Eva Bazant

Women's satisfaction with delivery care in Nairobi's informal settlements

OBJECTIVE To quantify womens satisfaction with delivery care in informal settlements of Nairobi, Kenya, and to determine characteristics of women and delivery care associated with satisfaction. DESIGN Household survey data analysis of 1266 women who delivered in health facilities in 2004 or 2005. SETTING Two densely populated informal settlements 7 and 12 km from Nairobis center, where residents work primarily in the nearby industrial area or in the informal sector. Outcome Satisfaction was assessed by whether women would recommend the delivery care facility and deliver there again. RESULTS Over half (56%) of women would both recommend and deliver again in the same facility. In multivariate analysis, womens satisfaction with delivery care was associated with greater provider empathy (OR = 3.68, 95% CI 2.27, 5.97). Womens satisfaction with delivery care was also associated with the pregnancy having been wanted (OR = 2.75, 95% CI 1.82, 4.14) or mistimed vs. unwanted. Women delivering at private facilities in the settlement near the industrial area were more satisfied than women delivering at private facilities in the more distant and marginalized settlement (OR = 2.12, 95% CI 1.45, 3.09). The association of womens satisfaction and provider empathy was stronger among women who experienced complications compared to those who did not. CONCLUSION Health providers should be sensitized to the finding that unintended pregnancy is associated with lower satisfaction with delivery care. Maternal health programmes should focus on increasing provider empathy, especially for women who experience complications, in both private and government health facilities.

Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa.

BackgroundPoor quality of care at health facilities is a barrier to pregnant women and their families accessing skilled care. Increasing evidence from low resource countries suggests care women receive during labor and childbirth is sometimes rude, disrespectful, abusive, and not responsive to their needs. However, little is known about how frequently women experience these behaviors. This study is one of the first to report prevalence of respectful maternity care and disrespectful and abusive behavior at facilities in multiple low resource countries.MethodsStructured, standardized clinical observation checklists were used to directly observe quality of care at facilities in five countries: Ethiopia, Kenya, Madagascar, Rwanda, and the United Republic of Tanzania. Respectful care was represented by 10 items describing actions the provider should take to ensure the client was informed and able to make choices about her care, and that her dignity and privacy were respected. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Clinical observers’ open-ended comments were also analyzed to identify examples of disrespect and abuse.ResultsA total of 2164 labor and delivery observations were conducted at hospitals and health centers. Encouragingly, women overall were treated with dignity and in a supportive manner by providers, but many women experienced poor interactions with providers and were not well-informed about their care. Both physical and verbal abuse of women were observed during the study. The most frequently mentioned form of disrespect and abuse in the open-ended comments was abandonment and neglect.ConclusionsEfforts to increase use of facility-based maternity care in low income countries are unlikely to achieve desired gains if there is no improvement in quality of care provided, especially elements of respectful care. This analysis identified insufficient communication and information sharing by providers as well as delays in care and abandonment of laboring women as deficiencies in respectful care. Failure to adopt a patient-centered approach and a lack of health system resources are contributing structural factors. Further research is needed to understand these barriers and develop effective interventions to promote respectful care in this context.

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 Malawis 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.

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

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.

Evaluation of a quality improvement intervention to prevent mother-to-child transmission of HIV (PMTCT) at Zambia defence force facilities

BackgroundThe Zambian Defence Force (ZDF) is working to improve the quality of services to prevent mother-to-child transmission of HIV (PMTCT) at its health facilities. This study evaluates the impact of an intervention that included provider training, supportive supervision, detailed performance standards, repeated assessments of service quality, and task shifting of group education to lay workers.MethodsFour ZDF facilities implementing the intervention were matched with four comparison sites. Assessors visited the sites before and after the intervention and completed checklists while observing 387 antenatal care (ANC) consultations and 41 group education sessions. A checklist was used to observe facilities’ infrastructure and support systems. Bivariate and multivariate analyses were conducted of findings on provider performance during consultations.ResultsAmong 137 women observed during their initial ANC visit, 52% came during the first 20 weeks of pregnancy, but 19% waited until the 28th week or later. Overall scores for providers’ PMTCT skills rose from 58% at baseline to 73% at endline (p=0.003) at intervention sites, but remained stable at 52% at comparison sites. Especially large gains were seen at intervention sites in family planning counseling (34% to 75%, p=0.026), HIV testing during return visits (13% to 48%, p=0.034), and HIV/AIDS management during visits that did not include an HIV test (1% to 34%, p=0.004). Overall scores for providers’ ANC skills rose from 67% to 74% at intervention sites, but declined from 65% to 59% at comparison sites; neither change was significant in the multivariate analysis. Overall scores for group education rose from 87% to 91% at intervention sites and declined from 78% to 57% at comparison sites. The overall facility readiness score rose from 73% to 88% at intervention sites and from 75% to 82% at comparison sites.ConclusionsThese findings are relevant to civilian as well as military health systems in Zambia because the two are closely coordinated. Lessons learned include: the ability of detailed performance standards to draw attention to and strengthen areas of weakness; the benefits of training lay workers to take over non-clinical PMTCT tasks; and the need to encourage pregnant women to seek ANC early.

Penile Measurements in Tanzanian Males: Guiding Circumcision Device Design and Supply Forecasting

PURPOSE Voluntary medical male circumcision decreases the risk in males of HIV infection through heterosexual intercourse by about 60% in clinical trials and 73% at post-trial followup. In 2007 WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that countries with a low circumcision rate and high HIV prevalence expand voluntary medical male circumcision programs as part of a national HIV prevention strategy. Devices for adult/adolescent male circumcision could accelerate the pace of scaling up voluntary medical male circumcision. Detailed penile measurements of African males are required for device development and supply size forecasting. MATERIALS AND METHODS Consenting males undergoing voluntary medical male circumcision at 3 health facilities in the Iringa region, Tanzania, underwent measurement of the penile glans, shaft and foreskin. Age, Tanner stage, height and weight were recorded. Measurements were analyzed by age categories. Correlations of penile parameters with height, weight and body mass index were calculated. RESULTS In 253 Tanzanian males 10 to 47 years old mean ± SD penile length in adults was 11.5 ± 1.6 cm, mean shaft circumference was 8.7 ± 0.9 cm and mean glans circumference was 8.8 ± 0.9 cm. As expected, given the variability of puberty, measurements in younger males varied significantly. Glans circumference highly correlated with height (r = 0.80) and weight (r = 0.81, each p <0.001). Stretched foreskin diameter moderately correlated with height (r = 0.68) and weight (r = 0.71, each p <0.001). CONCLUSIONS Our descriptive study provides penile measurements of males who sought voluntary medical male circumcision services in Iringa, Tanzania. To our knowledge this is the first study in a sub-Saharan African population that provides sufficiently detailed glans and foreskin dimensions to inform voluntary medical male circumcision device development and size forecasting.

A randomized evaluation of a demand creation lottery for voluntary medical male circumcision among adults in Tanzania

Background:Uptake of voluntary medical male circumcision (VMMC) among adult men has fallen short of targets in Tanzania. We evaluated a smartphone raffle intervention designed to increase VMMC uptake in three regions. Methods:Among 7 matched pairs of health facilities, 1 in each pair was randomly assigned to the intervention, consisting of a weekly smartphone raffle for clients returning for follow-up and monthly raffle for peer promoters and providers. VMMC records of clients aged 20 and older were analyzed over three months, with the number performed compared with the same months in the previous year. In multivariable models, the interventions effect on number of VMMCs was adjusted for client factors and clustering. Focus groups with clients and peer promoters explored preferences for VMMC incentives. Results:VMMCs increased 47% and 8% in the intervention and control groups, respectively; however, the changes were not significantly different from one another. In the Iringa region subanalysis, VMMCs in the intervention group increased 336% (exponentiated coefficient of 3.36, 95% CI: 1.14 to 9.90; P = 0.028), after controlling for facility pair, percentage of clients ≥ age 30, and percentage testing HIV positive; the control group had a more modest 63% increase (exponentiated coefficient 1.63, 95% CI: 1.18 to 2.26; P = 0.003). The changes were not significantly different. Focus group respondents expressed mixed opinions about smartphone raffles; some favored smaller cash incentive or transportation reimbursement. Implications:A smartphone raffle might increase VMMC uptake in some settings by helping late adopters move from intention to action; however, this study did not find strong evidence to support its implementation broadly.

Assessing the quality of HIV/AIDS services at military health facilities in Zambia

Summary After rapidly scaling up HIV/AIDS-related health services, the Zambian Defence Force (ZDF) has become concerned with assuring their quality. This evaluation assesses provider performance at eight ZDF facilities based on direct observations of 191 antenatal care (ANC) consultations and 175 follow-up consultations for antiretroviral therapy (ART). In addition, 43 ZDF health providers were interviewed about the work environment and service quality. On-the-job performance varied widely: providers completed as few as 0% and as many as 100% of tasks associated with each performance standard. Overall scores averaged 66% (range: 47–93%) for ANC consultations and 60% (range: 37–100%) for ART consultations. Perceptions of the work environment were generally positive, but 57% of providers lack confidence in their clinical skills and 42% think staffing is insufficient. These findings, which point to the unique opportunities and challenges in the military setting, will be used to guide a quality improvement initiative.

Effects of a performance and quality improvement intervention on the work environment in HIV-related care: a quasi-experimental evaluation in Zambia

BackgroundHuman resource shortages and reforms in HIV-related care make it challenging for frontline health care providers in southern Africa to deliver high-quality services. At health facilities of the Zambian Defence Forces, a performance and quality improvement approach was implemented to improve HIV-related care and was evaluated in 2010/2011. Changes in providers’ work environment and perceived quality of HIV-related care were assessed to complement data of provider performance.MethodsThe intervention involved on-site training, supportive supervision, and action planning focusing on detailed service delivery standards. The quasi-experimental evaluation collected pre- and post-intervention data from eight intervention and comparison facilities matched on defence force branch and baseline client volume. Overall, 101 providers responded to a 24-item questionnaire on the work environment, covering topics of drugs, supplies, and equipment; training, feedback, and supervision; compensation; staffing; safety; fulfilment; and HIV services quality. In bivariate analysis and multivariate analyses, we assessed changes within each study group and between the two groups.ResultsIn the bivariate analysis, the intervention group providers reported improvements in the work environment on adequacy of equipment, feeling safe from harm, confidence in clinical skills, and reduced isolation, while the comparison group reported worsening of the work environment on supplies, training, safety, and departmental morale.In the multivariate analysis, the intervention group’s improvement and the comparison group’s decline were significant on perceived adequacy of drugs, supplies, and equipment; constructive feedback received from supervisor and co-workers; and feeling safe from physical harm (all P <0.01, except P <0.04 for equipment). Further, the item “provider lacks confidence in some clinical skills” declined in the intervention group but increased in the comparison group (P = –0.005). In multivariate analysis, changes in perceived quality of HIV care did not differ between study groups. Provider perceptions were congruent with observations of preparing drugs, supplies, equipment, and in service delivery of prevention of mother-to-child transmission of HIV and antiretroviral therapy follow-up care.ConclusionsThe performance and quality improvement intervention implemented at Zambian Defence Forces’ health facilities was associated with improvements in providers’ perceptions of work environment consistent with the intervention’s focus on commodities, skills acquisition, and receipt of constructive feedback.

Respectful maternity care in Ethiopian public health facilities

BackgroundDisrespect and abuse of women during institutional childbirth services is one of the deterrents to utilization of maternity care services in Ethiopia and other low- and middle-income countries. This paper describes the prevalence of respectful maternity care (RMC) and mistreatment of women in hospitals and health centers, and identifies factors associated with occurrence of RMC and mistreatment of women during institutional labor and childbirth services.MethodsThis study had a cross sectional study design. Trained external observers assessed care provided to 240 women in 28 health centers and hospitals during labor and childbirth using structured observation checklists. The outcome variable, providers’ RMC performance, was measured by nine behavioral descriptors. The outcome, any mistreatment, was measured by four items related to mistreatment of women: physical abuse, verbal abuse, absence of privacy during examination and abandonment.We present percentages of the nine RMC indicators, mean score of providers’ RMC performance and the adjusted multilevel model regression coefficients to determine the association with a quality improvement program and other facility and provider characteristics.ResultsWomen on average received 5.9 (66%) of the nine recommended RMC practices. Health centers demonstrated higher RMC performance than hospitals. At least one form of mistreatment of women was committed in 36% of the observations (38% in health centers and 32% in hospitals).Higher likelihood of performing high level of RMC was found among male vs. female providers (β^=0.65