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  1. 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

  2. Report available at: www.worldbank.org/hnppublications

  3. Ghana - Kassena-Nankana District

  4. India – Uttar Pradesh State

  5. Nairobi, Kenya A private clinic in the slums Pumwani hospital outside slums

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

  7. 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

  8. 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

  9. Research Methods

  10. 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)

  11. 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

  12. Sampling

  13. 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

  14. 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 )

  15. 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

  16. 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

  17. 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

  18. Study Findings

  19. 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

  20. 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)

  21. KND – Causes of maternal mortality

  22. 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

  23. Nairobi – Causes of maternal mortality

  24. India – Uttar Pradesh • 73 maternal deaths/275 female deaths • 18,696 live births • MMRatio 409 maternal deaths per 100,000 live births

  25. 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

  26. 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

  27. 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

  28. UP - Analysis of First Delay Decision delay – time taken to make decision

  29. UP - Analysis of Second Delay Time Gap between Decision to Seek Care and Reaching a Qualified Doctor/Health Facility

  30. UP - Analysis of Third Delay Treatment delay

  31. All three delays are interconnected

  32. Compare findings of 3 settings

  33. % Pregnant Women Receiving Obstetric Care

  34. 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

  35. Maternal Mortality Ratio

  36. Abortion MMRatio

  37. 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

  38. HIV/AIDS MMRatio

  39. 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!

  40. Thanks