Client and staff views on facilities and services, before and after the convergence of sexual, reproductive and women's services.

OBJECTIVE: To evaluate client and staff views on existing facilities and services, before and after the convergence of sexual, reproductive and women's services. METHODS: Evaluation involved questionnaire survey of clients and staff, one-to-one interviews with staff and review of routinely collected clinical activity data. RESULTS: The integration of the three services led to a reduction in stigma associated with attending sexual health services. Despite some staff concerns, the number of men attending the services did not decrease. There was increased satisfaction with the new service, especially the quality of facilities. There were increased numbers of referrals between clinical services in the Sandyford Initiative. CONCLUSIONS: Sexual, reproductive and women's services can be integrated to provide improved facilities for clients.     

The role of the Standard Days Method in modern family planning services in developing countries

Background: The mere availability of family planning (FP) services is not sufficient to improve reproductive health; services must also be of adequate quality. The introduction of new contraceptive methods is a means of improving quality of care. The Standard Days Method (SDM) is a new fertility-awareness-based contraceptive method that has been successfully added to reproductive health care services around the world. CONTENT: Framed by the Bruce-Jain quality-of-care paradigm, this paper describes how the introduction of SDM in developing country settings can improve the six elements of quality while contributing to the intrinsic variety of available methods. SDM meets the needs of women and couples who opt not to use other modern methods. SDM providers are sensitised to the potential of fertility-awareness-based contraception as an appropriate choice for these clients. SDM requires the involvement of both partners and thus offers a natural entry point for providers to further explore partner communication, intimate partner violence, condoms, and HIV/STIs. CONCLUSION: SDM introduction broadens the range of FP methods available to couples in developing countries. SDM counselling presents an opportunity for FP providers to discuss important interpersonal and reproductive health issues with potential users.     

Quality of family planning services at primary care facilities in an urban area of East Azerbaijan, Iran.

OBJECTIVE: To determine the quality of family planning (FP) services at primary care facilities in Tabriz, Iran, and to identify areas for improvement. METHODS: Structured observations of 469 client-provider interactions and some clinical procedures at 34 facilities. Exit interviews with 416 of the observed clients. RESULTS: The providers treated the clients respectfully in more than 80% of the consultations and discussed a return visit in 89%. Privacy was not assured in one-third of the cases. Over two-thirds of the clients were not encouraged to ask questions or raise concerns, and 54% were not satisfied with the amount of information given. The use of educational audio-visual and printed materials was very infrequent. Reported waiting time was less than 30 minutes in 89%. Most new clients received their preferred contraceptive method, but were informed about neither other available methods, nor common side effects and warning symptoms due to the chosen method. Provider performance in some clinical procedures, such as the implementation of hand hygiene, was insufficient. CONCLUSIONS: All elements of the FP services need improvement. Special attention should be paid to interactive communication, information given to clients, privacy and confidentiality, as well as to infection prevention procedures. Multifaceted interventions seem necessary to improve the quality.     

Barriers to high-quality primary reproductive health services in an urban area of Iran: views of public health providers

Objective

to explore public primary reproductive health providers’ views on their own roles and tasks in their present organisation, and the perceived barriers to providing high-quality services.

Design

a qualitative approach using semi-structured, audio-taped focus group discussions (FGDs). The discussions were held in Farsi or Turkish, transcribed verbatim, translated into English and analysed using content analysis.

Setting

family health units of public health facilities, Tabriz, Iran.

Participants

two FGDs with 12 midwives and two FGDs with eight other family health providers working at the facilities.

Findings

the providers identified the most satisfying part of their duties as working with clients. A dominant theme in all FGDs was the providers’ frustration about a number of factors, most of which were beyond their control. The identified system and organisational barriers were grouped into five categories: multiplicity of tasks and incompatibility with the providers’ own basic training; suboptimal supervision and management; too little time for clients; lack of privacy and appropriate materials for education and counselling; and inadequate opportunities for continuing education.

Key conclusions

this study highlighted the providers’ satisfaction in working with clients, and their dissatisfaction with not being used to the best of their capabilities due to a number of systemic and organisational barriers.

Implications for practice

based on these findings, multifaceted interventions seem to be necessary to improve staff productivity and service quality. The interventions should include needs-based pre-service education, supportive supervision and management, provision of educational materials, simplifying record management, and appointing more staff in socio-economically deprived areas. Research is needed to identify the best way to integrate the services, as well as basic and continuing educational needs of staff.     

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Abstract

Background The mere availability of family planning (FP) services is not sufficient to improve reproductive health; services must also be of adequate quality. The introduction of new contraceptive methods is a means of improving quality of care. The Standard Days Method (SDM) is a new fertility-awareness-based contraceptive method that has been successfully added to reproductive health care services around the world.

Content Framed by the Bruce-Jain quality-of-care paradigm, this paper describes how the introduction of SDM in developing country settings can improve the six elements of quality while contributing to the intrinsic variety of available methods. SDM meets the needs of women and couples who opt not to use other modern methods. SDM providers are sensitised to the potential of fertility-awareness-based contraception as an appropriate choice for these clients. SDM requires the involvement of both partners and thus offers a natural entry point for providers to further explore partner communication, intimate partner violence, condoms, and HIV/STIs.

Conclusion SDM introduction broadens the range of FP methods available to couples in developing countries. SDM counselling presents an opportunity for FP providers to discuss important interpersonal and reproductive health issues with potential users.     

Reproductive health services in Malawi: an evaluation of a quality improvement intervention

Objective

this study was to evaluate the impact of a quality improvement initiative in Malawi on reproductive health service quality and related outcomes.

Design

(1) post-only quasi-experimental design comparing observed service quality at intervention and comparison health facilities, and (2) a time-series analysis of service statistics.

Setting

sixteen of Malawi's 23 district hospitals, half of which had implemented the Performance and Quality Improvement (PQI) intervention for reproductive health at the time of the study.

Participants

a total of 98 reproductive health-care providers (mostly nurse–midwives) and 139 patients seeking family planning (FP), antenatal care (ANC), labour and delivery (L&;D), or postnatal care (PNC) services.

Intervention

health facility teams implemented a performance and quality improvement (PQI) intervention over a 3-year period. Following an external observational assessment of service quality at baseline, facility teams analysed performance gaps, designed and implemented interventions to address weaknesses, and conducted quarterly internal assessments to assess progress. Facilities qualified for national recognition by complying with at least 80% of reproductive health clinical standards during an external verification assessment.

Measurements

key measures include facility readiness to provide quality care, observed health-care provider adherence to clinical performance standards during service delivery, and trends in service utilisation.

Findings

intervention facilities were more likely than comparison facilities to have the needed infrastructure, equipment, supplies, and systems in place to offer reproductive health services. Observed quality of care was significantly higher at intervention than comparison facilities for PNC and FP. Compared with other providers, those at intervention facilities scored significantly higher on client assessment and diagnosis in three service areas, on clinical management and procedures in two service areas, and on counselling in one service area. Service statistics suggest that the PQI intervention increased the number of Caesarean sections, but showed no impact on other indicators of service utilisation and skilled care.

Conclusions

the PQI intervention showed a positive impact on the quality of reproductive health services. The effects of the intervention on service utilisation had likely not yet been fully realized, since none of the facilities had achieved national recognition before the evaluation. Staff turnover needs to be reduced to maximise the effectiveness of the intervention.

Implications for practice

the PQI intervention evaluated here offers an effective way to improve the quality of health services in low-resource settings and should continue to be scaled up in Malawi.     

The role of MCH and family planning services in HIV/STD control: is integration the answer?

During the mid 1990s, high HIV and sexually transmitted disease (STD) prevalence led to calls for the integration of effective services with maternal and child health and family planning (MCH/FP) programs. There are advantages and disadvantages to integration, but little evidence existed to assess the practicalities of implementing this policy. Analysis of policy development for integration was conducted in Ghana, Kenya, South Africa, and Zambia. Semi-structured interviews were conducted with policy-makers at national, provincial and district levels and a survey of facilities was undertaken to identify gaps between policy intent and implementation. Significant advances had been made at the national level to formulate policies to integrate reproductive health and primary health care. However, barriers to implementation included entrenched HIV/STD and MCH/FP vertical programs; diverse demands on district managers and providers, such as on-going institutional reform; and conflicting objectives of international donors. Policy-makers need to address conflicting objectives between the needs for vertical accountability and the reality of providing integrated services. More careful consideration of implementation is required at earlier stages of policy design. Increased consultation with those who are to implement and provide integrated services is recommended.     

Confidentiality for adolescents seeking reproductive health care in Lithuania: the perceptions of general practitioners

Confidentiality is a major determinant of the accessibility and acceptability of sexual and reproductive health care for adolescents. Previous research has revealed that Lithuanian adolescents lack confidence in guarantees of confidentiality in primary health care settings. This study aimed to assess the factors that affect general practitioners' decisions whether to respect confidentiality for Lithuanian adolescents under the age of 18. Twenty in-depth interviews were carried out with a purposive sample of general practitioners. The decision whether to respect confidentiality was found to be influenced by external forces, including the legislative framework and societal attitudes towards adolescent sexuality; institutional features in clinical facilities, such as the presence of a nurse during consultations and the openness of the medical record filing system; and individual factors, including GPs' relationships with adolescents' families and their personal attitudes towards sexual and reproductive health issues. The findings reflect the urgent need for a comprehensive policy to ensure adolescents' right to confidentiality in Lithuanian primary care settings, including legislative reforms, institutional changes in health care settings, professional guidelines and (self-)regulation, and changes in medical training and continuing medical education. Other ways to safeguard confidentiality in adolescent health services, such as establishing youth clinics, should also be explored.     

Nurse-midwives' attitudes towards adolescent sexual and reproductive health needs in Kenya and Zambia

Adolescent sexuality is a highly charged moral issue in Kenya and Zambia. Nurse-midwives are the core health care providers of adolescent sexual and reproductive health services but public health facilities are under-utilised by adolescents. The aim of this study was to investigate attitudes among Kenyan and Zambian nurse-midwives (n=820) toward adolescent sexual and reproductive health problems, in order to improve services for adolescents. Data were collected through a questionnaire. Findings revealed that nurse-midwives disapproved of adolescent sexual activity, including masturbation, contraceptive use and abortion, but also had a pragmatic attitude to handling these issues. Those with more education and those who had received continuing education on adolescent sexuality and reproduction showed a tendency towards more youth-friendly attitudes. We suggest that critical thinking around the cultural and moral dimensions of adolescent sexuality should be emphasised in undergraduate training and continuing education, to help nurse-midwives to deal more empathetically with the reality of adolescent sexuality. Those in nursing and other leadership positions could also play an important role in encouraging wider social discussion of these matters. This would create an environment that is more tolerant of adolescent sexuality and that recognises the beneficial public health effect for adolescents of greater access to youth-friendly sexual and reproductive health services.     

Menstrual regulation in Bangladesh: an evaluation of training and service programs

This article evaluates the performance of three urban menstrual regulation (MR) training and service programs in Bangladesh. Virtually all of the MR providers including physicians and paramedics in the three centers received training in various MR procedures by means of demonstration or class lectures. However, a significant proportion of the trained MR providers were unable to render proper MR services due to the lack of clinical facilities and lack of equipment. Analysis of follow-up data for MR clients revealed that those women who utilized MR procedures offered through the centers had an average of about three live births. Physician providers were more likely to serve clients from a higher socioeconomic strata, while paramedical providers were more likely to serve MR clients from lower socioeconomic strata or agricultural background. Most of the clients receiving MR services were ever and current users of contraceptives and developed fewer complications from MR procedures than those served by untrained traditional herbalists, healers or birth attendants.     

Focus on women: linking HIV care and treatment with reproductive health services in the MTCT-Plus Initiative

Despite important advances in expanding access to antiretroviral therapy in the countries most heavily affected by HIV/AIDS, there has been little consideration of the connections between HIV prevention, care and treatment programmes and reproductive health services. In this paper, we explore the integration of reproductive health services into HIV care and treatment programmes. We review the design and progress of the MTCT-Plus Initiative, which provides HIV care and treatment services to HIV positive women as well as their HIV positive children and partners. By emphasising the long-term follow-up of families and the provision of comprehensive care across the spectrum of HIV disease, MTCT-Plus highlights the potential synergies in linking reproductive health services to HIV care and treatment programmes. While HIV care and treatment programmes in resource-limited settings may not be able to integrate all reproductive health services into a single service delivery model, there is a clear need to include basic reproductive health services, such as access to appropriate contraception and counselling and management of unplanned pregnancies. The integration of these services would be facilitated by greater insight into the reproductive choices of HIV positive women and men, and into how health care providers influence access to reproductive health services of people with HIV and AIDS.     

Providing safe abortion services: Experiences and perspectives of providers in South Africa

Despite abortion being legally available on request up to and including the gestational age of 12 weeks in South Africa, barriers to access remain. Barriers include provider opposition to abortion and a shortage of trained and willing providers, which has implications for access to safe abortion services. Exploring the factors that determine providers’ levels of involvement in abortion services can facilitate improvements in service provision.Providers' conceptualizations of abortion are influenced by numerous factors, including moral and religious views, in which abortion is perceived by some as a sin, whereas others view access to safe abortions as an important component of a woman's right to reproductive autonomy and choice.Barriers to service provision include limited abortion and values clarification training and misinterpretation of conscientious objection. Providers have difficulties with the emotional and visual impact of second trimester abortions.There is an urgent need to address provider shortage, and abortion education and training need to be included in medical and nursing curricula to ensure sustaining abortion services.     

Characteristics of private abortion services in Mexico City after legalization

In 2007, first trimester abortion was legalized in Mexico City, and the public sector rapidly expanded its abortion services. In 2008, to obtain information on the effect of the law on private sector abortion services, we interviewed 135 physicians working in private clinics, located through an exhaustive search. A large majority of the clinics offered a range of reproductive health services, including abortions. Over 70% still used dilatation and curettage (D&C); less than a third offered vacuum aspiration or medical abortion. The average number of abortions per facility was only three per month; few reported more than 10 abortions monthly. More than 90% said they had been offering abortion services for less than 20 months. Many women are still accessing abortion services privately, despite the availability of free or low-cost services at public facilities. However, the continuing use of D&C, high fees (mean of $157-505), poor pain management practices, unnecessary use of ultrasound, general anaesthesia and overnight stays, indicate that private sector abortion services are expensive and far from optimal. Now that abortions are legal, these results highlight the need for private abortion providers to be trained in recommended abortion methods and quality of private abortion care improved.     

Knowledge about emergency contraception among family-planning providers in urban Ghana

Objective

To assess the theoretical and practical knowledge about emergency contraception (EC) among family-planning (FP) providers in Ghana and to examine the association between FP providers’ theoretical and practical knowledge.

Methods

Data on 600 FP providers were collected through a census of facilities offering FP services in Kumasi, Ghana, in 2008. Nested linear multivariate regression analysis was used to identify sociodemographic, facility-related, and work-related variables associated with FP providers’ theoretical and practical knowledge about EC.

Results

On average, FP providers gave 4.1 correct answers to the 11 questions assessing theoretical knowledge and 5.6 correct answers to the 8 questions assessing their practical ability to provide EC. The FP providers seemed to learn provision-related aspects through practice without having a particularly good theoretical knowledge on EC as a contraceptive method. The health sector in which FP providers worked, their education and having received EC-specific training, the number of services offered, and the number of women seen during a week were all significant correlates of both theoretical and practical knowledge about EC. The 2 knowledge domains were significantly and positively associated.

Conclusion

There is need to improve knowledge about EC among FP providers in Ghana through in-service training.     

The MOM Project: delivering maternal health services among internally displaced populations in eastern Burma

Alternative strategies to increase access to reproductive health services among internally displaced populations are urgently needed. In eastern Burma, continuing conflict and lack of functioning health systems render the emphasis on facility-based delivery with skilled attendants unfeasible. Along the Thailand-Burma border, local organisations have implemented an innovative pilot, the Mobile Obstetric Maternal Health Workers (MOM) Project, establishing a three-tiered collaborative network of community-based reproductive health workers. Health workers from local organisations received practical training in basic emergency obstetric care plus blood transfusion, antenatal care and family planning at a central facility. After returning to their target communities inside Burma, these first-tier maternal health workers trained a second tier of local health workers and a third tier of traditional birth attendants (TBAs) to provide a limited subset of these interventions, depending on their level of training. In this ongoing project, close communication between health workers and TBAs promotes acceptance and coverage of maternity services throughout the community. We describe the rationale, design and implementation of the project and a parallel monitoring plan for evaluation of the project. This innovative obstetric health care delivery strategy may serve as a model for the delivery of other essential health services in this population and for increasing access to care in other conflict settings.     

Delivering maternal health care services in an internal conflict setting in Maguindanao, Philippines

To improve access to maternal health care and family planning services in conflict-stricken Maguindanao province, southern Philippines, several non-governmental organisations have begun collaborating with local public health services. This exploratory study describes the experiences of local government service providers and two NGOs in a context of long-standing internal armed conflict, how and to what extent provision has been affected by the conflict and what has been done to overcome its effects. It is based on interviews with six health service coordinators and providers. Local government-NGO partnership takes the form of giving NGOs space in government health care facilities and receiving from them critical supplies, personnel and contraceptives. Service delivery structures have generally been spared from direct attacks by the parties involved locally in armed conflict due to the perceived benefits of their services, including for rebels and their families, their neutral stance and willingness to treat everyone. However, they do suffer from occasional disruption and kidnappings and need to seek protection from local leaders. When mass evacuation is required providers follow displaced families to evacuation points to ensure they continue to get services. Collaboration for maternal health care provision is recent, but the planned expansion of NGO projects will help it to evolve.     

The sexual and reproductive health care market in Bangladesh: where do poor women go?

In Bangladesh, the formal public health system provides few services for common sexual and reproductive health problems such as white discharge, fistula, prolapse, menstrual problems, reproductive and urinary tract infections, and sexual problems. Recent research has found that poor women and men resort to informal providers for these problems instead. This paper draws on interviews with 303 providers and 312 women from two rural and one urban area of Bangladesh from July 2008 to January 2009. Both informal and formal markets played an important role in treating these problems, including for the poor, but the treatments were often unlikely to resolve the problems. Providers ranged from village doctors without formal training to qualified private practitioners. The health system is heavily marketised and boundaries between “public” and “private” are blurred. There exists a huge, neglected domain of sexual and reproductive health needs which are a source of silent suffering and for which there are no trained health staff providing treatment in government facilities. The complexity of this situation calls for engaged debate in Bangladesh on how to improve the quality of existing services, discourage or prevent obviously harmful practices, and develop financing mechanisms to enable women to access effective treatment, regardless of the source, for these neglected problems.     

Integration of cervical screening in family planning clinics.

OBJECTIVES: To assess the suitability of cervical cancer screening in family planning (FP) clinics and the relevance for women's health. METHODS: A survey was done on clients visiting the clinics of the Family Planning Association of Kenya (FPAK). Client characteristics, age, screening status and PAP smear results were registered. In-depth interviews were held with a limited number of staff and clients. RESULTS: In 1999, 38052 clients visited FPAK clinics, 43.5% were younger than 30 years old. More than 10000 cervical smears were taken. A total of 4.5% of the smears were abnormal, including 1.5% high-grade squamous intraepithelial lesions (HSIL) and 0.2% invasive cancers. The clinics were well prepared to provide high quality screening services. Patients and staff had a positive view on screening. CONCLUSIONS: Providing cervical cancer screening in FP clinics is beneficial for the clients but is unlikely to have an impact on the epidemiology of cervical cancer morbidity as FP services reach only a small percentage of the women who are most at risk. Measures to reach more and older women could assure a larger impact.     

An assessment of postabortion care in three regions in Ethiopia, 2000 to 2004.

OBJECTIVE: To assess postabortion care services in 3 regions in Ethiopia following provider training and service improvements between 2000 and 2004. METHODS: Data on availability and quality of services were collected at 119 facilities in 3 regions of Ethiopia before and after postabortion care (PAC) provider training in 42 of the sites; supervision, supplies, and equipment were also provided. Changes over time, changes attributable to the training intervention, and overall self-reported improvements in PAC were assessed for outcomes of interest, including availability of uterine evacuation services, postabortion contraceptive methods and supply availability (including manual vacuum aspiration [MVA]), and minimum-skilled providers. RESULTS: Between 2000 and 2004, the capacity for offering uterine evacuation increased from 57% to 79% among intervention facilities, while remaining relatively constant among the comparison facilities. The training intervention was significantly associated with improvements in the availability and use of MVA, the availability of a minimum number of skilled providers and availability of postabortion contraceptive services. The proportion of uterine evacuation procedures performed with MVA increased among comparison facilities, but increased even more among intervention facilities, from 14% to 50% of procedures. CONCLUSIONS: Training and supporting providers in comprehensive PAC effectively improve women's access to PAC services in Ethiopia, but more attention must be paid to training midlevel providers, extending services into health centers, pain management, and provision of postabortion contraceptives.