The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon.

Abstract

to provide basic information on the distribution (public/private and geographically) and the nature of maternity health provision in Lebanon, including relevant health outcome data at the hospital level in order to compare key features of provision with maternal/neonatal health outcomes.
a self-completion questionnaire was sent to private hospitals by the Syndicate of Private Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a functioning maternity ward by the study team in cooperation with the Ministry of Public Health.
childbirth in an institutional setting by a trained attendant is almost universal in Lebanon and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available data on the organisation, distribution and quality of maternal health services. An accreditation system for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon.
in total, 58 (out of 125 eligible) hospitals responded to the survey (46% total response rate). Only hospital-level aggregate data were collected.
the survey addressed the volume of services, mode of payment for deliveries, number of health providers, number of labour and childbirth units, availability of neonatal intensive care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome data related to childbirth care and stillbirths for the year 2008.
the study provides the first data on maternal health provision from a survey of all eligible hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the Ministry of Public Health is the single most important source of payment for childbirth. The reported hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of obstetricians to deliveries.
there is a need for greater interaction between maternal/neonatal health, health system specialists and policy makers on how the health system can support both the adoption of evidence-based interventions and, ultimately, better maternal and perinatal health outcomes.

Full text

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The safety and quality of childbirth in the context of health
systems: mapping maternal health provision in Lebanon
Jocelyn DeJonga, Chaza Akikb, Faysal El Kakc, Hibah Osmanc, and Fadi El-Jardalid,⁎
aDepartment of Epidemiology and Population Health, Faculty of Health Sciences, American
University of Beirut, Beirut, Lebanon
bFaculty of Health Sciences, American University of Beirut, Beirut, Lebanon
cDepartment of Health Behavior and Education, Faculty of Health Sciences, American University of
Beirut, Beirut, Lebanon
dDepartment of Health Management and Policy, Faculty of Health Sciences, American University
of Beirut, P.O. Box 11-0236, Riad El Solh, 1107 2020 Beirut, Lebanon
Abstract
Objective—to provide basic information on the distribution (public/private and geographically)
and the nature of maternity health provision in Lebanon, including relevant health outcome data at
the hospital level in order to compare key features of provision with maternal/neonatal health
outcomes.
Design—a self-completion questionnaire was sent to private hospitals by the Syndicate of Private
Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a
functioning maternity ward by the study team in cooperation with the Ministry of Public Health.
Setting—childbirth in an institutional setting by a trained attendant is almost universal in Lebanon
and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-
old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available
data on the organisation, distribution and quality of maternal health services. An accreditation system
for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon.
Participants—in total, 58 (out of 125 eligible) hospitals responded to the survey (46% total
response rate). Only hospital-level aggregate data were collected.
Measurements—the survey addressed the volume of services, mode of payment for deliveries,
number of health providers, number of labour and childbirth units, availability of neonatal intensive
care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome
data related to childbirth care and stillbirths for the year 2008.
Findings—the study provides the first data on maternal health provision from a survey of all eligible
hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the
Ministry of Public Health is the single most important source of payment for childbirth. The reported
hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn
© 2010 Elsevier Ltd.
⁎Corresponding author. fe08@aub.edu.lb.
This document was posted here by permission of the publisher. At the time of deposit, it included all changes made during peer review,
copyediting, and publishing. The U.S. National Library of Medicine is responsible for all links within the document and for incorporating
any publisher-supplied amendments or retractions issued subsequently. The published journal article, guaranteed to be such by Elsevier,
is available for free, on ScienceDirect.
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health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal
intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of
obstetricians to deliveries.
Key conclusions and implications for practice—there is a need for greater interaction
between maternal/neonatal health, health system specialists and policy makers on how the health
system can support both the adoption of evidence-based interventions and, ultimately, better maternal
and perinatal health outcomes.
Keywords
Maternal health; Safety; Health system
Introduction
Global efforts to reduce maternal mortality – including the millennium development goals –
have focused on increasing trained attendance at childbirth (Campbell and Graham, 2006).
Such a strategy would also reduce neonatal deaths (Darmstadt et al., 2005). This approach
indirectly encourages institutional childbirth but assumes that facility-based quality of care
avoids harm and is life-saving. The actual quality of care – for both normal deliveries, which
constitute the majority of deliveries worldwide, and those with complications – has received
relatively less research attention than other areas of health care (Althabe et al., 2008). Quality
of maternal health internationally has been described as a ‘neglected’ agenda in maternal health
(Van den Broek and Graham, 2009). Moreover, maternal and neonatal care has been identified
as one of the top 20 patient safety problems in developing countries and for economies in
transition (World Health Organization Patient Safety, 2008).
Recommendations to improve practice in order to enhance patient safety and quality need to
be grounded in knowledge of available structures and processes in health-care delivery in order
to be able to link these to actual health outcomes. It is increasingly recognised that promoting
safety and quality in maternal health is dependent on the overall functioning of health systems
(Penn-Kekana et al., 2007; Bhutto et al., 2008), but the contribution of health system factors
to maternal health has not been well specified to date (Parkhurst et al., 2005) This is particularly
the case for middle-income countries, given that most of the literature on health system impacts
on maternal health focuses on settings where human resource constraints are severe and access
to obstetric care is poor, such as in low-income countries affected by human resource losses
due to human immunodeficiency virus/acquired immunodeficiency syndrome or to outward
migration to richer countries (e.g. Gerein et al., 2006; Turan et al., 2008). There are, however,
evident problems of quality in many countries with relatively good coverage of services, both
in terms of patient safety/health outcomes and women’s experiences of childbirth (Miller et
al., 2003; Hulton et al., 2007). High coverage is not sufficient without good quality of care to
improve maternal/newborn health outcomes (Countdown Working Group on Health Policy
and Health Systems, 2008).
In countries of the Middle East, access to a health professional for childbirth care is no longer
a key constraint; the large majority of women now deliver with doctors or midwives in
institutional settings (World Health Organization Department of Reproductive Health and
Research, 2008). The region, in general, has high access to hospital obstetric care mainly by
clinicians, but with gender imbalances and a deficiency in the number of other categories of
providers, midwives and nurses, who might contribute to an effective, sustainable and
satisfying model of care for normal childbirth (Hatem et al., 2008). The multidisciplinary
regional research network, the Choices and Challenges in Changing Childbirth Research
Network1 established in 2001, has documented problems in quality and safety across five
countries of the Middle East region including Lebanon (Choices and Challenges in Changing
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Childbirth Research Network, 2005; Sweidan et al., 2008). Studies have found that the reasons
for these safety and quality deficiencies, however, are complex and highly dependent on
different health system factors that warrant further exploration.
In the specific case of Lebanon, the country is well endowed with facilities and medical
manpower, and access to childbirth care is high (see Table 1). However, a study of a nationally
representative sample of hospitals in the country documents the lack of adherence to evidence-
based recommendations in a number of areas of maternal health provision, with some
widespread practices being potentially harmful (Khayat and Campbell, 2000). Practising
clinicians from the Network further report that augmentation and induction of labour with
oxytocin is a widespread practice.2 Analysis of population-based data and hospital-based
studies by the Network has also revealed an excessive rate of caesarean section at the population
level in Lebanon, well above the World Health Organization recommended maximum of 15%
(Jurdi and Khawaja, 2004; Khawaja et al., 2004). Moreover, the most recent nationally
representative population-based survey for Lebanon, fielded in 2004, indicates that maternal
mortality is relatively high given the middle-income level of the country and the high
availability of health care (Tutelian et al., 2007), although studies currently underway suggest
that it is likely to be much lower. Finally, qualitative research by network members with women
who had recently delivered in Lebanon revealed that many encounters with the maternity
services are negative and that some routine hospital practices are uncomfortable for women
(Kabakian-Khasholian et al., 2000).
At the same time, however, Lebanon lacks basic information about the organisation,
distribution and quality of maternal health services, and hospital-level maternal and newborn
health outcome data are neither publically available nor systematically collected.3 These
deficiencies in the information base are due to the inter-related factors of the legacy of a 15-
year civil war (1975–1990) and the limited role of the state in a health sector heavily dominated
by the private sector. This paper reports on findings from the first part of a three-pronged study
investigating health system factors affecting the quality and safety of maternal health delivery
in Lebanon. This first stage consists of a mapping of available hospital-based childbirth services
in the public and private sectors given the absence of available information on maternal health-
care provision and maternal/neonatal health outcomes in the country. The study aims to provide
basic national information on the distribution (public/private and geographically) and the
nature of maternity health provision (including both human and physical resources) and
relevant health outcome data at the hospital level in order to compare key features of provision
and maternal/neonatal health outcomes. The other study components (currently underway)
consist of a survey of heads of maternity wards concerning hospital practices and policies to
update and expand upon earlier research (Khayat and Campbell, 2000), and qualitative research
with providers (both clinicians and nurses/midwives). This paper will first present the health
system context of Lebanon and the organisation of maternity care before turning to the study
methods, findings and discussion of the implications of the research findings for policy,
practice and research.
The health system/health policy context in Lebanon
Lebanon has a large pluralistic and highly fragmented health sector where several players are
involved in the financing and provision of health-care services to the population (Mohammad
Ali Osseiran et al., 2005). The private sector flourished as a result of the Civil War (1975–
1See http://fhs.aub.edu.lb/cccc/for a description of the Network and list of publications.
2For findings from Egypt on almost universal use of oxytocin, the majority of which is not indicated, see Khalil et al. (2004).
3One exceptional area where data are available is a database on neonatal health which was the initiative of one neonatologist in the private
sector and now includes a network of over 20 participating hospitals (see http://www.ncpnn.org/users/index.asp). See, for example,
Tamim et al. (2007).
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1990) which saw many of the existing public sector hospitals destroyed, leading to the
marginalisation of the public sector and, as such, the role of the Government in the delivery of
health services. It should be noted, however, that private hospitals are highly dependent on
revenue from public funding, mainly the Ministry of Public Health (MOPH) in addition to
other ministries including the Ministry of Labour, the Ministry of Defence, the Ministry of
Interior and Office of the Prime Minister (Mohammad Ali Osseiran et al., 2005; Ammar,
2009). The proliferation of the private sector led to several challenges including: weakening
of the MOPH, inflation of the medical bill due to emphasis on curative care and high-
technology medical care, weakening of primary care, and oversupply of health facilities and
their concentration in urban areas (Mohammad Ali Osseiran et al., 2005).
In one of the only comprehensive recent studies of the health system in Lebanon, Ammar
(2009) notes that the overwhelming majority of the estimated 168 hospitals in Lebanon is
privately owned. He further reports that in spite of the recent establishment of 28 public
hospitals, private hospitals represent around 80% of all hospitals in Lebanon, and the prices of
public hospitals are 10% lower than those of private hospitals. Public hospitals do not operate
to generate profit, but rather aim to break even which creates incentives to attract patients and
reduce transfer to private hospitals. As such, admissions to public hospitals increased between
2005 and 2007 (Ammar, 2009).
Despite many attempts at gaining some form of control, the MOPH has limited authority and
regulation over care provision in private hospitals (Mohammad Ali Osseiran et al., 2005;
Ammar, 2009). Private hospitals enjoy the luxury of being able to invest in areas that allow
them to maximise profit. As such, they are less concentrated in rural areas as urban areas are
more profitable. This has led to severe regional discrepancies which are reflected in inequitable
service provision across geographic regions. The distribution of public hospitals is believed to
be more equitable than private hospitals, although they only comprise 2550 beds (Ammar,
2009). In 1999, the Lebanese Syndicate of Private Hospitals reported an estimated 9297 active
beds in private hospitals in Lebanon (Mohammad Ali Osseiran et al., 2005). Recent estimates
indicate that the number of hospital beds is 2.9 beds per 1000 population, which is believed to
be comparable to rates in developed countries and exceeds the rate in other countries in the
region (Mohammad Ali Osseiran et al., 2005). The Lebanese Syndicate of Private Hospitals,
on the other hand, estimates the bed per population ratio at one bed for every 255 people
(Mohammad Ali Osseiran et al., 2005).
Accreditation
In an effort to improve the quality of hospital care and establish regulation mechanisms, the
hospital accreditation policy was enacted in 2002. With the assistance of an Australian
consultant team, the MOPH developed and implemented a process of evaluating the quality of
care in terms of processes of care, rather than outcomes. This new policy, which replaced the
old classification system which had been in use since 1983, was implemented in four phases
(Ammar et al., 2007). The MOPH is now using this policy as an incentive-based regulation by
implementing a payment system which links accreditation to reimbursement (Ammar, 2009).
The MOPH implemented accreditation of private hospitals through two national surveys, the
first between September 2001 and July 2002 and the second in 2004–2005 (Ammar et al., 2007;
Ammar, 2009). The second survey which included 142 hospitals found that only 85 hospitals
met requirements. A study aimed at assessing the impact of accreditation on quality of care as
perceived by nurses showed that nurses believed it to be a good tool for improving quality of
care, and perceived quality of care was found to have improved (El-Jardali et al., 2008).
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Human resources
The health-care sector is both labour-intensive and labour-reliant, and the delivery of quality
health-care services is strongly dependent on having enough well-trained health-care workers
to meet patient needs and expectations (El-Jardali et al., 2007). As with most countries,
Lebanon is suffering from critical problems with its health workforce which can affect health-
care delivery. The most pressing problem is the imbalance between clinicians and nurses.
Recent evidence indicates that the ratio of clinicians is almost three times that of nurses in
Lebanon (El-Jardali et al., 2007). The country is also believed to be suffering from a shortage
of nurses including midwives (Ammar, 2009). This is critical as recent evidence links the health
provider density with population outcomes. In fact, increasing clinician density was found to
be linked to lower maternal mortality, infant mortality and under-5 mortality. Improving nurse
density was linked to lower maternal mortality rates (El-Jardali et al., 2007). However, it should
be noted that such improvements are more pronounced in countries of higher income
classification, which might imply that there are other critical predictors that are as important
as the overall number of health-care providers that can improve population outcomes in
countries of lower income classification (El-Jardali et al., 2007).
Maternal health care in Lebanon
According to the most recent nationally representative population-based survey at the
household level that included questions on maternal health (Tutelian et al., 2007), childbirth
with a skilled attendant is almost universal in Lebanon: 98.2% of births in the preceding five
years (see Table 1). Most births take place in hospital, with private hospitals accounting for
80.1% of all deliveries within the five years preceding the survey. Antenatal care is relatively
high (with 70.5% of respondents having made five or more antenatal visits), but only roughly
half of the respondents had any postnatal care. The population-based caesarean section rate
was found to be high at 23.2% (Table 1).
Maternal health in Lebanon, like other areas of health care, has historically been, and remains,
dominated by the medical profession. This can be traced to the highly privatised nature of the
health system and the fact that private clinicians are the main agents of medical care. This is
particularly the case in maternal health, which is viewed, in the medicalised culture of the
country, as an important and private matter that should be entrusted to clinicians’ professional
skills (obstetricians). There has been an unregulated increase in the number of medical doctors
(from both genders) seeking residency programmes and training in obstetrics and gynaecology.
Today, according to the Order of Physicians in Lebanon, the estimated number of registered
obstetricians is close to 950, with about 650–700 currently practising in Lebanon. This
dominant pattern of maternal health care being obstetrician-led has consistently marginalised
midwifery, which has been losing the narrow grounds occupied historically in private practice
(in the 1960–1980s). Midwives are now mainly relegated to the role of assisting obstetricians
in labour and childbirth within hospitals. Lebanese law stipulates that maternity patients cannot
register in hospitals under the name of midwives, but must do so under the name of
obstetricians. Pregnant women tend to stay with the provider who deals with conception,
pregnancy care, ultrasound examinations and related procedures, and all the other aspects of
medicalised care. This situation has reduced the chances of midwives being alternative
providers of maternal health care with competitive benefits, especially that private obstetric
providers have opportunities to work in accessible, subsidised health centres and dispensaries,
either governmental or non-governmental, eliminating the financial obstacles to care that
historically favoured midwives.
The differential status of the midwifery profession has further contributed to this imbalance.
The Lebanese Society of Obstetrics and Gynaecologists actively promotes that profession in
terms of administrative, organisational and scientific issues. In contrast, midwives – due to
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political and professional reasons – have not yet succeeded in organising and registering a
professional society that could promote their profession and the right to lead/co-lead maternal
health care. There is increased competition over the provision of maternal health care given
the privatised nature of the health system, the declining birth rate in the country (with the total
fertility rate below replacement level) and the market-driven increase in the number of
obstetricians in the absence of any regulation on specialties – which have together exacerbated
these differentials between the two professions.
Nevertheless, the recently introduced process of accreditation of private hospitals could
potentially contribute to an enhanced status for midwives in the country. The latest
accreditation criteria for maternity wards stipulate that obstetric departments should be under
the direction of a qualified obstetrician, but be managed by a ‘registered midwife qualified by
education and a minimum of five years experience’ (Criterion OB2, Ministry of Public Health,
2003), and that ‘the staff schedule provides for at least one registered general nurse with
midwifery qualifications on duty’ (Criterion OB3.4, Ministry of Public Health, 2003).
Methods
This study was conducted in collaboration with the MOPH and the Syndicate of Private
Hospitals which have real or de facto jurisdiction, respectively, over the public and private
hospitals in Lebanon. In February 2009, the Syndicate of Private Hospitals sent out, via fax,
questionnaires to all private hospitals in Lebanon that are members of the Syndicate (n=127
of which n=108 proved to be eligible with a maternity ward), accompanied by an explanatory
letter, and requested that they be completed and returned to the Syndicate within two weeks
of receipt. For public hospitals, all operational hospitals in the country were contacted in order
to identify their eligibility in terms of having a functioning maternity ward. In June 2009,
questionnaires were sent out by fax to all eligible public hospitals by the study team with an
explanatory letter signed by the MOPH which endorsed the study; hospitals were asked to
return the completed questionnaires to the study team within two weeks of receipt. The
administration of all study hospitals were asked to assign a focal person who would collect the
information from relevant departments. In total, the questionnaire was sent to 144 hospitals.
Given the voluntary nature of the survey and the anticipated reluctance of many hospitals –
particularly private hospitals – to reveal hospital-based statistics, and in order to increase the
response rate, follow-up phone calls were conducted in April and mid-June 2009 for private
and public hospitals, respectively, with administrators to confirm receipt of the questionnaire
and to encourage their completion and return.
Ethical considerations
This study was submitted for ethical review by the Institutional Review Board at the American
University of Beirut, and granted exemption as it involved the collection of aggregate statistics
available at hospitals.
Questionnaire design
The survey instrument was developed and refined by a multidisciplinary study team combining
expertise in health policy, maternal health, the Lebanese health system and clinical experience
in family medicine and obstetrics in Lebanese hospitals. The questionnaire was developed in
English then translated into Arabic. The Arabic version was reviewed by both the Syndicate
of Private Hospitals and the MOPH. The main components of the survey address the volume
of services, mode of payment for deliveries, number of health providers, number of labour and
childbirth units, and the volume of the different types of deliveries and availability of infusion
rate regulation pumps (used to regulate the administration of oxytocin) and neonatal intensive
care units (NICU) for 2008. Health outcome data at the hospital level were requested on
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caesarean section (including for primigravidae and multigravidae), instrumental deliveries,
numbers of stillbirths and live births. Given the reluctance of hospitals generally in Lebanon
to disclose health outcome data, particularly in a context of an on-going accreditation process
for private hospitals, which is process rather than outcome orientated, it was deemed too
sensitive to collect data on maternal and neonatal mortality that could have jeopardised the
response rate. Given the highly privatised and competitive environment of the health system
in Lebanon, hospitals do not readily release patient outcome data for research purposes and
are not required to make this data available in the public domain.
Data analysis
Data were entered and analysed using Statistical Package for the Social Sciences Version 16.0
for Windows. Univariate analysis was performed to obtain a general description of the volume
of services, payment coverage, number of health providers, number of labour and childbirth
units, and the volume of the different types of deliveries in hospitals. t-Tests were performed
to assess the relationship between the indicators stated above and hospital type and location.
p-Values were computed for all above tests with p≤0.05 considered to be statistically
significant.
Findings
Out of 108 eligible private hospitals in Lebanon, 46 responded and thus the private hospital
response rate was 43.0%.4 Out of the 17 eligible public hospitals in the country, 12 responded
giving a response rate for the public hospitals of 70.6%. In total, the 585 (out of 125 eligible)
hospitals which responded to the survey (46% total response rate) provided data on 35,883
deliveries which occurred in their settings in 2008 (see Table 2 on the numbers of deliveries,
live births and stillbirths by type and region of hospitals that responded to the survey). Table
3 presents the role within the study hospitals of the respondents to the surveys; some hold
multiple roles within hospitals, depending on hospital size and available human resources, but
all those who responded to the survey are knowledgeable about maternal health.
The private sector accounted for the majority of deliveries in 2008 in the respondent hospitals:
77.8% of deliveries vs 22.2% in the public sector (Table 4). Table 5 shows the distribution of
payments for deliveries by different modes of payment, allowing for the fact that deliveries
could be paid for by multiple sources and therefore the denominator does not correspond to
the number of deliveries. Payment by the MOPH is the biggest single source of payment for
childbirth, accounting for 36.8% of all modes of payment for childbirth, but the MOPH
accounts for 85.3% of modes of payment for childbirth within public hospitals and 21.9%
within private hospitals (Table 5).
The mean reported caesarean section rate was found to be 40.8% across all hospitals, with a
negligible (and non-significant) difference in the reported rate between the public (40.2%) and
private sectors (41.0%) and between hospitals within the capital city, Beirut, and its suburbs
(38.7%) compared with reporting hospitals in the rest of the country (41.7%) (see Table 6).
Vaginal instrumental deliveries account for 10.7% of all reported deliveries overall, with the
reported percentage being significantly higher within private hospitals (at 12.4%) compared
with public hospitals (at 3.9%), and the same rate was higher in hospitals within Beirut and its
close suburbs (at 18.0%) compared with hospitals in the rest of the country (mean rate 6.9%)
(Table 7).
4One medical centre was excluded as it reported that it was exclusively accepting planned caesarean section deliveries during renovation
of the maternity ward at the time of the survey.
5One hospital was excluded as it only conducts caesarean sections and thus the total included was 57.
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Comparisons of means revealed significant differences in the caesarean section rate between
private hospitals accredited in 2004 (mean of 44.4%) compared with non-accredited hospitals
(mean of 31.4%) (Table 8). However, although there was a difference in the reported use of
instrumental deliveries between those that passed accreditation (at 13.1%) and those that did
not (at 7.0%), this difference was not statistically significant. Taking instrumental deliveries
alone, accredited hospitals reported a significantly higher rate of use of forceps (at 41.0%) than
the non-accredited hospitals (at 8.3%). An inverse relationship applies for the use of vacuum
extraction, whereby accredited hospitals reported a rate of 56.7% among instrumental
deliveries, as opposed to 91.7% for non-accredited hospitals.
The mean ratio of the annual number of deliveries to the numbers of midwives with delivery
privileges employed in each hospital is about three times higher than the same ratio for
obstetricians (Table 9), with no significant difference between public and private hospitals or
between Beirut and outside Beirut (data not shown).
Overall, 10 out of 57 hospitals (or 17.5%) reported that they did not have infusion pumps, and
one hospital reported that it did not have fetal monitors (see Fig. 1). The mean availability of
fetal monitors per childbirth per day (calculated as a ratio of total annual deliveries divided by
365) was found to be 3.8. The availability of infusion pumps per childbirth per day was found
to be 2.7. The availability of NICUs was less, at only 0.3 per patient per day overall, but 25
out of 47 hospitals (or 53.2%) reported that they did not have an NICU. There was no significant
difference in the availability of fetal monitoring, infusion pumps or NICU per childbirth per
day across public versus private hospitals, or between hospitals in Beirut/close suburbs and
the rest of the country (Table 10). The mean number of deliveries per labour bed per day was
the same, at 0.6 in total, in the public and private hospitals and in hospitals within Beirut/its
suburbs and the rest of the country (Table 10). However, the non-accredited hospitals reported
a significantly lower number of deliveries per labour bed per day and a significantly lower
number of deliveries per childbirth room per day than accredited hospitals (Table 8).
Hospitals that did not pass the accreditation process had a higher mean availability of fetal
monitors and NICUs, and a lower mean availability of infusion pumps than hospitals that did
pass, although these differences were not statistically significant (Table 8).
Discussion
In many developing countries, particularly middle-income countries, constraints related to
access to care are lessening with the increased trend towards institutional deliveries (World
Health Organization Department of Reproductive Health and Research, 2008). Thus attention
is needed to ensure the quality and safety of care received, and in reducing differentials in
provision and quality across geographic region, public and private sectors. This appears to be
the case in Lebanon where institutional deliveries are nearly universal but problems of quality
have been documented; more and better information is needed on how provision relates to
health outcomes and how inequities at health system level affect quality. This study makes a
first step in rectifying this gap. Lebanon may be exceptional in the degree to which information
about maternal health-care provision is lacking, but the problems identified in this research are
likely to resonate with other developing countries where the private sector dominates and which
lack a comprehensive picture of maternal health-care provision and how health system factors
affect it.
The overall response rate to the survey (46% of eligible hospitals) and the deliveries reported
by these hospitals account for about 42% of all live births that are reported to have taken place
nationally in Lebanon in 2008 . This level of response is on a par with similar surveys of
hospitals in Lebanon (El-Jardali et al., 2008, 2009a), and indicates that even in a highly
fragmented, competitive and privatised health system context, it is possible to obtain data on
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hospital provision from a high proportion of hospitals nationally. The higher response rate for
public than private hospitals illustrates the challenge of obtaining information on provision
and health outcomes from the private sector particularly, despite the fact that the survey was
administered by the Syndicate of Private Hospitals.
The findings from hospital-level data confirm earlier nationally representative data at a
household level (Tutelian et al., 2007) that the vast majority of deliveries (77.8%) in Lebanon
occur in private hospitals, and that despite efforts to increase public sector provision (Ammar,
2009), the proportion of all deliveries that take place in the public sector appears to have
increased negligibly since 2004, with the proportion in this study only 2.5% higher than the
national figure in 2004 (Table 1). As is the case with health care generally in Lebanon, within
the public sector, the predominant mode of payment is public, and within the private sector,
the predominant mode of payment is private. For this reason, the analysis by public and private
sector was conducted, although it is acknowledged that the picture is complicated in that within
both the public and private hospitals, deliveries are paid for from both private and public
sources. The data indicate, however, that while outside Beirut, the main source of payment for
deliveries was the MOPH, within Beirut and its suburbs, the main sources of payment are
private. The mode of payment for childbirth is important in considering hospital administrators’
motivation for quality improvement (El-Jardali et al., 2009b).
This study found an alarmingly high mean hospital caesarean section rate, at 40.8% of all
reported deliveries in 2008. A high and rising caesarean section rate is consistent with the
pattern found in the region (Jurdi and Khawaja, 2004; Khawaja et al., 2004)6 but is much higher
than the population-based rate for Lebanon of 23% in 2004 (Tutelian et al., 2007). It is also
higher than other available data on hospital caesarean section rates, which found a rate of 31.4%
for the period 2001–2002 in nine hospitals in Beirut participating in a neonatal database
network (Tamim et al., 2007). This high hospital-based caesarean section rate is, however,
consistent with more recent hospital-based studies (Osman et al., unpublished). Research by
network members has found a range of factors that encourage high caesarean section in
Lebanon, including lack of regulation, financial and convenience factors for clinicians, and a
trend towards encouraging and accommodating women’s demand for caesarean section
(Kabakian-Khasholian et al., 2007). The reasons for the high observed caesarean section rates
need further exploration within individual hospitals. The topic is of particular interest to policy
makers in Lebanon concerned, with encouragement by the World Bank, to rationalise health
services (Shadi Saleh, American University of Beirut, personal communication, 20/11/2009).
The finding that caesarean section rates are higher in accredited hospitals than non-accredited
hospitals is puzzling, especially given that one of the criteria for accreditation is the availability
of policies and procedures, and caesarean criteria are specifically mentioned (Criterion
OB12.10, Ministry of Public Health, 2003). It may be due to the fact that accredited hospitals
are likely to be the larger hospitals which also serve as referral centres. This would need to be
explored in further research.
This study found an overall rate of instrumental deliveries of 10.7%. Clinician members of the
Choices and Challenges in Changing Childbirth Research Network report that training in
obstetrics in the country is de-emphasising instrumental delivery, and the overall medical
environment encourages caesarean section over instrumental deliveries. There were also
significant differences in use of instrumental deliveries between public and private hospitals,
and between those in Beirut/its suburbs and the rest of the country. Although no significant
difference was noted between hospitals that were or were not accredited in the overall rate of
instrumental deliveries, significantly higher use of forceps was found in accredited hospitals
6In Egypt, a country of over 80 million, recent population-based data indicate that 27.6% of preceding births were delivered by caesarean
section (El-Zanaty and Way, 2009).
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and significantly lower use of vacuum was found in accredited hospitals compared with non-
accredited hospitals. The findings concerning human resources indicate that, at least in terms
of overall numbers of providers to annual numbers of deliveries at the hospital level, midwives
with childbirth privileges appear to have a higher load than obstetricians despite their lower
professional status, which is likely explained by the fact that the obstetricians’ role is more
focused on high-risk cases. However, the authors do not have data on the degree of assistance
provided by other categories of health workers on the maternity ward, which will be further
explored in the qualitative component of the research. The fact that there was no significant
difference in this ratio between the public and private sectors and between Beirut/its suburbs
and outside the capital indicates that this pattern appears to hold across the country.
In terms of the availability of essential equipment for safe maternal and newborn health care,
the data indicate that both infusion pumps and fetal monitoring equipment are readily available
across the public and private sectors, and in both Beirut and the rest of the country. The findings
need to be considered in light of the above-noted high level of labour augmentation reported
in Lebanon by clinicians within the Network – an issue that will be further explored in a planned
survey of heads of maternity wards. This raises questions of safety for the one hospital lacking
fetal monitors and the 17.5% of reporting hospitals that lacked infusion pumps about whether
the potential effects on mother and newborn of labour augmentation are being monitored safely.
Moreover, there are large variations in the availability of NICUs (although the differences
between hospitals in Beirut/suburbs and the rest of the country were found to be non-
significant). Over half of hospitals responding to that question did not have an NICU. The fact
that no significant variations between hospitals in Beirut/suburbs and the rest of the country
in the provision of equipment and human resources, however, may be because less endowed
hospitals were less likely to respond; indeed, the response rate of hospitals in less privileged
areas of the country was lower (data by region not shown). This issue needs further research
because of the noted predominance of the private sector in Beirut and its suburbs.
The finding that nearly half of responding hospitals lack an NICU needs to be further studied
in context. Unlike in many health systems, the provision of NICUs is not regulated by the
Lebanese Government to ensure a rational provision according to geography or population
concentration (Khalid Yunis, Neonatologist, personal communication, 23/03/2010). NICUs
are a major investment for hospitals to make, and there is no need for every hospital to have
one if an adequate referral system exists. Nevertheless, anecdotal information from an
obstetrician-gynaecologist in our network indicates that when a hospital lacks a NICU, it
becomes complicated to transfer both mother and infant to a hospital supplied with one. This
is mainly because the acceptance of the patient dyad is contingent upon the patient's mode of
payment. In the Lebanese health system, this responsibility is not systematised but rather
depends on a case-by-case negotiation by clinicians (Reem Abu Rustum, personal
communication, 14/09/2009). The processes and problems in referral between hospitals for
maternal/neonatal health have not been researched in Lebanon, and indeed internationally, this
has been identified as an area in need of further research (Murray and Pearson, 2006).
Limitations
These findings need to be qualified by the fact that under half of eligible hospitals responded
to the survey and that limited information is available on the non-respondents; moreover, the
response rate for the public sector was higher than that for the private sector, and was lower
for less privileged areas of the country. There is a potential bias in the results, as noted, in that
hospitals with better quality or higher levels of provision may have been more likely to respond.
However, this bias is unlikely to affect the reported high caesarean section rate as capacity to
perform caesarean section is high and widespread in Lebanese hospitals irrespective of size
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and location. Nevertheless, the nearly half response rate allows the authors to make some
conclusions about hospitals in Lebanon with these provisos. Secondly, as the questionnaire
was self-administered, some respondents may have misunderstood questions and there is
potential for misreporting, although as noted, all respondents were knowledgeable about the
maternal health services in the reporting hospitals. Data collected through the survey will be
verified in the process of conducting structured interviews with heads of maternity wards in
subsequent stages of the study described above. Thirdly, analysis by accreditation status was
presented, but the last round of accreditation was in 2004 and therefore there is the possibility
that hospital provision has changed since that date. Finally, a limitation in the scope of this
study is its focus on provision of care and hospital-based statistics, not on the perspective of
women who deliver in the maternity wards.
Implications for practice and further research
This study confirms the importance of looking at the health system context of maternal health
including mode of payment, distribution of services by sector and geographic region, and
human resources. The lack of regulation over the expansion and distribution of maternal health
services in Lebanon and the market incentives to invest in technologically sophisticated care,
at the potential expense of training and oversight of human resources, is likely to be a factor
contributing to the escalation of care illustrated by the very high reported hospital caesarean
section rates. Moreover, understanding the predominant mode of payment for deliveries in
different settings illuminates financial incentives to hospitals of quality improvement, and the
scope for the MOPH, as the most significant single source of funding for childbirth overall, to
influence the quality of care. A specific mapping of hospital-level provision and health outcome
data allows us to ground recommendations for improvement in the context of what is actually
provided.
These findings point to the importance of maternal health specialists engaging with health
policy makers in the country and in other settings on the question of how health systems can
support both the adoption of evidence-based interventions and, ultimately, better maternal and
perinatal health outcomes. Given that there are other areas of maternal health care where lack
of evidence-based care has been identified in Lebanon, in addition to caesarean section (Khayat
and Campbell, 2000), there is an opportunity to inform the accreditation process with a broader
range of appropriate indicators of quality of care in maternal health care at the hospital level.
The lack of hospital-based metrics of quality of care has been noted as an urgent research gap
internationally (Say et al., 2009), and is important to policy makers given that maternity care
accounts for a high proportion of hospital services.
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Acknowledgments
This paper is part of a larger regional research project on Choices and Challenges in Changing Childbirth in the Arab
Region sponsored by the Center for Research on Population and Health at the American University of Beirut, Lebanon,
with generous support from the Wellcome Trust [074986/Z/04/Z]. We thank the Ministry of Public Health, the
Syndicate of Private Hospitals and the surveyed hospitals for their cooperation.
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Fig. 1.
Availability of fetal monitors, neonatal intensive care units (NICU) and infusion pumps in the
sampled hospitals.
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DeJong et al.Page 15
Table 1
Latest nationally representative indicators on maternal health in Lebanon – PAPFAM 2004 (for all births in five
years preceding survey).
Indicator%
Childbirth by skilled attendant 98.2
Childbirth by unskilled attendant 1.8
Place of childbirth
Private hospital or clinic80.1
Public hospital11.9
Private doctor 2.8
Home 2.4
Non-governmental health centre1.2
General health centre0.7
Maternal mortality ratio (per 100,000 live births) 88
Made five or more antenatal care visits70.5
Antenatal care by medical doctor93.6
Antenatal care by nurse/midwife 2.2
Proportion of births by caesarean section23.2
Had at least one postnatal check up51.6
Source: PAPFAM survey (Tutelian et al., 2007).
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