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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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slide1

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
slide2

Report available at:

www.worldbank.org/hnppublications

nairobi kenya
Nairobi, Kenya

A private clinic in the slums

Pumwani hospital outside slums

slide6

Outline

  • Objectives
  • Background
  • Methods (quantitative & qualitative)
  • Main findings
  • Choice of method for evaluation
slide7

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
slide8

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
slide10

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)
slide11

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
slide13

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
slide14

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 )
slide16

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
slide17

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
slide18

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
slide20

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
slide21

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)
slide23

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
slide25

India – Uttar Pradesh

  • 73 maternal deaths/275 female deaths
  • 18,696 live births
    • MMRatio 409 maternal deaths per 100,000 live births
slide26

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

slide27

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

slide28

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
slide29

UP - Analysis of First Delay

Decision delay – time taken to make decision

slide31

UP - Analysis of Second Delay

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

slide38

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
slide41

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
slide43

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!