Abbey Byrne

How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance

Forty years of safe motherhood programming has demonstrated that isolated interventions will not reduce maternal mortality sufficiently to achieve MDG 5. Although skilled birth attendants (SBAs) can intervene to save lives, traditional birth attendants (TBAs) are often preferred by communities. Considering the value of both TBAs and SBAs, it is important to review strategies for maximizing their respective strengths.

What Works? Strategies to Increase Reproductive, Maternal and Child Health in Difficult to Access Mountainous Locations: A Systematic Literature Review

Background Geography poses serious challenges to delivery of health services and is a well documented marker of inequity. Maternal, newborn and child health (MNCH) outcomes are poorer in mountainous regions of low and lower-middle income countries due to geographical inaccessibility combined with other barriers: poorer quality services, persistent cultural and traditional practices and lower socioeconomic and educational status. Reaching universal coverage goals will require attention for remote mountain settings. This study aims to identify strategies to address barriers to reproductive MNCH (RMNCH) service utilisation in difficult-to-reach mountainous regions in low and lower-middle income settings worldwide. Methods A systematic literature review drawing from MEDLINE, Web of Science, Scopus, Google Scholar, and Eldis. Inclusion was based on; testing an intervention for utilisation of RMNCH services; remote mountain settings of low- and lower-middle income countries; selected study designs. Studies were assessed for quality and analysed to present a narrative review of the key themes. Findings From 4,130 articles 34 studies were included, from Afghanistan, Bolivia, Ethiopia, Guatemala, Indonesia, Kenya, Kyrgyzstan, Nepal, Pakistan, Papua New Guinea and Tajikistan. Strategies fall into four broad categories: improving service delivery through selected, trained and supported community health workers (CHWs) to act alongside formal health workers and the distribution of critical medicines to the home; improving the desirability of existing services by addressing the quality of care, innovative training and supervision of health workers; generating demand by engaging communities; and improving health knowledge for timely care-seeking. Task shifting, strengthened roles of CHWs and volunteers, mobile teams, and inclusive structured planning forums have proved effective. Conclusions The review highlights where known evidence-based strategies have increased the utilisation of RMNCH services in low income mountainous areas. While these are known strategies in public health, in such disadvantaged settings additional supports are required to address both supply and demand barriers.

Context-specific, evidence-based planning for scale-up of family planning services to increase progress to MDG 5: health systems research

BackgroundUnmet need for family planning is responsible for 7.4 million disability-adjusted life years and 30% of the maternity-related disease burden. An estimated 35% of births are unintended and some 200 million couples state a desire to delay pregnancy or cease fertility but are not using contraception. Unmet need is higher among the poorest, lesser educated, rural residents and women under 19 years. The barriers to, and successful strategies for, satisfying all demand for modern contraceptives are heavily influenced by context. Successfully overcoming this to increase the uptake of family planning is estimated to reduce the risk of maternal death by up to 58% as well as contribute to poverty reduction, women’s empowerment and educational, social and economic participation, national development and environmental protection.MethodsTo strengthen health systems for delivery of context-specific, equity-focused reproductive, maternal, newborn and child health services (RMNCH), the Investment Case study was applied in the Asia-Pacific region. Staff of local and central government and non-government organisations analysed data indicative of health service delivery through a supply–demand oriented framework to identify constraints to RMNCH scale-up. Planners developed contextualised strategies and the projected coverage increases were modelled for estimates of marginal impact on maternal mortality and costs over a five year period.ResultsIn Indonesia, Philippines and Nepal the constraints behind incomplete coverage of family planning services included: weaknesses in commodities logistic management; geographical inaccessibility; limitations in health worker skills and numbers; legislation; and religious and cultural ideologies. Planned activities included: streamlining supply systems; establishment of Community Health Teams for integrated RMNCH services; local recruitment of staff and refresher training; task-shifting; and follow-up cards. Modelling showed varying marginal impact and costs for each setting with potential for significant reductions in the maternal mortality rate; up to 28% (25.1-30.7) over five years, costing up to a marginal USD 1.34 (1.32-1.35) per capita in the first year.ConclusionLocal health planners are in a prime position to devise feasible context-specific activities to overcome constraints and increase met need for family planning to accelerate progress towards MDG 5.

Factors influencing place of delivery for pastoralist women in Kenya: a qualitative study

BackgroundKenya’s high maternal mortality ratio can be partly explained by the low proportion of women delivering in health facilities attended by skilled birth attendants (SBAs). Many women continue to give birth at home attended by family members or traditional birth attendants (TBAs). This is particularly true for pastoralist women in Laikipia and Samburu counties, Kenya. This paper investigates the socio-demographic factors and cultural beliefs and practices that influence place of delivery for these pastoralist women.MethodsQualitative data were collected in five group ranches in Laikipia County and three group ranches in Samburu County. Fifteen in-depth interviews were conducted: seven with SBAs and eight with key informants. Nineteen focus group discussions (FGDs) were conducted: four with TBAs; three with community health workers (CHWs); ten with women who had delivered in the past two years; and two with husbands of women who had delivered in the past two years. Topics discussed included reasons for homebirths, access and referrals to health facilities, and strengths and challenges of TBAs and SBAs. The data were translated, transcribed and inductively and deductively thematically analysed both manually and using NVivo.ResultsSocio-demographic characteristics and cultural practices and beliefs influence pastoralist women’s place of delivery in Laikipia and Samburu counties, Kenya. Pastoralist women continue to deliver at home due to a range of factors including: distance, poor roads, and the difficulty of obtaining and paying for transport; the perception that the treatment and care offered at health facilities is disrespectful and unfriendly; lack of education and awareness regarding the risks of delivering at home; and local cultural values related to women and birthing.ConclusionsUnderstanding factors influencing the location of delivery helps to explain why many pastoralist women continue to deliver at home despite health services becoming more accessible. This information can be used to inform policy and program development aimed at increasing the proportion of facility-based deliveries in challenging settings.

Looking Beyond Supply A Systematic Literature Review of Demand-Side Barriers to Health Service Utilization in the Mountains of Nepal

Significant disparities in reproductive, maternal, newborn, and child health (RMNCH) outcomes and intervention coverage exist between the Mountains and other ecoregions of Nepal. Delivery of essential health services to remote mountainous areas is challenging and access is a known barrier to utilization. However, the contribution of demand-side barriers is poorly understood. Consequently, policies and programs cannot strategically target constraints to increase coverage. This systematic review identifies demand-side barriers to utilization of RMNCH services in the Mountain districts of Nepal. Research was drawn from MEDLINE, Web of Science, Scopus, Google Scholar, Eldis, and unpublished literature. Beyond inaccessibility, utilization is undermined by costs of care-seeking, traditional attitudes and practices, low status of women, limited health knowledge, dissatisfaction with service quality, and low and inequitable care by community health workers. The intensity and repercussions of these barriers are of greater magnitude in the Mountains where delayed care-seeking combines with long distances for critical health consequences.

Informing family planning research priorities: a perspective from the front line in Asia.

Impressive reductions of up to 29% in maternal deaths may be expected from satisfying unmet need for contraception as shown in a recent analysis covering 172 countries (Ahmed et al. 2012). Despite the cost-effectiveness of family planning (Prata et al. 2010) investments remain low (Osotimehin 2012) a concern declared under Goal 5 on the UN Millennium Development Goals website ‘Inadequate funding for family planning is a major failure in fulfilling commitments to improving women’s reproductive health.’ Alongside investment and political commitment clear indicators for the coverage and quality of family planning services are required to design and implement strategies to improve family planning. However the evidence used in planning and monitoring of family planning is often suboptimal and poses a serious problem for effective efficient responses to scale up these services. The 2012 London Summit on Family Planning signalled renewed interest in this important intervention by the global community. Large investments were pledged and ambitious targets of access to contraception for 120 million women and girls by 2020 were set. This has also prompted the Alliance for Reproductive Maternal and Newborn Health to work with WHO and development partners to facilitate a prioritisation of the family planning research agenda. With a view to informing these discussions we were commissioned by the Australian Agency for International Development (AusAID) to identify the key knowledge gaps for evidence-based planning and budgeting for family planning. As part of a multicountry initiative working with policy makers to effect a more rational use of resources for reproductive maternal newborn and child health (Jimenez-Soto et al. 2012) we collated the data necessary to inform local decision-making on scaling up family planning services. Our work highlighted major evidence gaps that have the potential to undermine efforts to plan and invest in family planning and interfere with monitoring progress. The seven leading knowledge gaps identified are outlined in this short paper and provide an essential ‘front-line’ perspective to inform research priorities for effective scaling-up of family planning. We draw on examples from our study sites in four countries: two districts and two cities in Indonesia two provinces and one city in the Philippines three clusters of districts in Nepal two districts in the Indian state of Orissa and two districts in the state of Uttar Pradesh. We believe that this view from the front line provides a much-needed link between global agendas and the realities of implementation at a local level. (excerpt)