Introducing client-centered reproductive health services in a Pakistani setting

Pakistan is a high-fertility country with elevated levels of maternal mortality and unmet need for family planning. Limited access to and poor quality of reproductive health services and gender-related problems comprise the major explanations for these poor indicators. The authors designed an intervention to address some of these issues and implemented it on a quasi-experimental basis in Bhalwal Tehsil of the Sargodha district of Punjab. The intervention introduced a client-centered approach to providing reproductive health services, including family planning and infant, child, and maternal health care. The intervention consisted of training health-care providers based in fixed-location clinics and in communities. It introduced the concept of SAHR (an acronym for salutation, assessment, help, and reassurance), to inculcate a client-centered approach to care that acknowledges explicitly and addresses a client's gender and power relations within her family and household. Results of the intervention indicate significant effects on providers' behavior related to SAHR elements. The changes provide demonstrable evidence that the public sector can shift toward client-centered services in reproductive health care in a challenging setting.     

The impact of maternal health improvement on perinatal survival: cost-effective alternatives

Each year, an estimated half million women die from complications related to child birth either during pregnancy, delivery or within 42 days afterwards. When pregnant women have complications, their infants are at greater risk of becoming ill, permanently disabled or dying. For every maternal death, there are at least 20 infant deaths: stillbirths, neonatal or postneonatal deaths. Altogether, an estimated 7 million infants each year die perinatally (stillborn or deaths within the first week of life). Low cost, feasible, and effective intervention strategies include: a) improved family planning and abortion services; b) obstetric care at delivery; and, c) prenatal services. Two hypothetical populations of one million (a low mortality and a high mortality country) are used to illustrate maternal and perinatal program strategies and priorities. In countries with high fertility, major reductions in maternal and infant deaths result both from reductions in the number of pregnancies through family planning and from improved obstetric care. Where fertility is already low, reductions result almost entirely from improved obstetric and prenatal care. The investments required are relatively low, while the potential gains are great. The cost to avert each death in a high mortality population is estimated between $800 and $1,500 or as low as $0.50 per capita per year. The priorities for programs targeting maternal and perinatal health depend on demographic, ecologic and economic factors, and should include the promotion of good health, not merely the avoidance of death. More operational research is required on various aspects of maternal and perinatal health; in particular, on the cost-effectiveness of different service components.     

山西省百姓生殖健康促进工程实施情况

目的 调查山西省百姓生殖健康促进工程实施情况.方法 2019年3-4月对山西省117个县(区)的妇幼保健院保健部负责人和计划生育协会组织负责人234人、妇幼保健院从事生殖健康服务工作人员702人、村计生服务员和乡镇计生专干1 170人开展问卷调查,对比项目县和非项目县开展生殖健康咨询服务的情况.结果 项目县妇幼保健院、...     

The influence of maternal intergenerational education on health behaviors of women in peri-urban Bolivia

The influence of maternal education on infant mortality has been demonstrated repeatedly in health and social science literature. Less explored is the influence of the education level of the mother's mother. In the present paper the authors examine the possible effect of grandmother's education on maternal behaviors. The relationship between intergenerational education and selected health behaviors, including utilization of health services for prenatal care, breast-feeding and family planning, are reported. The data were collected in peri-urban Santa Cruz, Bolivia among mothers of infants between 0 and 18 months of age. It appears that grandmother's education does exert an effect on health behaviors above and beyond the effect of maternal education. This effect is more pronounced for health services which fall clearly in the domain of the formal health care system. While the results are exploratory, the results suggest the worth of further study and consideration of the influence of mothers' mothers in the design of culturally sensitive quality health services.     

Family planning within and beyond MCH. (maternal and child health)

Advocates of family planning through maternal and child health (MCH) facilities often argue that reduction of infant mortality must precede and motivat family planning while national family planning program proponents argue that reduction of infant mortality is not possible before reduction of fertility. The National Family Planning Program of Ghana, an approach within and beyond MCH, explicitly aims to reduce the rate of population growth. The Secretariat for the Program is part of the Ministry of Finance and Economic Planning, responsible for budget approval, development planning, and coordination of the activities of other ministries. The program is thus assured of status, visibility, and finance. Other ministries also have responsilities in the program. The private sector, e.g., communication networks and commercial distributors will be utilized in order to reach the estimated 75% of the population for whom MCH services are not generally available. Hospitals and health centers operated by the Ministry of Health will continue to provide family planning services.     

Providing maternal and child health-family planning services to a large rural population: results of the Bohol Project, Philippines.

The Bohol Project (1975-1979) sought to improve maternal and child health and to increase the use of family planning among a rural Philippine population of 400,000. Research indicated that maternal and child health (MCH) services did become more available during the Project period and coverage of the priority populations improved. Family planning (FP) use, particularly of less effective methods, increased and fertility declined although some change could have been expected even without the Project. Deaths due to neonatal tetanus were almost eliminated by mortality rates did not decline for a number of reasons, including the fact that services were probably not tailored closely enough to local health problems, especially respiratory diseases. The Project showed that it was possible to increase health and family planning services by using low-cost strategies (such as setting up community drug stores) and by employing paramedical workers, in this case, midwives. Preventive MCH-FP services were not overwhelmed by curative services as had been feared. Perhaps the most significant contributions of the Project were the lessons learned about delivering health and family planning services and conducting evaluation research. In general, if developing countries could maintain well-evaluated field laboratories for working out health and family planning delivery approaches before going nationwide, it is likely that time and money would be saved in the long run.     

The importance of family planning in reducing maternal mortality

Maternal mortality in many developing countries remains at distressingly high levels despite improvements in hospital obstetrics. WHO estimates that 1/2 million maternal deaths occur each year, 99% of which are in developing countries. While many people expect that widespread acceptance of family planning will bring down levels of maternal mortality, some analyses have claimed disappointing reductions, though others were more encouraging. The primary reason for this discrepancy lies in the choice of measure of maternal mortality, compounded somewhat by a confusion in terminology. Maternal mortality can be measured by: 1) the number of maternal deaths; 2) the maternal mortality ratio; 3) the maternal mortality rate; or 4) the lifetime risk of death in childbirth. Family planning use influences the maternal mortality ratio only to the extent that it reduces the proportion of pregnancies to high-risk women. The maternal mortality rate can be substantially influenced by the prevalence of contraception, but it is primarily the reduction in the number of births, per se, that exerts the influence. The choice of measure should be determined by the issue being addressed, and which of the 2 determinants of maternal mortality (obstetric risk or prevalence of pregnancy) is the focus. Current levels of maternal mortality in the developed countries have been achieved only with both good obstetric care and with low fertility. In developing countries today, modern obstetric care is often available only in a few teaching hospitals, but family planning programs are feasible even in remote areas. While implementing family planning programs is not easy, it is more feasible than the implementation of significant improvements in the quality and availability of obstetric care. The contribution of family planning to lower maternal mortality and morbidity should not be underestimated.     

市县级妇幼保健与计划生育服务机构资源整合研究

为推动妇幼保健机构和计划生育服务机构的资源整合,采用现场问卷调查、专题小组访谈、个人深入访谈等方法调查了7个省的5个地市级和9个区县级14所完成了妇幼保健和计划生育整合的实施机构。了解其资源整合模式、资产归属、人员安置和人员薪酬分配等内容,梳理归纳了整合中存在的技术人员未得到有效补充、人员培养和配备不能满足新形势需求、免费计划生育技术服务政策落实受到影响、妇幼保健与计划生育信息整合有待加强、科室设置还需规范等问题,提出建立健全补偿与激励机制、加强人才队伍建设、加强绩效考核和薪酬管理、加强医疗服务机构价格管理和信息化建设、做好生育全程优质服务等建议,为我国妇幼保健和计划生育服务的资源整合提供借鉴。     

Pediatric health promotion through risk reduction

The purpose of pediatric risk reduction is to both decrease the force of mortality acting in infancy and childhood and to promote the development of physically and emotionally comfortable adults. Due to the fact that much of the organism's capacity for optimal growth and development seems to be established during childhood, the ultimate potential of pediatric risk reduction is the improvement of the quality of life throughout its entire course. In discussing the concern of pediatric health promotion through risk reduction, attention is directed to the risks to children (mortality and morbidity risks), recommendations for pediatric risk reduction (family planning, prenatal care, care at birth, postnatal followup, and child health supervision), and children's life style and society. Risks may be divided into those affecting the child by their impact on the mother and those that affect the child directly. Maternal mortality represents a loss to any child in the family, as well as being the possible cause of an associated fetal or neonatal death. Infant mortality is largely due to conditions related to premature birth and congenital anomalies. True family planning is an essential measure for the reduction of pediatric risk. Possibly the most helpful approaches include the provision of sex education to adolescents and ensuring the availability of birth control devices. Research evidence shows that it is in the best interests of the child for parents to space pregnancies 2 or more years apart. Prenatal care needs to begin before conception occurs; both parents should be in optimal health. The need for education of parents who are having their 1st child cannot be overemphasized; much self-care and home care is both necessary and desirable.     

Reproductive Health and Reproductive Freedom

Health care for mothers and children has been a cornerstone of the Swedish system of health care for many years, starting in the 1930s, when a national network of maternal health centers offered a variety of free prenatal services. This paper describes modern maternal health services whose primary oal is preventive care. Instruments for attaining this goal are regular check-ups for early detection of problems and for maintenance of good health; social and psychological support to expectant parents; information and training to prepare parents for delivery and parenting; information and education about risk factors in the parents' local environment and in society in general. Details of how these programs were developed, delivered and evaluated are provided by the author, a former Senior Medical Officer at the National Board of Health and Welfare, responsible for maternal health care and family planning on a national level.     

基于集中指数的妇幼健康服务和妇幼健康公平性分析

目的 对妇幼健康公平性进行分析,为促进妇幼保健服务和提高妇幼健康公平程度提供借鉴和参考.方法 利用《中国卫生统计年鉴》《中国卫生和计划生育统计年鉴》《中国统计年鉴》中的相关资料,计算反映妇幼保健服务和妇幼健康水平的各项指标的集中指数.结果 孕产妇系统管理、产前检查、产后访视、儿童保健管理的集中指数均为正值,反映出其主要集中在社会经济发展水平相对富裕的省份,围产儿死亡、孕产妇死亡的集中指数均为负值,反映出其主要集中于社会经济发展水平相对落后的省份.2008-2013年我国妇幼保健服务及妇幼健康的不公平性在各省(市、区)间的差距有所改善.结论 不同省(市、区)的妇幼保健服务和妇幼健康状况的不公平程度有所改善,应发展贫困地区经济,缩小贫富差距,注重对中部地区的支持,提高妇幼保健服务的效率和质量,从而改善妇幼健康.     

Reproductive health and reproductive freedom: maternal health care and family planning in the Swedish health system

Health care for mothers and children has been a cornerstone of the Swedish system of health care for many years, starting in the 1930s, when a national network of maternal health centers offered a variety of free prenatal services. This paper describes modern maternal health services whose primary goal is preventive care. Instruments for attaining this goal are regular check-ups for early detection of problems and for maintenance of good health; social and psychological support to expectant parents; information and training to prepare parents for delivery and parenting; information and education about risk factors in the parents' local environment and in society in general. Details of how these programs were developed, delivered and evaluated are provided by the author, a former Senior Medical Officer at the National Board of Health and Welfare, responsible for maternal health care and family planning on a national level.     

Community-based approach to refugee relief: experiences from Thailand

The Community Based Emergency Relief Services (CBERS) of Thailand pioneered a new approach to solving the problem of assisting Cambodian refugees. In 1980 following the influx of more than 150,000 Cambodians into Thailand CBERS proposed family planning to address the potential infant and maternal health threat posed by hazardous conditions within the refugee camps. Based on a survey CBERS launched a voluntary family planning and maternal and child health care program which offered oral contraceptives (OCs), IUDs, and injectables through existing health units, mobile service vans, and community-based distributors. Approximately 1500 Khmer leaders were trained in family planning and mass media techniques passed the information to the general population. Movies were shown and desensitization techniques were used. Each acceptor was counseled about choice and method as well as use of contraceptives and appropriate health education; sessions were held in groups of 30 women. A total of 8236 women chose to practice family planning during the campaign with 95% of all acceptors choosing the injectable contraceptive. Following service delivery a community-based family planning program was initiated to provide followup services. Other services provided by CBERS include sanitation services, vector control, and waste disposal as well as agriculture and skills development programs to train the refugees. By the end of 1981 over 12,000 people received specialized training. These programs have heightened the refugees' self esteem and they are well prepared to begin their return to Cambodia.     

Pakistan's maternal and child health policy: analysis, lessons and the way forward

An estimated 400,000 infant and 16,500 maternal deaths occur annually in Pakistan. These translate into an infant mortality rate and maternal mortality ratio that should be unacceptable to any state. Disease states including communicable diseases and reproductive health (RH) problems, which are largely preventable account for over 50% of the disease burden. The analysis of Pakistan's maternal and child health (MCH) and family planning (FP) policy covers the period 1990-2002, and focuses on macroeconomic influences, priority programs and gaps, adequacy of resources, equity and organizational aspects, and the process of policy formulation. The overall MCH/FP policy is well directed. MCH/FP has been a priority in all policies; resource allocation, although unacceptably low, has substantially increased during the last decade; and there is a progressive shift from MCH to the reproductive health (RH) agenda. Areas in need of improvement include greater use of evidence as a basis for policy; increased priority to nutrition programs, measures to reduce neonatal and perinatal mortality, provision of emergency obstetric care, availability of skilled birth attendants, and a clear policy on integrated management of childhood illnesses. Enhanced planning capacity, development of a balanced human resource, improved governance to reduce staff absenteeism and frequent transfers, and a greater role of the private sector in the provision of services are some organizational aspects that need the governments' consideration. There are several lessons to be learnt: (i) Ministries of Health need sustained stewardship and well-documented evidence to protect cuts in resource allocation; (ii) frequent policy announcement sends inappropriate signals to managers and weakens on-going implementation; (iii) MCH/FP policies unless informed by evidence and participation of interest groups are unlikely to address gaps in programs; (iv) distributional and equity objectives of MCH/FP be addressed while setting overall national goals; (v) institutional capacity is a vital ingredient in translating MCH/FP policies into effective services. The suggested strategic directions emphasize, among others, the need for a comprehensive MCH/FP framework; strengthened stewardship in ministry of health, cost-effective strategies to address the gaps identified and doubling of the public sector resource allocation to MCH/FP over the next 5 years. The ability to ensure delivery of quality health services remains the biggest challenge in the Pakistani health sector. Unless sound policies are backed by well-functioning programs they are likely to become a victim of poor implementation.     

Coping with changing conditions: alternative strategies for the delivery of maternal and child health and family planning services in Dhaka, Bangladesh

The door-to-door distribution of contraceptives and information on maternal and child health and family planning (MCH-FP) services, through bimonthly visits to eligible couples by trained fieldworkers, has been instrumental in increasing the contraceptive prevalence rate and immunization coverage in Bangladesh. The doorstep delivery strategy, however, is labour-intensive and costly. More cost-effective service delivery strategies are needed, not only for family planning services but also for a broader package of reproductive and other essential health services. Against this backdrop, operations research was conducted by the Centre for Health and Population Research at the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) from January 1996 to May 1997, in collaboration with government agencies and a leading national nongovernmental organization, with a view to developing and field-testing alternative approaches to the delivery of MCH-FP services in urban areas. Two alternative strategies featuring the withdrawal of home-based distribution and the delivery of basic health care from fixed-site facilities were tested in two areas of Dhaka. The clinic-based service delivery strategy was found to be a feasible alternative to the resource-intensive doorstep system in urban Dhaka. It did not adversely affect programme performance and it allowed the needs of clients to be addressed holistically through a package of essential health and family planning services.     

The home-based maternal record: a tool for family involvement in health care

The home-based maternal record offers an opportunity for family involvement in health care. Home-based records of maternal health have been used in several developing countries, and have led to increased detection and monitoring of women at high risk for complications during pregnancy. Home-based cards that include menstrual information remind health workers to educate and motivate women for family planning, and serve as a source of health statistics. Records that use pictures and symbols have been used by illiterate traditional birth attendants, and had an accurate completion rate of over 90%. The WHO has prepared a prototype record and guidelines for local adaptation. The objectives were to provide continuity of care throughout pregnancy, ensure recognition of at-risk women, encourage family participation in health care, an provide data on maternal health, breastfeeding, and family planning. The guidelines have been evaluated and results show that the records have improved the coverage, acceptability, and quality of MCH/FP care. The records have also led to an increase in diagnosis and referral of at-risk women and newborns, and the use of family planning and tetanus toxoid immunization has increased in the 13 centers where the reports are being used. Focus group discussions have shown that mothers, community members, primary health workers, and doctors and nurses liked the records. It is important to adapt criteria for high-risk conditions to the local areas where the records will be used to ensure the relevance of risk diagnosis. The evidence shows that home-based maternal and child records can be an important tool in the promotion of self-reliance and family participation in health care. In addition, home-based records can be used for the implementation of primary health care at the local level, and serve as a resource for data collection.     

How safe is motherhood in India?

Strategies for reducing maternal mortality in India are suggested for prioritizing maternal and child health (MCH) nationally, for including MCH within welfare services, and for integrating vertical programs into MCH. Attention should be directed to delivery practices and facilities, which account for most of maternal mortality. Clean and well-equipped labor huts which provide quality care should be available in each community. High-risk patients should be housed in maternity waiting homes located near hospitals. Improvements should be made in provision of quality prenatal care in villages, primary health care, and evaluation of services. A focus on family planning targets is not sufficient. Postpartum care programs should function as centers for family activities. A national blood transfusion network should be examined as a feasible plan. All government vehicles should be at the disposal of emergency situations. Home science books for prospective mothers should include chapters on pregnancy, childbirth, and care of the newborn. Television serials hold promise as useful tools for mass health education. Medical students in Departments of Gynecology and Obstetrics should spend 66% of their training time in obstetrics and practical skills in childbirth and newborn care. Regional centers for research and evaluation should be established by the Council on Medical Research. The right to safe motherhood should be assured. A nationwide study conducted in the late 1970s found that maternal mortality was 753/100,000 deliveries. A hospital-based study in 1982-83 found that there were 133 maternal deaths/32,812 deliveries, a maternal mortality rate of 405/100,000 live births. 58.8% of maternal deaths were attributed to obstetric causes: 12.8% to hemorrhage, 17.3% to infection, 12% to hypertensive disorders, 8.3% to ruptured uterus. An additional 15.8% of deaths were caused by hepatitis and 7.5% by anemia. Indian maternal mortality in one week equals the total maternal mortality in all of Europe in one year.     

Alternative Measures of Spatial Distribution and Availability of Health Facilities for the Delivery of Emergency Obstetric Services in Island Communities

International guidelines and recommendations for availability and spatial distribution of emergency obstetric care services do not adequately address the challenges of providing emergency health services in island communities. The isolation and small population sizes that are typical of islands and remote populations limit the applicability of international guidelines in such communities. Universal access to emergency obstetric care services, when pregnant women encounter complications, is one of the three key strategies for reducing maternal and newborn mortality; the other two being family planning and skilled care during labor. The performance of selected lifesaving clinical interventions (signal functions) over a 3-month period is commonly used to assess and assign performance categories to health facilities but island communities might not have a large enough population to generate demand for all the signal functions over a 3-month period. Similarly, availability and spatial distribution recommendations are typically based on the size of catchment populations, but the populations of island communities tend to be sparsely distributed. With illustrations from six South Pacific Island states, we argue that the recommendation for availability of health facilities, that there should be at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500,000 population, and the recommendation for equitable distribution of health facilities, that all subnational areas meet the availability recommendation, can be substituted with a focus on access to blood transfusion and obstetric surgical care within 2 hours for all pregnant residents of islands. Island communities could replace the performance of signal functions over a 3-month period with a demonstrated capacity to perform signal functions if the need arises.     

Health education for safe motherhood

In many African countries, costly advertising campaigns have warned the public about smoking, sexually transmitted diseases, and AIDS. Similar campaigns should be launched to reduce maternal mortality. Radio and television should deliver messages, focused upon specific target groups, which relate both to family planning and safe motherhood. The aim of such health education should be to improve traditional practices and to help women and communities understand that factors such as early marriage, too many pregnancies, poor nutrition, lack of antenatal care, illegal abortions, use of medicinal herbs, and home delivery contribute to the toll of maternal mortality. All health messages should reflect the realities of village life and promote behavior which requires little or no financial expenditure. Community participation is important. Successful strategies to prevent maternal mortality will highlight the role that women and communities can play. A willingness to use health services, a belief that preventive measures are worthwhile, and community participation in changing behavior are crucial in any program.