises have taken on maternal health, especially labor and
delivery services. This may be due to the inherent risks of providing emergency obstetric care given the
potential for death and disability, as well as the cost of providing services and the need for round-the-clock
availability.
Yet social franchising’s standardization of service provision and focus on quality makes it well-suited to
overcoming the challenges with both providing and assuring quality maternal health services and has the
potential to make an important contribution to reducing maternal mortality.
Challenges and Solutions to Successfully Franchising Maternal Health Services
Providing high-quality maternal health care, especially labor and delivery services, entails a more complex set
of requirements than what is required of other services typically offered by social franchises. As the field
considers a collective vision for successful franchising of maternal health services, the following areas were
identified as requiring special consideration.
Infrastructure needs are greater for maternal health services, especially labor and delivery, than for other
health services such as family planning and primary care. Facilities must have special clinical equipment and
supplies available at all times, including gynecological tables, delivery kits and refrigerators for proper storage
of essential maternal health medicines like oxytocin. Maternal health infection prevention measures are more
involved given the invasive procedures and potential exposure to large amounts of blood and bodily fluids
during childbirth. They require additional equipment and supplies for protection and to ensure that providers
do not inadvertently introduce infections that can lead to sepsis (the third greatest cause of maternal death).
Finally, labor and delivery is a 24 hour service and thus facilities must have reliable access to electricity for
night-time deliveries.
Providers must have both a variety and higher-level of skills to provide comprehensive care before, during
and after childbirth. While most deliveries are uncomplicated, there are many types of complications that can
arise, and their unpredictability means that franchisors need to ensure that providers’ skills are up-to-date and
that they know how to identify and manage complications in a timely manner, as well as when to refer. In
some settings, it can be difficult to identify human resources with the specialized qualifications required for
certain procedures (e.g. c-section). Ensuring adequate skills may require that the franchisor offer or facilitate
continuing medical education and in-service training and that they make a significant investment in supportive
supervision and mentorship. For franchise clinics with a low volume of deliveries, maintaining provider
obstetric skills is especially challenging. For this reason, franchisors should develop clear criteria to help
determine which clinics are best suited to offer franchised labor and delivery services as well as clear
deselection criteria for clinics that are not able to provide quality maternal health care despite significant
investment and training.
Quality maternal healthcare entails the provision of a variety of services before, during and after childbirth,
which means franchisors need to ensure a full range of services are quality assured across their network or
available through referral. If franchisees are offering labor and delivery services in addition to others, but labor
and delivery is not being franchised (“fractional franchising”), the franchise brand can erroneously imply that
labor and delivery has been quality assured.
Franchise clinics offering labor and delivery services should, at minimum, also offer basic emergency
obstetric and newborn care (EmONC). For clinics unable to provide comprehensive EmONC, franchisors need
to ensure that clinics have robust referral mechanisms to higher-level care. Most participants recommended
that social franchises should not offer labor and delivery at all if they cannot offer at least basic EmONC.
Referral mechanisms for maternal health are different than typical franchise referral systems because they
are made during an emergency when a woman’s life is in danger. Referral systems need to include reliable
transportation to comprehensive emergency obstetric and neonatal care (CEmONC) n cases where only basic
emergency care is offered on-site, and franchisors must make sure that strong referral systems and emergency
transportation are in place. Robust referral mechanisms should include written agreements with referral
facilities, clear points of contact, standardized referral forms and effective follow up procedures to better
understand referral outcomes and inform feedback loops. In cases where franchise clinics are referring
women to public facilities for higher-level care, franchisors should take special care to manage relationships
with district management teams and public referral facilities to ensure those facilities triage emergencies well
and welcome referrals from private providers.
Essential maternal health medicines require strong supply chains and appropriate storage. While ensuring a
functioning supply chain is an ongoing challenge for all services, maternal health franchises must have a
consistently available stock of supplies and appropriate storage for antibiotics, oxytocin (which requires
refrigeration), misoprostol, magnesium sulfate and a broad mix of family planning products – in addition to
strong procurement and inventory management systems.
Measuring and Assuring Quality Maternal Health Care
Emphasize content of care
Unlike other fields, there is little consensus around a standardized set of maternal health quality indicators,
which makes ensuring quality care particularly challenging. Measuring quality of care is difficult for any social
franchise, but measuring quality of care for maternal health is somewhat unique and different than other
health services because the link between quality of care and outcomes is not straight forward. Clinical
outcomes are insufficient indicators of quality of care because poor quality care can still result in good
outcomes, given that most deliveries are uncomplicated, and complications can occur even in the presence of
good care. Most indicators that are common in the field, such as the presence of a skilled birth attendant at
delivery, do not fully capture care quality.
For this reason, the maternal health field is trying to move away from a focus on outcomes or contact with a
skilled provider toward capturing “content of care” (sometimes referred to as the “process of care” or
“practice of care”) – i.e. what is actually occurring during an episode of care. Currently, commonly used quality
indicators tend to report on the “structure of care” (e.g., provider knowledge, facility readiness) or clinical
outcomes (e.g., complications) which do not adequately reflect quality during the provision of care. It is
especially important to assess providers’ actions during labor and delivery because modifications of these
actions can improve prevention or early identification of complications, increasing the likelihood of proper and
timely management.
Social franchises must pay special attention to developing appropriate measurement systems that take into
account both the structure and content of care as well as the experience of care or patient satisfaction.
Likewise, franchisors must consider how they can best tailor their quality assurance and improvement
processes to ensure providers consistently deliver quality maternal health care across the franchise.
Prioritize and stage indicator roll-out
Given the large number of indicators needed to fully assess maternal health services, it may be difficult to
incentivize private providers to routinely record large amounts of data, and it may be difficult for franchisors to
dedicate sufficient resources for external quality assurance staff to spend significant time collecting data from
many small private providers. Franchisors will likely need to prioritize indicators and/or address subsets of
indicators during various quality assurance visits.
Collect data creatively
Given that timing of childbirth cannot be predicted and that some franchises may have very few deliveries, it is
difficult for quality assurance staff to observe provider practices, so alternative means are needed to assess
skills (e.g., drills, vignettes, case studies).
The group identified accurate use of the partograph as a particularly important quality indicator. The
partograph is designed to identify obstructed labor and fetal complications, and while other complications
such as postpartum hemorrhage and preeclampsia are more common, participants felt that use of the
partograph is a good measure of quality because the provider must track the entire process of delivery as it
evolves and pay careful attention to their actions.
The Way Forward
Social franchising holds tremendous promise to effectively leverage the local private health sector to improve
access to quality maternal health services and to contribute to efforts to reduce maternal mortality. Assuring
quality care is one of social franchising’s key value propositions – making the model uniquely positioned to
organize the delivery of private maternal health services.
While there may be opportunities for social franchises to make important contributions to reducing maternal
mortality, participants who have engaged in social franchising for labor and delivery services highlighted the
importance of ensuring that care is high quality enough to successfully manage life threatening complications.
They cautioned that there are distinct challenges inherent in assuring and measuring the quality of a complex
service, and that unless franchises can ensure that providers offer, at minimum, quality basic emergency
obstetric care with timely referral to higher level care, it may be counterproductive to drive women to these
services.
The pre-conference session highlighted the need for the field to continue to explore approaches that will
encourage social franchises to expand their maternal health services and successfully measure and assure the
quality of these services. MSD for Mothers and UCSF are committed to sharing collective learnings and
advancing this work with the larger social franchising and maternal health communities. In the coming year,
UCSF will launch an online community of practice where the community can continue to share experiences in
social franchising of maternal healthcare.