Q&A: Transforming the health system for better antenatal care in Georgia

WHO/David Kharatishvili

Georgia is playing an important role in eastern Europe and central Asia as one of the first countries to implement the WHO antenatal care recommendations, which were developed based on evidence gathered during the last 15 years.

Dr Nino Berdzuli, Programme Manager for Sexual and Reproductive, Maternal and Newborn Health at WHO/Europe, is a former Deputy Minister of Labour, Health and Social Affairs in Georgia. Here, she explains how Georgia managed to implement a policy that provides expecting mothers with high-quality, people-centred care.

Q: What has improved for pregnant women and mothers in Georgia?

Dr Berdzuli: In the past, the national programme for pregnant women covered only 4 antenatal care visits. The new WHO guidelines, released in 2016, recommend at least 8 antenatal contacts with the health-care provider. Creating a positive pregnancy experience for the expecting mother and reducing poor health outcomes for both the mother and baby are key objectives of the guidelines.

Georgia took this forward and increased the number of antenatal contacts funded by the government from 4 to 8, increasing the opportunity for systematic monitoring of pregnant women and fetuses. As a result of this policy change, we can expect that the financial protection of pregnant women will improve, because previously they had to pay out of pocket for any visit beyond the 4 covered by the government.

Additionally, Georgia has revised and introduced a package of interventions – the essential and high-impact interventions that are suggested by WHO. This means that pregnant women in Georgia now are entitled to receive the improved package of antenatal care interventions and services. Moreover, it has removed interventions from its antenatal care programme that were not supported by evidence. Georgia has also chosen to focus on key preventive interventions such as providing folic acid and iron supplements, screening for hyperglycaemia and asymptomatic bacteriuria, among others, as well as evidence-based practices for management of pregnancy-related complications.

Georgia has also become one of the first developing countries in the world to introduce a national digital medical birth registry, which is a big achievement. The completeness of the digital birth registry is pretty high, at over 94%, meaning that nearly every pregnant woman that comes into contact with the health system is registered electronically. The birth registry collects all the information about each antenatal visit and delivery, and newborn and postpartum care. This provides valuable information and presents an opportunity to analyse both progress and gaps in quality of care.

This marks a new frontier for Georgia – the introduction of new quality assurance measures and new opportunities to measure performance and develop system-wide policies and incentives to deliver better care.

Q: How did the WHO recommendations help with the implementation of this new package?

Dr Berdzuli: From my own experience in policy development, these guidelines are very important. Without the WHO guidelines it would have been very difficult to develop the clear guidance on which interventions to implement, when and how, and why they are needed. The WHO guidelines make it easy to discuss the key issues with stakeholders and come up with appropriate national guidelines and policies.

Q: What were the important factors for successfully implementing the new policy?

Dr Berdzuli: First of all, it was vital to have the political will to prioritize the health of mothers and children, and the political will to change policy. Improving access to health care and protecting the population from financial risks have been the main objectives of the Universal Health Care programme introduced by the Georgian government in 2013. Fortunately, ensuring that women and children have universal access to key health services is also priority for the government.

Second, whenever you think about changing a policy, it is absolutely crucial to have robust evidence, especially when resources for heath are limited – so you can explain to decision-makers and the public the precise rationale for introducing the change. Once you have this robust evidence, it is always easier to communicate it to different audiences.

Analysing maternal and perinatal deaths, the root causes of these deaths and preventability of complications played a crucial role. Based on the analysis and research, we also tried to understand inequities in complete antenatal care coverage in the country. These were prerequisites for policy change.

Third, engaging numerous stakeholders in the process was essential for building long-term support for the new antenatal care programme. This included an intensive consultation with key national experts and professional associations, as well as engaging the health services purchasing agency at all stages.

Finally, frequent and ongoing communication was needed to demonstrate the value of the new policy, and that is what happened in Georgia.

A positive response to new antenatal care policy

Anecdotal evidence shows that both pregnant women and medical providers have responded enthusiastically to the newly implemented policy. Dr Konstantin Bochorishvili works in Zestafoni District and has first-hand experience with the changes in antenatal care in Georgia.

Q: What is your opinion of the new policy?

Dr Bochorishvili: Definitely positive, for sure!

The goal, of course, is reduction of maternal and perinatal mortality rates and timely detection of complications. So having more visits and increased regular contacts with a health-care provider in the last few weeks of pregnancy is vitally important for tracking this and taking measures earlier.

Q: What are mothers’ reactions to the programme?

Dr Bochorishvili: Their reaction is very positive. They used to see a doctor rarely, only 4 times during the entire pregnancy. When additional visits were needed, the rural population I mostly serve had a hard time affording them, as they had to pay for them themselves. Now they get to see the doctor more often and without additional cost.

That is great! They get to voice their concerns soon after they appear and there are more opportunities for the doctor to respond to their needs and concerns faster.