Development and testing of a composite index to monitor the continuum of maternal health service delivery at provincial and district level in South Africa

PLoS One. 2021 May 25;16(5):e0252182. doi: 10.1371/journal.pone.0252182. eCollection 2021.


Introduction: The continuum of care is a recommended framework for comprehensive health service delivery for maternal health, and it integrates health system and social determinants of health. There is a current lack of knowledge on a measurement approach to monitor performance on the framework. In this study we aim to develop and test a composite index for assessing the maternal health continuum in a province in South Africa with the possibility of nationwide use.

Materials and methods: The composite index was computed as a geometric mean of four dimensions of adequacy of the continuum of care. Data was sourced from the district health information system, household surveys and the census. The index formula was tested for robustness when alternative inputs for indicators and standardization methods were used. The index was used to assess performance in service delivery in the North West province of South Africa, as well as its four districts over a five-year period (2013-2017). The index was validated by assessing associations with maternal health and other outcomes. And factor analysis was used to assess the statistical dimensions of the index.

Results: The provincial level index score increased from 62.3 in 2013 to 74 in 2017, showing general improvement in service delivery over time. The district level scores also improved over time, and our analysis identified areas for performance improvement. These include social determinants of health in some districts, and access and linkages to care in others. The provincial index was correlated with institutional maternal mortality rates (rs = -0.90, 90% CI = (-1.00, -0.25)) and the Human Development Index (r = 0.97, 95% CI = (0.63, 0.99). It was robust to alternative approaches including z-score standardization of indicators. Factor analysis showed three groupings of indicators for the health system and social determinants of health.

Conclusions: This study demonstrated the development and testing of a composite index to monitor and assess service delivery on the continuum of care for maternal health. The index was shown to be robust and valid, and identified potential areas for service improvement. A contextualised version can be tested in other settings within and outside of South Africa.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Delivery of Health Care / statistics & numerical data
  • Humans
  • Maternal Health / statistics & numerical data
  • Maternal Health Services / statistics & numerical data*
  • South Africa

Grants and funding

MM received funding to conduct this study. This work is based on the research supported by the South African Research Chairs Initiative of the Department of Science and Technology ( and National Research Foundation ( of South Africa (Grant No. 82769). MM would also like to acknowledge funding from the South African Medical Research Council( and the Belgian Development Cooperation, through the Institute of Tropical Medicine( Antwerp. Any opinion, finding and conclusion or recommendation expressed in this material is that of the authors and not the funders. The funders did not have a role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.