Programming for safe motherhood: a guide to action.
The Safe Motherhood Initiative has successfully stimulated much interest in reducing maternal mortality. To accelerate programme implementation, this paper reviews lessons learned from the experience of industrial countries and from demonstration projects in developing countries, and proposes intervention strategies of policy dialogue, improved services and behavioural change. A typological approach with three hypothetical settings from resource poor to resource rich environments is used to address the variability in health behaviours and infrastructure encountered when programming for safe motherhood. (+info)
Is antenatal care effective in reducing maternal morbidity and mortality?
Women in developing countries are dying from simple preventable conditions but what impact can the procedures collectively called antenatal care having in reducing maternal mortality and morbidity? More importantly what is antenatal care? This review found that questions have been raised about the impact of antenatal care (specifically on maternal mortality) since its inception in developed countries, and that although the questions continue to be asked there is very little research trying to find answers. Many antenatal procedures are essentially screening tests yet it was found that there were very few results showing sensitivity and specificity, and that they rarely complied with the established criteria for the effectiveness of a screening test. The acknowledged gold standard measurement of effectiveness is the randomized controlled trial, yet the only results available referred to nutritional supplementation. This service of flawed methodology has been exported to developing countries and is being promoted by WHO and other agencies. This paper argues that there is insufficient evidence to reach a firm decision about the effectiveness of antenatal care, yet there is sufficient evidence to cast doubt on the possible effect of antenatal care. Research is urgently required in order to identify those procedures which ought to be included in the antenatal process. In the final analysis the greatest impact will be achieved by developing a domiciliary midwifery service supported by appropriate local efficient obstetric services. That this domiciliary service should provide care for women in pregnancy is not disputed but the specific nature of this care needs considerable clarification. (+info)
Demonstrating programme impact on maternal mortality.
Reducing maternal mortality if one of the primary goals of safe mother hood programmes in developing countries. Maternal mortality is not, however, a feasible outcome indicator with which to judge the success of these programmes. This is due to an unfortunate combination of obstacles to measurement--some general to assessing the mortality impact of health programmes and some peculiar to estimating maternal mortality. There is a need to promote alternative views and measures of programme success, and alternative uses for information on maternal deaths. (+info)
The role of private providers in maternal and child health and family planning services in developing countries.
This paper uses data from the Demographic and Health Surveys program (DHS) in 11 countries in Asia, Africa, and Latin America to explore the contribution of private health care providers to population coverage with a variety of maternal and child health and family planning services. The choice of countries and services assessed was mainly determined by the availability of data in the different surveys. Private providers contribute significantly to family planning services and treatment of children's infectious diseases in a number of the countries studied. This is as expected from the predictions of economic theory, since these goods are less subject to market failures. For the more 'public goods' type services, such as immunization and ante-natal care, their role is much more circumscribed. Two groups of countries were identified: those with a higher private provision role across many different types of services and those where private provision was limited to only one or two types of the services studied. The analysis identified the lack of consistent or systematic definitions of private providers across countries as well as the absence of data on many key services in most of the DHS surveys. Given the significance of private provision of public health goods in many countries, the authors propose much more systematic efforts to measure these variables in the future. This could be included in future DHS surveys without too much difficulty. (+info)
Integrating MCH/FP and STD/HIV services: current debates and future directions.
The issue of integrating MCH/FP and STD/HIV services has gained an increasingly high priority on public health agendas in recent years. In the prevailing climate of health sector reform, policy-makers are likely to be increasingly pressed to address the broader concept of "reproductive health' in the terms consolidated at the Cairo International Conference on Population and Development, and the UN Conference on Women in Beijing. Integrated MCH/FP and STD/HIV services could be regarded as a significant step towards providing integrated reproductive health services, but clarity of issues and concerns is essential. A number of rationales have emerged which argue for the integration of these services, and many concerns have been voiced. There is little consensus, however, on the definition of "integrated services' and there are few documented case studies which might clarify the issues. This paper reviews the context in which rationales for "integrated services' emerged, the issues of concern and the case studies available. It concludes by suggesting future directions for research, noting in particular the need for country-specific and multi-dimensional frameworks and the appropriateness of a policy analysis approach. (+info)
Costs and financing of improvements in the quality of maternal health services through the Bamako Initiative in Nigeria.
This paper reports on a study to assess the quality of maternal health care in public health facilities in Nigeria and to identify the resource implications of making the necessary quality improvements. Drawing upon unifying themes from quality assurance, basic microeconomics and the Bamako Initiative, locally defined norms were used to estimate resource requirements for improving the quality of maternal health care. Wide gaps existed between what is required (the norm) and what was available in terms of fixed and variable resources required for the delivery of maternal health services in public facilities implementing the Bamako Initiative in the Local Government Areas studied. Given such constraints, it was highly unlikely that technically acceptable standards of care could be met without additional resource inputs to meet the norm. This is part of the cost of doing business and merits serious policy dialogue. Revenue generation from health services was poor and appeared to be more related to inadequate supply of essential drugs and consumables than to the use of uneconomic fee scales. It is likely that user fees will be necessary to supplement scarce government budgets, especially to fund the most critical variable inputs associated with quality improvements. However, any user fee system, especially one that raises fees to patients, will have to be accompanied by immediate and visible quality improvements. Without such quality improvements, cost recovery will result in even lower utilization and attempts to generate new revenues are unlikely to succeed. (+info)
Operational factors affecting maternal mortality in Tanzania.
Identification of the main operational factors in cases of maternal death within and outside the health care system is necessary for safe motherhood programmes. In this study, a follow-up was done of all 117 cases of maternal deaths in Ilala district, Dar es Salaam, 1991-1993, at all levels of care. In all, 79% received some medical care whereas 11% arrived too late for treatment. For each case the major operational factors and all health care interventions were defined through interviews with family members and health care staff and from hospital records, and the avoidability of each case was determined. In the health institutions where the women had consulted, the available resources were assessed. It was found that in most cases the husband (29%) or the mother (31%) of the woman decided on her care in cases of complications, and together with the lack of transport, this often caused delay at home. Also, delay in transfer from the district hospital was common. Cases of abortion complications were often not managed on time because of the delay in reporting to hospital or misleading information. Suboptimal care was identified in 77% of the cases reaching health care. Inadequate treatment was identified by the district health staff in 61% and by the referral centres in 12% of their cases. Wrong decision at the district level and lack of equipment at the referral centre were the main reasons for inadequate care. It is concluded that although community education on danger signs in pregnancy and labour is important, provision of the core resources and supplies for emergency obstetric interventions, as well as clear protocols for management and referral, are absolutely necessary for improvement of maternal survival. (+info)
Reducing perinatal mortality in developing countries.
The perinatal mortality rate (PNMR) is a key health status indicator. It is multifactorial in aetiology and is significantly influenced by the quality of health care. While there is an ethical imperative to act to improve quality of care when deficiencies are apparent, the lack of controls--when an interventions is applied to an entire service--makes it difficult to infer a causal relationship between the intervention and any subsequent change in PNMR. However, by specifically measuring avoidable perinatal deaths (those due to error or omission on the part of the health service), this limitation is partially overcome, and the impact of the intervention can be more rigorously evaluated. This paper reports the impact of perinatal audit in a rural African health district between 1991 and 1995. A total of 21,112 consecutive births were studied: the average number of deliveries increased by 31% from 325 to 424 per month. The PNMR (birth weight > or = 1000g) in 1991 was 27/1000, increased to 42/1000 in 1992, and fell steadily to 26/1000 in 1995 (40% reduction; p = 0.002). The proportion of avoidable deaths fell from 19% in 1991 to zero in the second half of 1995 (p = 0.0008). While factors associated with perinatal mortality are many, complex, and interrelated, this report suggests that mortality can be reduced significantly in resource-poor settings by improving quality of health care. Including the measurement of avoidable deaths in perinatal audit allows the impact of interventions to be more rigorously assessed than by simple measuring the PNMR. (+info)