Access to health care, reproductive health and disability: a large scale survey in Sierra Leone

This is the first study to compare health status and access to health care services between disabled and non-disabled men and women in urban and peri-urban areas of Sierra Leone. It pays particular attention to access to reproductive health care services and maternal health care for disabled women. A cross-sectional study was conducted in 2009 in 5 districts of Sierra Leone, randomly selecting 17 clusters for a total sample of 425 households. All adults who were identified as being disabled, as well as a control group of randomly selected non-disabled adults, were interviewed about health and reproductive health. As expected, we showed that people with severe disabilities had less access to public health care services than non-disabled people after adjustment for other socioeconomic characteristics (bivariate modelling). However, there were no significant differences in reporting use of contraception between disabled and non-disabled people; contrary to expectations, women with disabilities were as likely to report access to maternal health care services as did non-disabled women. Rather than disability, it is socioeconomic inequality that governs access to such services. We also found that disabled women were as likely as non-disabled women to report having children and to desiring another child: they are not only sexually active, but also need access to reproductive health services. We conclude that disparity in access to government-supported health care facilities constitutes a major and persisting health inequity between persons with and without disabilities in Sierra Leone. Ensuring equal access will require further strengthening of the country's health care system. Furthermore, because the morbidity and mortality rates of pregnant women are persistently high in Sierra Leone, assessing the quality of services received is an important priority for future research.     

The quality of free antenatal and delivery services in Northern Sierra Leone

Background

The number of maternal deaths in sub-Saharan Africa continues to be overwhelmingly high. In West Africa, Sierra Leone leads the list, with the highest maternal mortality ratio. In 2010, financial barriers were removed as an incentive for more women to use available antenatal, delivery and postnatal services. Few published studies have examined the quality of free antenatal services and access to emergency obstetric care in Sierra Leone.

Methods

A cross-sectional survey was conducted in 2014 in all 97 peripheral health facilities and three hospitals in Bombali District, Northern Region. One hundred antenatal care providers were interviewed, 276 observations were made and 486 pregnant women were interviewed. We assessed the adequacy of antenatal and delivery services provided using national standards. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility, and the proportion of facilities in a chiefdom within 15 km of each CEOC facility was also calculated. A thematic map was developed to show inequities.

Results

The quality of services was poor. Based on national standards, only 27% of women were examined, 2% were screened on their first antenatal visit and 47% received interventions as recommended. Although 94% of facilities provided delivery services, a minority had delivery rooms (40%), delivery kits (42%) or portable water (46%). Skilled attendants supervised 35% of deliveries, and in only 35% of these were processes adequately documented. None of the five basic emergency obstetric care facilities were fully compliant with national standards, and the central and northernmost parts of the district had the least access to comprehensive emergency obstetric care.

Conclusion

The health sector needs to monitor the quality of antenatal interventions in addition to measuring coverage. The quality of delivery services is compromised by poor infrastructure, inadequate skilled staff, stock-outs of consumables, non-functional basic emergency obstetric care facilities, and geographic inequities in access to CEOC facilities. These findings suggest that the health sector needs to urgently investigate continuing inequities adversely influencing the uptake of these services, and explore more sustainable funding mechanisms. Without this, the country is unlikely to achieve its goal of reducing maternal deaths.

     

Assessing Indian public health standards for community health centers: a case study with special reference to essential newborn care services

The main objective of the study is to identify the availability of infrastructure facility, human resources, investigative services, and facility based newborn care services with respect to Indian Public Health Standards (IPHS) at community health centers (CHC) of Bharatpur District of Rajasthan State. Data were collected from service providers at CHC through well structured questionnaire at thirteen CHCs situated at Bharatpur District of Rajasthan State. It was found that infrastructure facilities were available in almost all the CHCs, but shortage of manpower especially specialists was observed. Availability of investigative services was found quite satisfactory except ECG. It was also observed that none of the CHCs have fully equipped facility based newborn care services (including newborn corner and newborn care stabilization unit). As per IPHS suggested in the revised draft (2010) important deficiencies were revealed in the studied CHCs of Bharatpur district and by additional inputs such as recruiting staff, improving infrastructure facilities, CHCs can be upgraded.     

Obstetric complications: does training traditional birth attendants make a difference?

OBJECTIVE: To assess the effect that a training intervention for traditional birth attendants (TBAs) in Guatemala had on the detection of obstetric complications, the referral of patients with complications to the formal health care system, and, ultimately, those patients' utilization of essential obstetric care services. METHODS: Using a quasi-experimental design, a surveillance system of births was implemented to collect population-based information from 3,518 women between 1990 and 1993. All women were interviewed postpartum by physicians. There were three key independent variables in our study: 1) geographical area (intervention community and non-intervention community), 2) time in relation to the training intervention (before or after), and 3) presence or absence of a TBA at the time of the complication. The key dependent variables for women interviewed were 1) development of an obstetric complication, 2) detection of the problem by the TBA, 3) referral to a health facility, 4) compliance with referral, and 5) use of services. RESULTS: The incidence of postpartum complications decreased after the intervention, controlling for intervention community. On the other hand, after the intervention TBAs were less likely to recognize most maternal complications, and referral rates did not increase significantly. The likelihood of using health care services increased six-fold among women who were not attended by TBAs, and no increase was observed among those who were attended by TBAs. CONCLUSION: Training TBAs may have had a positive effect on the rate, detection, and referral of postpartum complications. However, the evidence is less convincing for overall increases in the detection of complications, in referral to the formal health care system, and in the utilization of essential obstetric services among women attended by TBAs.     

Barriers to Formal Emergency Obstetric Care Services’ Utilization

Access to appropriate health care including skilled birth attendance at delivery and timely referrals to emergency obstetric care services can greatly reduce maternal deaths and disabilities, yet women in sub-Saharan Africa continue to face limited access to skilled delivery services. This study relies on qualitative data collected from residents of two slums in Nairobi, Kenya in 2006 to investigate views surrounding barriers to the uptake of formal obstetric services. Data indicate that slum dwellers prefer formal to informal obstetric services. However, their efforts to utilize formal emergency obstetric care services are constrained by various factors including ineffective health decision making at the family level, inadequate transport facilities to formal care facilities and insecurity at night, high cost of health services, and inhospitable formal service providers and poorly equipped health facilities in the slums. As a result, a majority of slum dwellers opt for delivery services offered by traditional birth attendants (TBAs) who lack essential skills and equipment, thereby increasing the risk of death and disability. Based on these findings, we maintain that urban poor women face barriers to access of formal obstetric services at family, community, and health facility levels, and efforts to reduce maternal morbidity and mortality among the urban poor must tackle the barriers, which operate at these different levels to hinder women's access to formal obstetric care services. We recommend continuous community education on symptoms of complications related to pregnancy and timely referral. A focus on training of health personnel on “public relations” could also restore confidence in the health-care system with this populace. Further, we recommend improving the health facilities in the slums, improving the services provided by TBAs through capacity building as well as involving TBAs in referral processes to make access to services timely. Measures can also be put in place to enhance security in the slums at night.     

Quality of Care for Maternal and Newborn Health in Health Facilities in Nepal

Introduction

Nepal has pledged to substantially reduce maternal and newborn death by 2030. Improving quality of intrapartum health services will be vital to reduce these deaths. This paper examines quality of delivery and newborn services in health facilities of Nepal.

Methods

Data were sourced from the Nepal Health Facility Survey 2015, which covered a national representative sample of health facilities. The datasets were analysed to assess service readiness, availability and quality of delivery and newborn care in a sample of 992 health facilities.

Results

Of the 992 facilities in the sample, 623 provided delivery and newborn care services. Of the 623 facilities offering delivery and newborn care services, 13.3% offered comprehensive emergency obstetric care (CEmONC), 19.6% provided basic emergency obstetric care (BEmONC) and 53.9% provided basic delivery and newborn service. The availability of essential equipment for delivery and newborn care was more than 80% in health facilities. Except for the coverage of vitamin K injection, the coverage of immediate newborn care was more than 85% in all health facilities. The coverage of use of chlorhexidine ointment to all newborns was more than 70% in government hospitals and primary health care centers (PHCCs) and only 32.3% in private hospitals.

Conclusions

These findings show gaps in equipment and drugs, especially in PHCCs and private health facilities. Improving readiness and availability of equipment and drugs in PHCCs and private health facility will help improve the quality of care to further reduce maternal and newborn mortality in Nepal.

     

Influence of Distance to Health Facilities on the Use of Skilled Attendants at Birth in Kenya

We sought to determine the spatial variation in the use of skilled providers during deliveries across Kenya and the relationship between distance to health facilities and the use of skilled delivery. We found that women who resided 5 km or less from the nearest health facility were more likely to use skilled care at delivery than women residing at greater distances, although the pattern of choice of health facility level for delivery differed at this distance. Outreach maternity services are urgently required in counties with remote communities in order to improve access to skilled attendants during deliveries in these areas.     

Implementing and Evaluating a Telephone-Based Centralized Maternity Care Coordination Program for Pregnant Veterans in the Department of Veterans Affairs

PurposeThe purpose of this study was to develop and evaluate a comprehensive, telephonic maternity care coordination (MCC) program for all pregnant veterans enrolled for care at New England Department of Veterans Affairs (VA) facilities that comprise the Veterans Integrated Service Network 1.Research DesignTelephone interviews were conducted with postpartum women veterans who had participated in the MCC program during their pregnancies. The program evaluation instrument assessed satisfaction and use of MCC services, prenatal education classes, and infant and maternal outcomes (e.g., newborn birthweight, insurance status, maternal depression) using both closed-ended and open-ended questions.ResultsA substantial majority (95%) of women enrolled in the MCC program expressed satisfaction with the services they received in the program. Women were most satisfied with help understanding VA maternity benefits and acquiring VA services and equipment, such as breast pumps and pregnancy-related medications. More than one-third of women noted their infants had experienced health problems since delivery, including neonatal intensive care unit hospitalizations. A majority of women planned to return to VA care in the future.ConclusionsOur findings suggest that MCC services play an important role for women veterans as they navigate both VA and non-VA care systems. MCC staff members coordinated maternity, medical, and mental health care services for women veterans. Additionally, by maintaining contact with the veteran during the postpartum period, MCC staff were able to assess the health of the mother and the infant, and refer women and their infants to medical and psychosocial services in the community as needed.     

Maternal and neonatal service delivery by traditional birth attendants in rural Benin: A case for integration?

ABSTRACT

The Republic of Benin faces high maternal, newborn and child (MNCH) morbidity and mortality. Traditional birth attendants (TBAs) continue to operate on the margins of the health system yet provide critical services to women and children. This study aims to further the understanding of TBA’s scope of practice for developing appropriate strategies to strengthen MNCH services at the community-level. TBAs were identified and surveyed on education, training, system support and scope of practice including management of obstetric and newborn emergencies. TBAs were found to perform diverse preventive and health promotion activities, including antenatal and newborn care counselling, promotion of family planning and immunizations. Among 109 TBAs, 11,102 births were documented in the prior year with a maternal mortality ratio (MMR) of 790/100,000 and neonatal mortality rate (NMR) 12.2/1000. The scope of TBA practices is broad and rural communities rely on this cadre for services. However, TBAs report higher rates of adverse maternal events compared to national statistics. Better understanding is needed on community preferences, training and methods of participation of TBAs within the health system. This could improve identification and referral for emergencies, reinforce safer practices and increase preventive and promotive health activities at the community level.     

Perceived quality of and access to care among poor urban women in Kenya and their utilization of delivery care: harnessing the potential of private clinics?

This paper uses data from a maternal health study carried out in 2006 in two slums of Nairobi, Kenya, to: describe perceptions of access to and quality of care among women living in informal settlements of Nairobi, Kenya; quantify the effects of women's perceived quality of, and access to, care on the utilization of delivery services; and draw policy implications regarding the delivery of maternal health services to the urban poor. Based on the results of the facility survey, all health facilities were classified as 'appropriate' or 'inappropriate'. The research was based on the premise that despite the poor quality of these maternal health facilities, their responsiveness to the socio-cultural and economic sensitivities of women would result in good perceptions and higher utilization by women. Our results show a pattern of women's good perceptions in terms of access to, and quality of, health care provided by the privately owned, sub-standard and often unlicensed clinics and maternity homes located within their communities. In the multivariate model, the association between women's perceptions of access to and quality of care, and delivery at these 'inappropriate' facilities remained strong, graded and in the expected direction. Women from the study area are seldom able to reach not-for-profit private providers of maternal health care services like missionary and non-governmental organization (NGO) clinics and hospitals. Against the backdrop of challenges faced by the public sector in health care provision, we recommend that the government should harness the potential of private clinics operating in urban, resource-deprived settings. First, the government should regulate private health facilities operating in urban slum settlements to ensure that the services they offer meet the acceptable minimum standards of obstetric care. Second, 'good' facilities should be given technical support and supplied with drugs and equipment.     

Addressing health system barriers to access to and use of skilled delivery services: perspectives from Ghana

Poor access to and use of skilled delivery services have been identified as a major contributory factor to poor maternal and newborn health in sub‐Saharan African countries, including Ghana. However, many previous studies that examine norms of childbirth and care‐seeking behaviours have focused on identifying the norms of non‐use of services, rather than factors, that can promote service use. Based on primary qualitative research with a total of 185 expectant and lactating mothers, and 20 healthcare providers in six communities in Ghana, this paper reports on strategies that can be used to overcome health system barriers to the use of skilled delivery services. The strategies identified include expansion and redistribution of existing maternal health resources and infrastructure, training of more skilled maternity caregivers, instituting special programmes to target women most in need, improving the quality of maternity care services provided, improving doctor–patient relationships in maternity wards, promotion of choice, protecting privacy and patient dignity in maternity wards and building partnerships with traditional birth attendants and other non‐state actors. The findings suggest the need for structural changes to maternity clinics and routine nursing practices, including an emphasis on those doctor–patient relational practices that positively influence women's healthcare‐seeking behaviours. Copyright © 2015 John Wiley & Sons, Ltd.     

Improving poor women's access to maternity care: Findings from a primary care intervention in Burkina Faso

To date, there has been little progress in reducing wealth inequities in access to maternity care. This paper describes the results of a maternal health intervention in Burkina Faso that was aimed at increasing access to skilled maternity care by improving availability and quality of maternity care, particularly at primary care health facilities, and promoting its use before, during, and after delivery. Post-intervention data show a large overall increase in use of facility-based maternity care in the intervention district, particularly at primary care facilities, but little change in the comparison district. In addition, large wealth inequities in the use of professional care during childbirth were almost eliminated in the intervention district while they increased in the comparison district—both among all women, and among the subset of women who reported experiencing complications during delivery. Study results suggest that efforts to upgrade maternity services at primary care facilities may be key for improving poor women's access to and use of skilled care during childbirth.     

Factors influencing choice of delivery sites in Rakai district of Uganda

In order to understand factors influencing choice of delivery sites in Rakai district of south-western Uganda, eight focus group discussions based on the Attitudes-Social influence-Self efficacy model were held with 32 women and 32 men. Semi-structured interviews were also held with 211 women from 21 random cluster samples who had a delivery in the previous 12 months (from 2 June 1997). Forty four percent of the sample delivered at home, 17% at traditional birth attendant's (TBA) place, 32% at public health units, and 7% at private clinics. Among the factors influencing choice of delivery site were: access to maternity services; social influence from the spouse, other relatives, TBAs and health workers; self-efficacy; habit (previous experience) and the concept of normal versus abnormal pregnancy. Attitudinal beliefs towards various delivery sites were well understood and articulated. Attendance of ante-natal care may discourage delivery in health units if the mothers are told that the pregnancy is normal. In order to make delivery safer, there is need to improve access to maternity services, train TBAs and equip them with delivery kits, change mother's self-efficacy beliefs, and involve spouses in education about safe delivery.     

Availability, distribution and use of emergency obstetric care in northern Tanzania

The objective of this study is to determine the availability, distribution and quality of facilities providing delivery services, as well as their use by pregnant women. The study is a survey of all facilities providing delivery services (n = 129) in six districts in northern Tanzania. The framework provided by the UNICEF/UNFPA/WHO (UN) Guidelines is applied. An attempt is made to answer the first three questions in this audit outline: are there enough emergency obstetric care (EmOC) facilities? Are they well distributed? And are enough women using them? The results show that there is a very low availability of basic emergency obstetric care (BEmOC) units (1.6/500,000), and a relatively high availability of comprehensive emergency obstetric care (CEmOC) units (4.6/500,000), both with large urban/rural variation. The percentage of expected deliveries in EmOC facilities is 36%, compared with the UN Guidelines minimum accepted threshold of 15%. Nevertheless, the distribution shows a much higher utilization in urban districts compared with rural, indicating that mothers have to travel long distances to receive adequate services when in need of them. The paper also discusses the provisional context of the services in terms of level of facilities providing them and their public/private mix. Most facility deliveries are conducted at CEmOC facilities. Pregnant women tend to utilize the services of voluntary agencies to a greater degree than government services in rural areas, while the government services have a higher burden of the workload in urban areas. A majority (86%) of the deliveries occurring in voluntary agency facilities occur in a qualified EmOC facility. Against a backdrop of a large availability of any facility regardless of their emergency obstetric care status (41.9/500,000), this paper argues that given the large number of potential BEmOC facilities, it seems more efficient to shift resources within the BEmOC level, compared with from CEmOC level down to BEmOC level, to improve access to quality services. There is a large potential for quality improvement, in particular at dispensary and health centre levels. We argue that the main barrier to access to quality care is not the mother's ignorance or their ability to get to a facility, but the actual quality of care meeting them at the facility.     

The state of motherhood in Sierra Leone

Barely 50% of births in Sierra Leone are attended by trained medical personnel, and an even smaller proportion of prospective mothers receive antenatal care. This absence of obstetric, antenatal, and postnatal services in many areas of the country makes motherhood in the country far from safe. The maternal mortality rate in many parts of Sierra Leone is estimated to be as high as 8.5 deaths per 1000 live births, or to constitute an almost one in eighteen lifetime risk of death from pregnancy-related causes. Infant mortality is currently 148 deaths per 1000 live births and of those children surviving beyond infancy, a further 200 die before reaching five years old. Marie Stopes International (MSI) has been working in Sierra Leone since 1986 through its local partner nongovernmental organization (NGO), the Marie Stopes Society, Sierra Leone (MSSSL), building a network of five clinic centers across the country. MSSSL has found that a complex set of cultural and social beliefs form a major obstacle to the treatment of obstetric emergencies in Sierra Leone. For example, the local definition of pregnancy complications may not include labor lasting as long as 48 hours. When complications are recognized, their cause is often defined as natural instead of medical. These and other factors like the lack of transport and inadequacy of resources in many facilities result in significant delays in the provision of emergency obstetric services. MSSSL trains traditional birth attendants to understand these issues and recognize complications when they develop, referring women for effective treatment when appropriate. The organization has also initiated a variety of community outreach projects to influence the status of modern obstetric care, including male awareness programs with family planning counseling and services. The MSSSL experience demonstrates how effectively an NGO can work within the framework of a national safe motherhood initiative.     

Perinatal care: The Kuranko context of choice

The ethnomedical aspects of childbirth and factors that influence Kuranko women in the northern Sierra Leone center of Kabala (a multiethnic town of some 15,000 inhabitants) in making decisions regarding perinatal care are the focus of this article. I found that Kuranko women develop perinatal care strategies from services available in the formal and informal health‐care sectors. The discussion is situated within a context that values primary health care and health promotion and advocates the use of these frameworks in ways that are informed by Kuranko social organization and concepts of development.     

District allocation and utilization of health care services in Pau da Lima, Salvador, Bahia, Brazil

This cross-sectional study is aimed at the identification of patterns in the utilization of health care services in Pau da Lima, a neighborhood in the city of Salvador, Bahia. In 1992, a household survey was carried out with 384 families selected through a random cluster sampling design. In each household, the family head or a surrogate informant was asked to answer a questionnaire about their use of any type of health care in the last month. From the total of 1,887 individuals, 236 reported at least one visit to health facilities during the referent period This means an estimated prevalence of health services utilization of 12.5%. With regard to the type of services, 25.9% of all visits were made to public sector facilities. Attendants were mainly women (73.7%) from 15 to 29 years of age. The main reason reported for the choice of the health facility was availability (63.7%), and the major reason for seeking health care was disease-related conditions (75.7%), rather than preventive procedures. These findings may result from the still unfinished process of distritaliza??o(district allocation of services), which is evident in the lack of health services' infrastructure or coverage, as well as in persistent organizational problems. These issues may lead the population living in the respective district to seek health care outside the assigned catchment area. The authors discuss these findings in the context of the expansion of the private sector in the health area and the financial collapse of the public budget in Brazil.     

Rebuilding people-centred maternal health services in post-Ebola Liberia through participatory action research

During the March 2014–January 2016 Ebola crisis in Liberia, Redemption Hospital lost 12 staff and became a holding facility for suspected cases, prompting violent hostility from the surrounding New Kru Town community, in the capital city Monrovia. Inpatient services were closed for 6 months, leaving the population without maternity care. In January 2015, Redemption reopened, but utilization was low, especially for deliveries. A key barrier was community trust in health workers which worsened during the epidemic. The New Kru Town council, Redemption Hospital, the International Rescue Committee, and Training and Research Support Centre initiated participatory action research (PAR) in July 2015 to build communication between stakeholder groups, and to identify impacts of the epidemic and shared actions to improve the system. The PAR involved pregnant women, community-based trained traditional midwives (TTMs) and traditional birth attendants (TBAs), and community leaders, as well as health workers. Qualitative data and a pre-post survey of PAR participants and community members assessed changes in relationships and maternal health services. The results indicated that Ebola worsened community-hospital relations and pre-existing weaknesses in services, but also provided an opportunity to address these when rebuilding the system through shared action. Findings suggest that PAR generated evidence and improved communication and community and health worker interaction.