The United Nations Millennium development Goal (MDG 5) aims to improve maternal health. This goal is structured around two key targets: First, to reduce maternal mortality rates by 75% between 1990 and 2015, and Second, to achieve universal coverage of skilled care at birth by 2015. Inequitable access to maternal health is a big challenge globally. There is also inequality of access to skilled care at delivery. The inequalities to maternal health are discussed with reference to the contextual factors as proposed by Walt and Gilson model .
As a useful starting point, the provision of adequate in-service training (IST) is considered vital in developing and keeping midwives with up to date practices in the field of maternal health care. The provision of adequate IST will go a long way to reduce maternal mortality. The clinical competencies of midwives need to be addressed through frequent IST and their curricular must have relevance in modern health care delivery practices. Consistent with our findings, several studies have also found that the clinical competencies of health providers in providing basic emergency obstetric care (BEmOC) are very low [14–16]. One of the major reasons why so many countries still have inadequate numbers of skilled midwifery providers is because those grappling with human resources have not paid attention to the need for 'proficiency' in the various competencies required to assist women and newborns. For too long it has been accepted that as long as the health workers received some (often too little) training in midwifery, this was sufficient . There has to be clarity as to the understanding of competence- ability to perform aspects of the job and competencies, the basic knowledge skills and behaviours required of a midwife to practice safely in any setting .
The implementation of any policy requires that those involved in implementing such a policy have adequate knowledge of the policy. Those engaged in the implementation of a policy must be engaged in the formulation process of the policy. This will ensure the success of such a policy as their commitment and support will be high. Most of the policies in developing countries tend to be implemented through a top-down approach and are not communicated to those engaged in direct service delivery of health services as evinced in this study. In essence, the dissemination of maternal policies at the local level is weak. Communication is also an essential ingredient for the success of a policy. Failure to communicate a policy effectively may lead to implementation failure. It has been suggested that by specifying and providing clarity on the policy, and ensuring that the policy is transmitted to the appropriate personnel, should lead to successful implementation . Besides, different meaning and interpretations assigned to the policy are minimal. In Thailand and the United States, most health professionals have low to moderate knowledge about the national policy, and their levels of involvement in policy formulation and implementation is low [20, 21].
The low motivation of health professionals has contributed to the high exodus of health professionals out of the country, to international organizations and to the private sector. This has created shortages of midwives resulting in heavy workloads in health care facilities. Moreover, the low status and recognition accorded to midwives have discouraged people who want to pursue that profession. Marginalization of midwives also implies that they face feelings of disappointments and confusion  and may not be able to take their own initiatives. To be able to achieve the MDG 5 requires well motivated and dedicated midwives who will show commitment towards the delivery of quality maternal health services. Several studies have shown that the low motivation in the health sector has impeded the implementation of most policies and reforms in Ghana [23, 24]. The low motivation of health professionals have forced some to supplement their income by engaging in other occupations.
Attention has focused recently on the importance of adequate and equitable provision of health personnel to raise levels of skilled attendance at delivery and thereby reduce maternal mortality [25–28]. However, the human resource crisis in health care means that many countries are far from reaching the health-related MDGs. Factors contributing to this crisis include mal-distribution and low workforce productivity together with an acute shortage of skilled workers in the government health sector . The effects of shortage of health professionals for maternal health are reduction in quality of services; increased workload; reduced time for the patient; and poorer infection control . When adequate skilled personnel are provided, they can better respond to the needs of maternal care, thereby, helping to reduce maternal mortality.
To enable midwives function effectively, there has to be an “enabling environment”. Provision of that environment for midwives will ensure delivery of quality maternal health care and reduction in maternal mortality. A skilled attendant should have the necessary equipment and medicines and adequate referral means to be effective in reducing maternal mortality. The environment can also be viewed broadly to include the political and policy context in which skilled attendants must operate, the socio-cultural influences, as well as the more proximate factors such as pre-and in-service training, supervision, deployment and health systems financing. This environment should also ensure there are sufficient skilled attendants with the necessary skills, satisfactory pay scales and career advancement opportunities; continuing education opportunities to maintain and upgrade skills; supportive supervision mechanisms; and possibilities of skilled attendants to refer women and newborns directly to higher level care if necessary .
Improving access to maternal health logistics is an essential component of strengthening maternal health programs and outcomes . Maternal health challenges in the entire health system come with deeply embedded issues of human resources, infrastructure competing priorities and community engagement. The shortages of maternal health logistics serve as a direct barrier to the utilization and positive outcomes at health facilities [33, 34]. Maternal health logistics often require a more highly trained health care provider who is available all the time. These providers are trained sufficiently on how to use these logistics. An efficient logistics system should be responsive to the needs of the end-users (the patients).
Improving logistics systems and ensuring product availability requires focusing on the customer regardless of the supply chain being considered . A reliable and efficient transportation system should be key to the success of logistics systems and should be able to respond to emergencies and also ensure that products are in constant supply. A legal system that does not allow for easy access to logistics have implications on the way health logistics are procured, and could be detrimental to achieving quality maternal health care. Laws and legislations could impede the successful implementation of health policies, especially during the formulation of such policies, when provisions were not made to take consideration of such legislations. This should serve as a lesson to policy implementers of health interventions that, there is always the need to ensure that legislations are less rigid to allow for effective implementation of health interventions.
Furthermore, the logistics management system should effectively function in each of the components to ensure that there are no hindrances in handling maternal health logistics. In many developing countries, logistics systems for public health facilities have been centralized, with central ministry offices responsible for planning, forecasting, procurement, warehousing and the distribution of essential drugs, contraceptives and vaccines. These systems have been notoriously inefficient and in many cases incapable of providing adequate supplies on a timely basis .
In essence, the availability of resources is an important ingredient in ensuring the success of policy implementations. As reviewed earlier, without adequate resources, implementation of health policies would encounter challenges as resources to ensure the execution of such programmes are insufficient or lacking. Working on the systems that will ensure time delivery of logistics is crucial for achieving MDG 5.