Alison Morgan

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.

How does progress towards the MDG 4 affect inequalities between different subpopulations? Evidence from Nepal

Background Few previous studies have examined non-wealth-based inequalities in child mortality within developing countries. This study estimates changes in under-5-year-olds and neonatal mortality in Nepal across a range of subnational levels, which allows us to assess the degree of equity in Nepals progress towards Millennium Development Goal 4. Methods Direct estimates of under-5-year-olds and neonatal death rates were generated for 1990–2005 using three Demographic and Health Surveys and two Living Standards Surveys by the following levels: national, rural/urban location, ecological region, development region, ethnicity and wealth. Absolute and relative inequalities were measured by rate differences and rate ratios, respectively. Additionally, wealth-related inequality was calculated using slope and relative indexes of inequality and concentration indices. Results Estimates suggest that while most rates of under-5-year-olds and neonatal mortality have declined across the different equity markers, leading to a downward trend in absolute inequalities, relative inequalities appear to have remained stable over time. The decline in absolute inequalities is strongest for under-5-year-olds’ mortality, with no statistically significant trend in either relative or absolute inequalities found for neonatal mortality. A possible increase in inequalities, at least in relative terms, was found across development regions, where death rates remain high in the mid-western region. Conclusions By 2015, our estimates suggest that more than 65% of deaths of under-5-year-olds will occur in the neonatal period, with stable trends in neonatal mortality inequalities. These findings along with the fact that health outcomes for neonates are more highly dependent on health systems, suggest further equitable reductions in under-5-year-olds mortality will require broad health-system strengthening, with a focus on the improvement of healthcare services provided for mothers and newborns. Other inequities suggest continued special attention for vulnerable subpopulations is warranted, particularly to overcome social exclusion and financial barriers to care in urban areas.

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.

Developing and costing local strategies to improve maternal and child health: the Investment Case Framework

Eliana Jimenez Soto and colleagues describe the Investment Case framework, a health systems research approach for planning and budgeting, and detail the implementation of the framework in four Asian countries to improve maternal, newborn and child health.

Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal.

In Nepal, where difficult geography and an under‐resourced health system contribute to poor health care access, the government has increased the number of trained skilled birth attendants (SBAs) and posted them in newly constructed birthing centres attached to peripheral health facilities that are available to women 24 h a day. This study describes their views on their enabling environment.

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.

Designing the framework for competency-based master of public health programs in India.

Competency in the practice of public health is the implicit goal of education institutions that offer master of public health (MPH) programs. With the expanding number of institutions offering courses in public health in India, it is timely to develop a common framework to ensure that graduates are proficient in critical public health. Steps such as situation assessment, survey of public health care professionals in India, and national consultation were undertaken to develop a proposed competency-based framework for MPH programs in India. The existing curricula of all 23 Indian MPH courses vary significantly in content with regard to core, concentration, and crosscutting discipline areas and course durations. The competency or learning outcome is not well defined. The findings of the survey suggest that MPH graduates in India should have competencies ranging from monitoring of health problems and epidemics in the community, applying biostatistics in public health, conducting action research, understanding social and community influence on public health developing indicators and instruments to monitor and evaluate community health programs, developing proposals, and involving community in planning, delivery, and monitoring of health programs. Competency statements were framed and mapped with domains including epidemiology, biostatistics, social and behavioral sciences, health care system, policy, planning, and financing, and environmental health sciences and a crosscutting domain that include health communication and informatics, health management and leadership, professionalism, systems thinking, and public health biology. The proposed competency-based framework for Indian MPH programs can be adapted to meet the needs of diverse, unique programs. The framework ensures the uniqueness and diversity of individual MPH programs in India while contributing to measures of overall program success.

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.

The potential of task shifting selected maternal interventions to auxiliary midwives in Myanmar: a mixed-method study

BackgroundAn estimated 282 women die for every 100,000 live births in Myanmar, most due to preventable causes. Auxiliary Midwives (AMWs) in Myanmar are responsible for providing a package of care during pregnancy and childbirth to women in rural hard to reach areas where skilled birth attendants (Midwives) are not accessible. This study aims to examine the role of AMWs in Myanmar and to assess the current practices of three proposed essential maternal interventions (oral supplement distribution to pregnant women; administration of misoprostol to prevent postpartum haemorrhage; management of puerperal sepsis with oral antibiotics) in order to facilitate a formal integration of these tasks to AMWs in Myanmar.MethodsA mixed methods study was conducted in Magwe Region, Myanmar involving a survey of 262 AMWs, complemented by 15 focus group discussions with midwives (MWs), AMWs, mothers and community members, and 10 key informant interviews with health care providers at different levels within the health care system.ResultsAccording to current government policy, AMWs are responsible for identifying pregnant women, screening for danger signs and facilitating early referral, provision of counselling on nutrition and birth preparedness for women in hard-to-reach areas. AMWs also assist at normal deliveries and help MWs provide immunization services. In practice, they also provide oral supplements to pregnant women (84%), provide antibiotics to mothers during the puerperium (43%), and provide misoprostol to prevent postpartum haemorrhage (41%). The current practices of AMWs demonstrate the potential for task shifting on selected essential maternal interventions. However, to integrate these interventions into formal practice they must be complemented with appropriate training, clear guidelines on drug use, systematic recording and reporting, supportive monitoring and supervision and a clear political commitment towards task shifting.ConclusionWith the current national government’s commitment towards one AMW in one village, this study highlights the potential for shifting specific maternal lifesaving tasks to AMWs.