Obstetric Care in Poor Settings in Ghana, India & Kenya:
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Obstetric Care in Poor Settings in Ghana, India & Kenya: Use of Qualitative and Quantitative methods. Samuel Mills Eduard Bos Elizabeth Lule GNV Ramana Rudolfo Bulatao. Report available at: www.worldbank.org/hnppublications. Ghana - Kassena-Nankana District. India – Uttar Pradesh State.

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Obstetric Care in Poor Settings in Ghana, India & Kenya:

Use of Qualitative and Quantitative methods

  • Samuel Mills

  • Eduard Bos

  • Elizabeth Lule

  • GNV Ramana

  • Rudolfo Bulatao


Report available at:

www.worldbank.org/hnppublications


Ghana - Kassena-Nankana District


India – Uttar Pradesh State


Nairobi, Kenya

A private clinic in the slums

Pumwani hospital outside slums


Outline

  • Objectives

  • Background

  • Methods (quantitative & qualitative)

  • Main findings

  • Choice of method for evaluation


Objectives

  • To investigate recent maternal deaths to understand the level and causes of maternal mortality

  • To explore 3-delays resulting in maternal deaths

    • 1st Decision delay

    • 2nd Travel delay

    • 3rd Treatment delay

  • To assess the adequacy and quality of EmOC

  • To describe the utilization of antenatal and delivery services


Background

  • Millennium Development Goal (MDG5)

    • Reduce MMR by 75% between 1990 & 2015

  • Global estimates of maternal mortality remains unchanged (1990-2005)

    • 0.4% annual decline instead of 5.5%

  • % of births with skilled attendant is another indicator for MDG5

  • However, access to quality emergency obstetric care is key to the reduction of maternal morbidity and mortality


Research Methods


Quantitative Methods

  • Household surveys

    • Socio-demographics

    • Assess utilization of ANC, delivery & postnatal care, payments for obstetric care

    • 3-delays

  • Health facilities survey

    • Assessment of health facilities

    • Adequacy and quality of care

  • Verbal autopsy

    • Structured (estimate and causes of MMR)

    • Unstructured (contributory factors)


Qualitative Methods

  • Focus groups

    • Describe utilization of care

    • Community perspective

    • Cultural issues

  • In-depth interviews

    • Near misses were interviewed

    • Near misses are women who had life threatening obstetric complications but survived


Sampling


Sampling: In-depth interview

  • Ghana

    • Purposive sampling of near misses

      • PS is a non-probability sampling

      • Sample with a purpose (not convenience)

      • Sample with a criteria in mind (age, sex etc)

  • District hospital

    • List names and addresses of all women who experienced near misses in 2004

    • Trained interviewers visited the homes of these women

    • Out of 33 cases, 28 were interviewed


Sampling: Focus groups

  • Ghana

    • District in N. Ghana with popu 142,000

  • Purposive sampling

    • 2 main languages (Kasem, Nankam)

    • 10 chiefdoms in district

    • 15 communities/villages selected

    • 18 homogenous groups selected

    • (source: Mills S, Bertrand JT. 2005. Use of Health Professionals for Obstetric Care in Northern Ghana. Studies in Family Planning 36(1): 45-56)


Focus group procedure

  • Design focus group guide/consent form

    • Guide should be unstructured

    • Should generate long responses

    • eg tell me about, what are your views on…

    • Not what is your name (quantitative)

  • Community contact person assemble informants at agreed place and time

  • Research team

    • 2 moderators (female & male)

    • 2 assistants (female & male)

    • 1 transcriptionist


Focus group session

  • Introduction & administer informed consent

  • 9-12 persons per group

  • 45-90 mins per session

  • Moderator/assistant and group of same sex

  • Audio recorded

    • Olympus digital voice recorder DS 3000

  • Transcription of interviews

    • Olympus DSS Pro transcription software & foot switch

  • Data analysis

    • Atlas.ti software


Focus group session

  • Successful in-depth interview/ focus groups

    • Informant or group does most of the talking

    • Informant's responses are spontaneous & relevant

    • Interviewer keeps questions short but asks all relevant questions

    • Interviewer does not read the questions in the guide verbatim

    • Interviewer follows up on leads


Study Findings


Ghana - Kassena-Nankana District

  • 45 maternal deaths/516 female deaths

  • 12,049 total live births

    • MMRatio is 373

  • 17 health facilities deaths

    • Health facility MMRatio is 141

  • MMRatio decline in district

    • 637 in 1995-1996


KND – Reasons for decline in MMR

  • Confluence of various research and communications activities over the decade

    • Community Health and Family Planning Project

  • Various reproductive health indicators have improved

    • Infant mortality (129 in 1994 to 73 in 2003)

    • TFR (5.1 in 1994 to 4.1 in 2003)

    • No prim education (77% in 1993 to 51% in 2002)

    • African trad religion (70% in 1993 to 31% in 2002)


KND – Causes of maternal mortality


Kenya - Nairobi slums

  • 29 maternal deaths/289 female deaths

  • 5,356 live births

    • MMRatio 630 maternal deaths per 100,000 live births

  • 22 late maternal deaths (6wks-1yr)

    • 13 were due to HIV/AIDS deaths


Nairobi – Causes of maternal mortality


India – Uttar Pradesh

  • 73 maternal deaths/275 female deaths

  • 18,696 live births

    • MMRatio 409 maternal deaths per 100,000 live births


UP - Causes of maternal deaths

Hemorrhage

27.2%

12.7%

Obstructed/Prolonged Labor

Complications of Abortion

10.9%

Postpartum Sepsis

5.5%

Toxemia

5.5%

Eclampsia

5.5%

Miscarriage

1.8%

Anemia

16.4%

Cardiac Failure

7.3%

Tuberculosis

1.8%

Acute Renal Failure

1.8%

Unidentifiable

3.6%

Causes Unidentifiable

Indirect Causes

Direct Causes


During 8-42 Days after Delivery

(14%)

Post-abortal

(11%)

During Pregnancy

(15%)

During 1-7 Days after Delivery

(9%)

During or Within Hours of Delivery

(51%)

UP - Time of Death


UP - Delays that Resulted in Deaths

  • Sudden deaths (delays not applicable) 10 cases

  • Delays reported – 45 cases

  • 18 of the 45 did not reach a health facility

  • All 3 delays interconnected


UP - Analysis of First Delay

Decision delay – time taken to make decision


UP - Analysis of Second Delay

Time Gap between Decision to Seek Care and Reaching a Qualified Doctor/Health Facility


UP - Analysis of Third Delay

Treatment delay


All three delays are interconnected


Compare findings of 3 settings


% Pregnant Women Receiving Obstetric Care


Barriers to obstetric care use

  • India

    • Preference for home deliveries

    • Public health facilities not adequately equipped & staffed

  • Ghana

    • Preference for hospital delivery but

      • Long distance & lack of transport

  • Kenya

    • Facilities are available in Nairobi but

      • High hospital fees


Maternal Mortality Ratio


Abortion MMRatio


Abortion laws

  • India

    • Liberal

      • to save woman’s life, mental health, rape/incest, fetal impairment, socio-economic reasons, contraceptive failure

  • Ghana

    • Similar to India but no induced abortion for socio-economic reasons

  • Kenya

    • Abortion is illegal except to save woman’s life


HIV/AIDS MMRatio


Mix methods

  • In the evaluation of programs, use

    • Quantitative methods to ascertain percentage increase or decrease of indicators of interest

    • Qualitative methods to explain why the project was or was not successful

    • Employ both for a meaningful evaluation!


Thanks


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