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Translating evidence into practice: An example from the Occupied Palestinian Territory ( oPt )

Translating evidence into practice: An example from the Occupied Palestinian Territory ( oPt ). By: Sahar Hassan RN, CNM, MSN Institute of Community and Public Health / Birzeit University, Occupied Palestinian Territory Third JNC International Nursing Conference Amman, April 2010.

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Translating evidence into practice: An example from the Occupied Palestinian Territory ( oPt )

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  1. Translating evidence into practice: An example from the Occupied Palestinian Territory (oPt) By: Sahar Hassan RN, CNM, MSN Institute of Community and Public Health / Birzeit University, Occupied Palestinian Territory Third JNC International Nursing Conference Amman, April 2010

  2. Outline • Background • Significance • Purpose • Methods • Results • Conclusion

  3. Background • Maternal health is a core component of any health system. • It serves more than half of any country population; women and their newborns. • Maternity facilities in many countries are facing many barriers to the implementation of evidence-based practices.

  4. Context in the oPt. • Health care is provided by 4 health sectors: Governmental, non-governmental, UNRWA & private. • High coverage but poor quality of antenatal care. • 97% of births occur in hospitals. • Deliveries in governmental hospital free of charge. • In Governmental hospitals, midwives are conducting almost all vaginal births. • Early discharge and little postpartum follow-up in the community. • Last minute referrals without records

  5. Perinatal and health service indicators in Palestine Palestinian Central Bureau of Statistics, 2007. Palestinian Family Health Survey 2006. Ramallah, Palestine. Rashad H et al. Marriage in the Arab World Population Reference Bureau Policy Brief, 2005.

  6. Significance • Why are women getting poor care during normal childbirth? • Nature & uniqueness of childbirth care

  7. Purpose • To improve the quality of maternal health services provided for women and their newborns in the maternity ward in ONE Palestinian governmental hospital through upgrading the midwives’ and nurses’ usual practices during normal childbirth.

  8. Overall hospital bed capacity: 143 bed. General referral teaching hospital. Maternity bed capacity: 36 maternity beds: (2 for delivery, 3 for labor and 31 for postpartum & gynecology cases). The total number of deliveries 300 – 330 deliveries per month. Midwives are the main providers in the L&D wards for women & newborns, while nurses provide postnatal care. Context of the hospital

  9. Methods • Design: a prospective observational action- oriented research. • Study population: pregnant laboring women admitted to the maternity ward. • Research methods: Quantitative & qualitative. • 3 phases: Phase I: Needs assessment (2006) Phase II: Interventions (2007 & 2008) Phase III: Post-intervention (2009 & still ongoing)

  10. Phase I: Needs assessment(2006) Publications: Hassan-Bitar S, and Narraine S. 2009. ‘shedding light’ on the challenges faced by Palestinian maternal health care providers. Midwifery do: 1016J.midw.2009.05.007. Hassan-Bitar S. and Wick L. 2007. Evoking the Guardian Angel: Childbirth Care in a Palestinian Hospital. Reproductive Health Matters 15 (30): 103-113. Hassan-Bitar S. 2007. Needs Assessment of Maternity Services in Ramallah Governmental Hospital West Bank. Report. Institute of Community and Public Health, Birzeit University. Ramallah.

  11. Phase I: Selected results 1) Physical Resources • Poor infrastructures. • Equipment & supplies: Occasional deficiencies, chronic shortages or frequently unavailable. • Infection prevention practices were not sufficient. 2) Human resources: Shortage of staff, low morale, poor working conditions. 3) Practices & quality of care: Practices that are not appropriate/harmful/not based on the current best evidence. Hassan-Bitar S, and Narraine S. 2009. ‘Shedding light’ on the challenges faced by Palestinian maternal health care providers. Midwifery do: 1016J.midw.2009.05.007. Hassan-Bitar S. and Wick L. 2007. Evoking the Guardian Angel: Childbirth Care in a Palestinian Hospital. Reproductive Health Matters 15 (30): 103-113.

  12. Routine use of harmful practices. Shortage of staff. Lack of basic supplies and equipments. Poor management and organization of care. Insufficient supervision. Midwives powerless to effect change. Reasons for suboptimal care Hassan-Bitar S. and Wick L. 2007. Evoking the Guardian Angel: Childbirth Care in a Palestinian Hospital. Reproductive Health Matters 15 (30): 103-113.

  13. Phase II: Interventions(2007 & 2008) Key questions: • What are the causes of poor performance-why the gap? • What are the effective changes in childbirth care in the hospital that can be implemented with minimal cost? • What is feasible to change given the existing conditions? Approach: • A model of continuous quality improvement • On-the-job training • Multifaceted interactive team work methods i.e. audit, feedback, supportive supervision, training & discussions. • participatory approach • Monitoring & Evaluation

  14. Phase II: Interventions Priority areas for improvement: • Practices during labor, delivery and immediate postpartum. • Active management of third stage of labor. • Vaginal examinations during labor. • Postpartum assessment of women after normal childbirth. • Health education.

  15. Phase II: Preliminary results • Positive changes in the usual practices of midwives during childbirth. • Saving resources. • Positive changes in the basics of immediate and late postpartum nursing care.

  16. Positive changes in midwives' practices during childbirth

  17. Phase III: Post-interventions(2009 & 2010) • Initiation: 9 months after the end of interventions. • Aim: to check out for sustainability of changes that occurred during the intervention phase. • Still ongoing!

  18. Conclusion • Despite many complex systemic challenges, low morale of staff, and an unstable political situation, change was possible. • It was possible to improve the quality of some aspects of maternity care provided for women during childbirth by adapting midwives and nurses’ usual practices to the best available evidence with no added cost. • We are in the process of evaluating the sustainability of the changes. • For sustainable improvements, a concentrated effort is needed for the systemic upgrading of the quality of maternity care. • The existing nursing & midwifery programs need to improve their quality of education & clinical training.

  19. Conclusion • Further work and effort is still needed to improve the capacity of hospital-based midwives and nurses in the other basic areas such as: • Partograph use. • Assisting in breastfeeding. • Communication. • Focused & individualized health education for postpartum women. • Care of high risk cases and emergency obstetric care.

  20. Hassan-Bitar S, and Narraine S. 2009. ‘Shedding light’ on the challenges faced by Palestinian maternal health care providers. Midwifery do: 1016J.midw.2009.05.007. Hassan-Bitar S. and Wick L. 2007. Evoking the Guardian Angel: Childbirth Care in a Palestinian Hospital. Reproductive Health Matters 15 (30): 103-113. Hassan-Bitar S. 2007. Needs Assessment of Maternity Services in Ramallah Governmental Hospital West Bank. Report. Institute of Community and Public Health, Birzeit University. Ramallah. References

  21. Thank you

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