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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

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


Obstetric care in poor settings in ghana india kenya

Report available at:

www.worldbank.org/hnppublications


Obstetric care in poor settings in ghana india kenya

Ghana - Kassena-Nankana District


Obstetric care in poor settings in ghana india kenya

India – Uttar Pradesh State


Nairobi kenya

Nairobi, Kenya

A private clinic in the slums

Pumwani hospital outside slums


Obstetric care in poor settings in ghana india kenya

Outline

  • Objectives

  • Background

  • Methods (quantitative & qualitative)

  • Main findings

  • Choice of method for evaluation


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

Research Methods


Obstetric care in poor settings in ghana india kenya

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)


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

Sampling


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

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)


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

Study Findings


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

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)


Obstetric care in poor settings in ghana india kenya

KND – Causes of maternal mortality


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

Nairobi – Causes of maternal mortality


Obstetric care in poor settings in ghana india kenya

India – Uttar Pradesh

  • 73 maternal deaths/275 female deaths

  • 18,696 live births

    • MMRatio 409 maternal deaths per 100,000 live births


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

UP - Analysis of First Delay

Decision delay – time taken to make decision


Obstetric care in poor settings in ghana india kenya

UP - Analysis of Second Delay

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


Obstetric care in poor settings in ghana india kenya

UP - Analysis of Third Delay

Treatment delay


Obstetric care in poor settings in ghana india kenya

All three delays are interconnected


Obstetric care in poor settings in ghana india kenya

Compare findings of 3 settings


Obstetric care in poor settings in ghana india kenya

% Pregnant Women Receiving Obstetric Care


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

Maternal Mortality Ratio


Obstetric care in poor settings in ghana india kenya

Abortion MMRatio


Obstetric care in poor settings in ghana india kenya

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


Obstetric care in poor settings in ghana india kenya

HIV/AIDS MMRatio


Obstetric care in poor settings in ghana india kenya

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!


Obstetric care in poor settings in ghana india kenya

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