Service users’ attributes associated with the uptake of medical versus surgical abortion at public health facilities in Vietnam

Objective

To investigate the attributes of service users associated with uptake of medical abortion (MA) versus manual vacuum aspiration (MVA) at public health facilities in Vietnam.

Methods

Structured exit interviews were conducted among women who underwent termination at 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City (HCMC) between August and December 2011. Data on sociodemographic, abortion-related, and service-related factors were compared between women who underwent MVA versus MA.

Results

Overall, 1233 women completed the study survey: 541 (43.9%) from Hanoi; 163 (13.2%) from Khanh Hoa; and 529 (42.9%) from HCMC. Almost one-quarter of women (23.1%) had chosen MA. After controlling for sociodemographic factors, women living in Khanh Hoa (odds ratio [OR], 13.4; 95% confidence interval [CI], 5.3–33.8) and HCMC (OR, 5.8; 95% CI, 2.1–15.9) were more likely to have undergone MA than women in Hanoi. Older women were less likely to have undergone MA (P < 0.05), and those who had previously heard of MA were twice as likely to have undergone MA (P = 0.020).

Conclusion

Uptake of MA was lower than that of MVA and varied by province. Women in Vietnam will make their own judgment about which method to choose if they have prior knowledge of both.     

The effects of group health education on childbearing knowledge,attitude, and behaviour among Southeast Asian immigrant women in Taiwan

Objectives

to explore the effects of a group health education programme on the childbearing knowledge, attitude, and behaviours among Southeast Asian immigrant women in Taiwan.

Design

a quasi-experimental design with convenience sampling was used.

Setting

participants living in Kaohsiung County, Taiwan, were randomly divided by districts into either the experimental group or the control group.

Participants

one hundred Southeast Asian immigrant women were recruited as research participants. Among the 100 participants, 50 were in the experimental group and 50 were in the control group. A total of 99 participants completed the entire research procedure.

Methods

a structured interview was used to evaluate the effects of a group health education programme.

Measurements

the interview consisted of four measurements: the Demographic Inventory Scale, the Childbearing Knowledge Scale, the Childbearing Attitude Scale, and the Childbearing Planning Scale.

Findings

after employing the group health education intervention, statistically significant changes from the pre-test to the post-test were found in the experimental group's scores for the Childbearing Knowledge Scale (P<0.0001), the Childbearing Attitude Scale (P<0.01), and the Childbearing Planning Scale (P<0.0001). The study's results indicated that providing education through group learning with guidance and support in childbearing health significantly improved Southeast Asian immigrant women's childbearing health knowledge, attitudes, and behaviours.

Conclusion

an appropriate, community-based group health education programme can create awareness for childbearing health among Southeast Asian immigrant women in Taiwan and improve their childbearing attitudes and behaviours.     

Efficacy and acceptability of a mifepristone–misoprostol combined regimen for early induced abortion among women in Mexico City

Objective

To evaluate the experience of women receiving mifepristone–misoprostol for early induced abortion in public sector facilities in the Federal District of Mexico City.

Methods

An open-label prospective study was conducted with 1000 pregnant women who sought induced abortion with a pregnancy of up to 63 days of gestation, as measured from the date of their last menstrual period. The study was conducted in three public sector healthcare facilities: two secondary level hospitals and one primary care clinic. Women ingested 200 mg mifepristone on day 1, followed by 800 μg buccal misoprostol 24 hours later, and they returned for follow-up on day 8. The primary outcome was complete abortion without recourse to surgical intervention.

Results

A total of 971 women received mifepristone–misoprostol and were included in the analysis for efficacy of treatment. The overall efficacy of the combined medical abortion regimen studied was 97.3% (n = 945); the success rate did not vary significantly by gestational age (95.9%–100%; P = 0.449). Most women (n = 922, 95.0%) had a successful induced abortion with only one dose of misoprostol.

Conclusion

The combined mifepristone and buccal misoprostol regimen was found to be highly effective and acceptable among Mexican women. www.ClinicalTrials.gov: NCT00386282.     

Risk factors for repeat abortion and implications for addressing unintended pregnancy in Vietnam

Objective

To determine predictors of repeat abortion in 3 provinces in Vietnam.

Methods

In a cross-sectional study between August and December 2011, women who underwent abortion were interviewed after the procedure in 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City (HCMC). Information on sociodemographic factors, contraceptive and reproductive history and intentions, and opinions and experience of abortion services was collected. The primary outcome was repeat (≥ 2) abortions.

Results

Overall, 1224 women were interviewed: 534 from Hanoi, 163 from Khanh Hoa, and 527 from HCMC. The mean age and parity of the respondents were 29 years and 1.8, respectively, and 79.6% were married. Approximately half of the respondents were not using contraception before pregnancy. The prevalence of repeat abortion was 31.7%. In multivariate models, significant predictors of repeat abortion included living in Hanoi, higher parity, age 35 years or older, and having 2 or more daughters (versus 1) or no sons (versus 1) after controlling for parity (all P < 0.05).

Conclusion

Repeat abortion remains high in Vietnam, fueled partly by inadequate contraceptive use. Son preference seems to be an important predictor of repeat abortion. Strengthening post-abortion contraceptive counseling and promoting long-acting contraceptive methods are essential to reduce repeat abortion.     

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.     

Defining the anesthesia gap for reproductive health procedures in resource-limited settings

Background

In resource-limited settings, severe shortages of anesthetists and anesthesiologists lead to surgical delays that increase maternal and neonatal mortality and morbidity.

Objectives

To more clearly understand the individual components of the anesthesia gap pertaining to reproductive health surgeries and procedures in resource-limited settings.

Search strategy

Medline, the Cochrane Library, CINAHL, Embase, and POPLINE were systematically searched for reports published before December 31, 2013. Search terms were related to obstetric surgery, resource-limited settings, and anesthesia.

Selection criteria

Studies that addressed the use of anesthesia in reproductive procedures in resource-limited settings were included.

Data collection and analysis

Reviewers independently evaluated the full text of identified studies, extracted information related to study objectives and conclusions, and identified the anesthesia gap.

Main results

Overall, 14 publications met the inclusion criteria. A significant lack of infrastructure, equipment and supplies, and trained personnel were identified as key factors responsible for a lack of anesthesia services.

Conclusions

A shortage of trained anesthesia providers, equipment, supplies, medications, and infrastructure, along with limitations in transportation in resource-limited settings have produced a wide gap between available anesthesia services and the demand for them for reproductive health surgeries and procedures. Safe, affordable, and scalable solutions to address the anesthesia gap are urgently needed.     

Risk factors for reproductive tract infections among married women in rural areas of Anhui Province,China

Objectives

The goal of this study is to identify factors that contribute to reproductive tract infections (RTIs) among women in rural China, including prevalence, influence of sociodemographic characteristics, knowledge, hygienic behaviors and the history of childbearing, menstruation and abortion.

Study design

A stratified cluster sample of 53,652 married women in rural Anhui Province of China completed an interviewer-administered standardized questionnaire, and underwent gynecological examination and laboratory investigation.

Results

RTIs were relatively common (30,939/58.1%) among our sample of 53,652 married women. The three most frequent RTIs in our samples were endocervicitis, bacterial vaginosis (BV) and trichomoniasis, with prevalences of 41.7%, 12.0% and 4.5%, respectively. Multiple infections were prevalent among our sample. 20.4% (10,854) of our sample had two RTIs and 8.8% (4713) had at least three RTIs. Multivariate analysis showed that women's age, education, occupation, dysmenorrhea, number of deliveries, personal hygiene habit, menstrual cycle, menstruation, abortion, the interval between abortion and sexual intercourse afterwards, RTI knowledge and the frequency of sexual intercourse per month were all related to RTIs in our sample.

Conclusions

Among married women in rural China, the prevalence of RTIs was high, indicating the need for health education.     

Poor quality of antenatal care services—Is lack of competence and support the reason? An observational and interview study in rural areas of Lao PDR

Objective

to explore the health-care providers' performance and their own perceptions of the ANC services they provide.

Design, setting and participants

this cross-sectional exploratory survey was carried out in 2009 at four district hospitals and 18 health centres in Khammouane and Champasack provinces in rural areas of Laos.

Measurements and findings

combinations of quantitative and qualitative methods were used: (i) 59 observations of ANC sessions (components performed and equipment used); (ii) 26 semi-structured interviews with health-care providers engaged in ANC services, interpreted through content analysis. The findings indicated an overall poor quality and performance of ANC services in rural health facilities with lack of routines, scarce or insufficient equipment and limited skills among providers. The health-care providers gave an often pessimistic picture of their competence and motivation to work with ANC. Some articulated a resignation due to lack of feedback from the patients and they expressed a need for support from health-care superiors. Compared to the district hospitals, the health centres were less well-equipped and supplied, and the providers had a heavier workload, because all activities including ANC were carried out by the same provider. The average consultation time for each woman was 5 mins.

Conclusions

the quality of ANC services in rural health facilities in Laos was poor due to lack of resources, the providers' limited skills concurrent with inadequate routines and insufficient backup from superiors.

Implications for practice

to comply with national and international recommendations for ANC services, our suggestion is to improve the quality of the rural health facilities in Laos by providing basic equipment, support from experienced superiors and in-service training.     

The relationship between women-centred care and women's birth experiences: a comparison between birth centres, clinics, and hospitals in Japan

Objective

the goal of women-centred care (WCC) is respect, safety, holism, partnership and the general well-being of women, which could lead to women's empowerment. The first step in providing WCC to all pregnant women is to describe women's perceptions of WCC during pregnancy in different health facilities. The objectives of this study were to ask (a) what are the perceptions and comparison of WCC at Japanese birth centres, clinics, and hospitals and (b) what are the relationships between WCC and three dimensions of women's birth experience: (1) satisfaction with care they received during pregnancy and birth, (2) sense of control during labour and birth, and (3) attachment to their new born babies.

Design

this was a cross-sectional study using self-completed retrospective questionnaires.

Setting

three types of health facility: birth centres (n=7), clinics (n=4), and hospitals (n=2).

Participants

participants were women who had a singleton birth and were admitted to one of the study settings. Women who were seriously ill were excluded. Data were analysed on 482 women.

Measurements

instrumentation included: a researcher-developed WCC-pregnancy questionnaire, Labour Agentry Scale, Maternal Attachment Questionnaire, and a researcher-developed Care Satisfaction Scale.

Findings

among the three types of settings, women who delivered at birth centres rated WCC highly and were satisfied with care they received compared to those who gave birth at clinics and hospitals. WCC was positively associated with women's satisfaction with the care they received.

Key conclusions

women giving birth at birth centres had the most positive perceptions of WCC. This was related to the respectful communication during antenatal checkups and the continuity of care by midwives, which were the core elements of WCC.

Implications for practice

health-care providers should consider the positive correlation of WCC and women's perception of satisfaction. Every woman should be provided continuity of care with respectful communication, which is a core element of WCC.     

Midwifery retention and coverage and impact on service utilisation in Afghanistan

Objective

to measure the rate of and determine factors associated with community midwifery education (CME) graduate retention in public sector health care in Afghanistan.

Design

cross-sectional.

Setting

performed in public health facilities of 11 Afghan provinces purposively selected by geographic location and security conditions, between October 2011 and April 2012. Facilities were selected by one of two criteria: either a registered deployment site for a CME graduate or randomly selected through population-proportionate sampling.

Participants

facility managers and midwives employed in public facilities at the time of data collection.

Measurements

three quantitative instruments were used: a facility checklist assessed staffing and service volume, and two separate questionnaires for midwives and facility managers, which measured employment duration and perceived barriers to midwife retention.

Findings

at 456 surveyed facilities, 570 midwives were interviewed. Overall, 61.3% (n=209/341) of CME graduates deployed in surveyed provinces were working in public sector facilities, whereas 36.8% were working at their assigned site. Facilities without midwife staff had lower average monthly volumes of antenatal care visits (14.6 (SD±22.7) versus 71.5 (SD±72.5)), family planning visits (10.4 (SD+13.9) versus 56.8 (SD+85.0)), or facility-based deliveries (0.55 (SD±2.2) versus 15.7 (SD±18.7)). Perceived reasons for leaving employment were insecurity (civil unrest/armed conflict) (46.4%), family disagreement (28.1%), increased workload without compensation (9.9%), and lack of appropriate housing (7.8%).

Key conclusions

CME graduate retention in public sector positions was relatively low and significantly impacted by insecurity and cultural issues related to women working outside the home.

Implications for practice

culturally appropriate measures are needed to attract and retain skilled female health care providers for rural public facilities in Afghanistan and similar settings. Advocacy to encourage family and community support for midwives working in rural facilities and providing amenities such as housing, education for children, and employment for the accompanying male family member are measures most likely to improve midwife retention.     

A pilot study on the combined use of letrozole,mifepristone and misoprostol in termination of first trimester pregnancy up to 9 weeks’ gestation

Objective

To assess the feasibility of adding letrozole to the standard regimen of mifepristone and misoprostol for termination of pregnancy up to 63 days.

Study design

We recruited 50 subjects who had requested legal termination of pregnancy up to 63 days. Medical abortion was performed with a singe dose of 200 mg mifepristone and 10 mg of letrozole daily for 3 days followed by 800 mcg vaginal misoprostol.

Results

The complete abortion rate was 98% (95% CI: 94–100%). The median induction-to-abortion interval of the regimen was 5.1 h (range 1.2–56 h). No serious adverse effects were reported.

Conclusions

The results of this pilot study suggest that a regimen of mifepristone, letrozole and misoprostol is associated with a high complete abortion rate without major adverse events.     

Competency-based training “Helping Mothers Survive: Bleeding after Birth” for providers from central and remote facilities in three countries

Objective

To validate a new training module for skilled and semiskilled birth attendants authorized to provide care at birth—Helping Mothers Survive: Bleeding After Birth (HMS:BAB)—aimed at reducing postpartum hemorrhage, the leading cause of maternal mortality worldwide. BAB training involves single-day, facility-based training that emphasizes simulation of scenarios related to prevention, detection, and management of postpartum hemorrhage.

Methods

A total of 155 skilled and semiskilled birth attendants participated in training in India, Malawi, and Zanzibar, Tanzania. Knowledge and confidence were assessed before and after training. Skills and acceptability were assessed after training.

Results

Knowledge and confidence scores improved significantly from pre- to post-training among all cadres in all three countries. The proportion of providers with passing knowledge scores increased significantly from pre- to post-training among all cadres except for those already high at baseline. On three post-training skills tests the overall proportion of individuals with a passing score ranged from 83% to 89%.

Conclusion

BAB training in prevention and management of postpartum hemorrhage increased knowledge and confidence among skilled and semiskilled birth attendants. Further studies are needed to determine the impact of this training on skills retention and clinical outcomes following postpartum hemorrhage, after broader implementation of the training program.     

Decentralizing postabortion care in Senegal with misoprostol for incomplete abortion

Objective

To expand access to postabortion care (PAC) services in Senegal by introducing misoprostol as a first-line treatment at the community level.

Methods

The present prospective study enrolled 481 women seeking treatment for incomplete abortion at 11 community health posts in Senegal between September 2011 and August 2012. Participants were given 400 μg of sublingual misoprostol and asked to return to the clinic 1 week later to confirm clinical status. At study completion, all women were asked to respond to a series of questions regarding their experience with this method. All care was provided by nurse midwives.

Results

All but three of the study women (99.4%; 474/477) had successful complete abortion after taking misoprostol. Almost all women were satisfied or very satisfied with the treatment (99.6%; 469/471), would select the method again if needed (98.9%; 465/470), and would recommend the method to a friend (99.8%; 468/469).

Conclusion

The results provide further evidence that 400 μg of misoprostol is highly effective for first-line treatment of incomplete abortion. Furthermore, this regimen can be fully provided by nurse midwives, and can be easily and successfully introduced in community health settings where other methods of PAC may not previously have been available. Clinicaltrials.gov: NCT01939457     

Acceptability and feasibility of medical abortion with mifepristone and misoprostol in Nigeria

Objective

To examine the acceptability and feasibility of medical abortion in Nigeria.

Methods

In total, 250 women who were eligible for legal pregnancy termination with a gestational age of up to 63 days since last menstrual period were enrolled in Benin City and Zaria between May 2005 and October 2006. Participants received 200 mg of oral mifepristone in the clinic and then took 400 μg of oral misoprostol 2 days later—choosing to either return to the clinic or take it at home. Women returned 2 weeks later for an assessment of abortion status.

Results

The vast majority (96.3%) of women had successful complete abortions. Ultrasound was used to determine outcome in less than one-third (28.9%) of participants. Most women (83.2%) took the misoprostol at home. Almost all (96.2%) participants were satisfied or very satisfied with the abortion method.

Conclusion

The introduction of medical abortion with mifepristone and misoprostol could greatly expand current method options and improve the quality of reproductive health care in Nigeria and other settings in which access to legal abortion services is limited.     

Abortion care for adolescent and young women

Background

Unintended pregnancy among adolescents (10–19 years) and young women (20–24 years) is a global public health problem. Adolescents face challenges in accessing safe abortion care.

Objective

To determine, via a systematic data review, whether abortion care for adolescent and young women differs clinically from that for older women.

Methods

In a comprehensive data review, the Cochrane Central Register of Controlled Trials, MEDLINE, and POPLINE databases were searched from the earliest data entered until November 2012. Randomized controlled trials and observational studies comparing effectiveness, safety, acceptability, and long-term sequelae of abortion care between adolescent/young women and older women were identified. Two reviewers independently extracted data, and the Cochrane guidelines and Newcastle–Ottawa Scale were used for quality assessment.

Results

In total, there were 25 studies including 346 000 women undergoing first- and second-trimester medical abortion, vacuum aspiration, or dilation and evacuation. Effectiveness and overall complications were similar among age groups. However, younger women had an increased risk for cervical laceration and a decreased risk of uterine perforation and mortality. Satisfaction and long-term depression were similar between age groups. Except for less uptake of intrauterine devices among adolescents, age did not affect post-abortion contraception.

Conclusions

Evidence from various healthcare systems indicates that abortion is safe and efficacious among adolescent and young women. Clinical services should promote access to safe abortion for adolescents.     

Postabortion contraception a decade after legalization of abortion in Nepal

Objective

To assess the contraceptive information received and methods chosen, received, and used among women having abortions one decade after legalization of abortion in Nepal.

Methods

We examined postabortion contraception with questionnaires at baseline and six months among women obtaining legal abortions (n = 838) at four facilities in 2011. Multivariate regression analysis was used to measure factors associated with method information, choice, receipt, and use.

Results

One-third of participants received no information on effective methods, and 56% left facilities without a method. The majority of women who chose to use injectables and pills were able to do so (88% and 75%, respectively). However, only 44% of women choosing long-acting reversible contraceptives and 5% choosing sterilization had initiated use of the method by six months. Levels of contraceptive use after medical abortion were on par with those after aspiration abortion. Nulliparous women were far less likely than parous women to receive information and use methods. Women living without husbands or partners were also less likely to receive information and supplies, or to use methods.

Conclusion

Improvements in postabortion counseling and provision are needed. Ensuring that women choosing long-acting and permanent contraceptive methods are able to obtain either them or interim methods is essential.     

A mixed-method study of factors associated with differences in caesarean section rates at community level: The case of rural China

Objective

to assess population-based caesarean section (CS) rates in rural China and explore determinants and reasons for choosing a CS.

Design

cross-sectional study, quantitative and qualitative methods, statistical modelling.

Setting

two rural counties in Anhui province, China.

Participants

(a) household survey participants: 2326 women who gave birth in the two counties from January 2005 to December 2006; (b) qualitative study participants: health providers at township and village level and maternal health-care providers (N=58).

Measurements and findings

the household survey were conducted among 2326 women, collecting data on socio-economic and health status and utilisation of maternal health services. Eleven Focus Group Discussions with health-care providers and users to explore perceptions surrounding CS.the CS rate in the two areas were 46.0% and 64.7%. There were complex and different interactions among social-economic and clinical determinants associated with differences in CS rates. The main determinants that emerged were maternal age, maternal education, yearly income, primiparity, uptake of antenatal care and recorded obstetric complications with complex and differing interactions for each county. Maternal fear of pain, worry about mothers' and infants' safety, not satisfied with doctors' competences and physicians' low confidence in vaginal delivery, and absence of a strong midwifery cadre together contributed to final determination of CS.

Key conclusions

the CS rates were extremely high in the two counties in rural China. Maternal socio-economic, clinic characteristics and health providers' preference contributed together to the high rates of CS.

Implications for practice

evidence-based knowledge and methods to reduce unnecessary CS should be communicated to medical professionals and women. Greater comprehensive attention needs to be paid to a complex pattern of medical, socio-cultural, political and economic contexts of maternity care.     

Barriers and solutions for timely initiation of antenatal care in Kigali,Rwanda: Health facility professionals' perspective

Objective

timely initiation of antenatal care (i.e. within the first trimester) is associated with attendance of the full recommended regimen of antenatal visits. This study assessed social and behavioural factors that affect timely initiation of antenatal care in Kigali, Rwanda from the perspective of health facility professionals.

Design

health facility professionals involved in antenatal care provision were interviewed on their perceptions about untimely initiation of antenatal care based on open-ended questions. These one-on-one interviews were tape recorded and transcribed for analysis.

Setting

interviews were performed in June and July 2011 at Muhima Health Center in Kigali, Rwanda.

Participants

17 health facility professionals with a wide range of skills and experience levels were selected from the 36 total staff members of Muhima Health Center based on their participation in and knowledge of antenatal care.

Measurements and findings

inductive content analysis was used to group responses from these qualitative interviews with the goal of creating a conceptual map around barriers and solutions for untimely antenatal care. Qualitative responses were coded to identify the most common themes and sub-themes following a consensus methodology. The health-care professional interviews identified five themes as barriers to timely initiation of antenatal care: (1) lack of knowledge; (2) experience with previous births; (3) issues with male partners not willing/able to attend the clinic; (4) poverty or problems with health insurance; and (5) antenatal care culture. As potential solutions to these hurdles, the following themes were identified: (1) maternal/community education and sensitisation; (2) incentives to attend antenatal care visits; and (3) tracking the content and recommended number of antenatal visits.

Key conclusions

qualitative results indicate that behavioural contextual interventions may help overcome antenatal care barriers. The Rwandan Government and health facilities should work together with target communities to improve antenatal care compliance, taking into account the solutions suggested by the health facility professional interviews.

Implications for practice

study findings suggest that there are specific solutions to increase adherence with timely initiation of antenatal care in Rwanda, including education and sensitisation, modifying couples' HIV testing policies, addressing costs of antenatal care, and tracking the number of recommended antenatal visits.     

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.