Are health facilities well equipped to provide basic quality childbirth services under the free maternal health policy? Findings from rural Northern Ghana.

BACKGROUND: Basic inputs and infrastructure including drugs, supplies, equipment, water and electricity are required for the provision of quality care. In the era of the free maternal health policy in Ghana, it is unclear if such basic inputs are readily accessible in health facilities. The study aimed to assess the availability of basic inputs including drugs, supplies, equipment and emergency transport in health facilities. Women and health providers' views on privacy and satisfaction with quality of care were also assessed. METHODS: The study used a convergent parallel mixed methods in one rural municipality in Ghana, Kassena-Nankana. A survey among facilities (n = 14) was done. Another survey was carried out among women who gave birth in health facilities only (n = 353). A qualitative component involved focus group discussions (FGDs) with women (n = 10) and in-depth interviews (IDIs) with midwives and nurses (n = 25). Data were analysed using descriptive statistics for the quantitative study, while the qualitative data were recorded, transcribed, read and coded using themes. RESULTS: The survey showed that only two (14%) out of fourteen facilities had clean water, and five (36%) had electricity. Emergency transport for referrals was available in only one (7%) facility. Basic drugs, supplies, equipment and infrastructure especially physical space were inadequate. Rooms used for childbirth in some facilities were small and used for multiple purposes. Eighty-nine percent (n = 314) of women reported lack of privacy during childbirth and this was confirmed in the IDIs. Despite this, 77% of women (n = 272) were very satisfied or satisfied with quality of care for childbirth which was supported in the FGDs. Reasons for women's satisfaction included the availability of midwives to provide childbirth services and to have follow-up homes visits. Some midwives were seen to be patient and empathetic. Providers were not satisfied due to health system challenges. CONCLUSION: Government should dedicate more resources to the provision of essential inputs for CHPS compounds providing maternal health services. Health management committees should also endeavour to play an active role in the management of health facilities to ensure efficiency and accountability. These would improve quality service provision and usage, helping to achieve universal health coverage.

Access to medicines for hypertension: a survey in rural Yogyakarta province, Indonesia.

INTRODUCTION: Obtaining an adequate supply of medicines is an important step in facilitating medication adherence. This study aimed to determine (1) how people with hypertension in rural villages in Indonesia obtain their supply of anti-hypertensive medications, (2) the type of hypertension medication taken and (3) factors associated with where and how people obtain their medicines supplies. METHOD: Data pertaining to people with hypertension (age ≥45 years) were collected from eight rural villages in the Bantul district, Yogyakarta province, Indonesia, using a researcher-administered questionnaire. RESULTS: Of 384 participants, 203 (52.9%) obtained anti-hypertensive medications from public or private healthcare services. The most common way was by purchasing these medicines without prescription in community pharmacies (n=64, 17%). The medicines obtained this way included captopril, amlodipine, nifedipine, and bisoprolol. One-hundred and nineteen (15%) participants obtained their medicines at no cost by visiting public healthcare services such as community health centres (n=51), the Integrated Health Service Post for the Elderly (n=53), and the public hospitals (n=15). Direct dispensing from clinicians was reported by participants who visited a doctor (n=15), midwife (n=23) or nurse (n=21). Having access to an adequate medication supply (ie for an entire 30 days) was reported by 40 (10.4%) participants, who obtained the medication from a community health centre (n=18), public hospital (n=4), community pharmacy (n=5), private hospital (n=2), or multiple sources (n=11). A higher formal education level was associated with obtaining medicines from multiple sources rather than from the public or private provider only. Living near a community health centre and having government insurance were associated with obtaining medicines from the public health service. Age, gender, employment, presence of other chronic diseases, and knowledge about hypertension were not significantly associated with how participants obtained their medications. CONCLUSION: These Indonesian participants obtained their anti-hypertensive medications from various sources; however, the inadequate supplies found in this study could compromise both short- and long-term management of hypertension. Direct dispensing, non-doctor prescribing, and self-medication with anti-hypertensive medications indicate the current complex healthcare system in Indonesia. This study also shows some challenges involved in managing patients with chronic diseases such as hypertension in resource-poor settings. It provides important findings for quality improvement practices that should be considered to improve the health lifespan in populous countries such as Indonesia.

The closure of rural and remote maternity services: Where are the midwives?

Decisions to close small maternity units in rural and remote communities have often precipitated a community response as women and families rally to save local services. But where are the midwives? We argue here that professional bodies such as colleges of midwives have a responsibility to advocate more strongly at a political level for evidence-based decisionmaking regarding the allocation of rural services. We suggest that adopting a comprehensive definition of maternity services risk that considers both social and health services risks and their impact on clinical risk, could provide a solid basis for effective advocacy by professional bodies.

Not Near Enough: Racial and Ethnic Disparities in Access to Nearby Behavioral Health Care and Primary Care.

BACKGROUND: Racial, ethnic, and geographical health disparities have been widely documented in the United States. However, little attention has been directed towards disparities associated with integrated behavioral health and primary care services. METHODS: Access to behavioral health professionals among primary care physicians was examined using multinomial logistic regression analyses with 2010 National Plan and Provider Enumeration System, American Medical Association Physician Masterfile, and American Community Survey data. RESULTS: Primary care providers practicing in neighborhoods with higher percentages of African Americans and Hispanics were less likely to have geographically proximate behavioral health professionals. Primary care providers in rural areas were less likely to have geographically proximate behavioral health professionals. CONCLUSION: Neighborhood-level factors are associated with access to nearby behavioral health and primary care. Additional behavioral health professionals are needed in racial/ethnic minority neighborhoods and rural areas to provide access to behavioral health services, and to progress toward more integrated primary care.

Exploring operational barriers encountered by community midwives when delivering services in two provinces of Pakistan: a qualitative study.

OBJECTIVES: to explore barriers experienced by community midwives (CMWs) when delivering services, from their own and their managers׳ perspectives, at provincial and district level in the context of organisational factors, and to determine other factors linked with the poor performance of CMWs in the delivery of maternal, neonatal and child health (MNCH)-related services within their communities. DESIGN: qualitative study design using in-depth interviews (IDIs) and focus group discussions (FGDs). SETTING: two districts in Khyber Pakhtunkhwa and Punjab provinces in Pakistan. PARTICIPANTS: 41 participants were interviewed in depth; they included CMWs, lady health supervisors and managerial staff of the MNCH programme. MEASUREMENTS: participants were interviewed about administrative issues including financial and policy areas, training and deployment in the community, functioning in the community, and supervision and referral for emergency cases. FINDINGS: CMWs reported financial constraints, training needs and difficulty with building relationships in the community. They required support in terms of logistics, essential supplies, and mechanisms for referral of complicated cases to higher-level health facilities. CONCLUSIONS: CMWs working in developing countries face many challenges; starting from their training, deployment in the field and delivery of services in their respective communities. Facilitating their work and efforts through improved programming of the CMW's services can overcome these challenges. IMPLICATIONS FOR PRACTICE: the MNCH programme, provincial government and other stakeholders need to take ownership of the CMW programme and implement it comprehensively. Long-term adequate resource allocation is needed to sustain the programme so that improvements in maternal and child health are visible.

Challenges regarding the implementation of the basic antenatal care approach in eThekwini District, Kwazulu-Natal.

AIM: The aim of the study was to investigate the challenges experienced by midwives during the implementation of the Basic Antenatal Care programme. BACKGROUND: The National Department of Health recommended that all primary health care facilities in South Africa start to implement the Basic Antenatal Care programme by the end of 2008. In her work as coordinator of the Maternal Child and Women's Health programme for the eThekwini Municipality, the researcher observed the slow progress in implementation of the programme in the eThekwini district. METHOD: A descriptive qualitative design using questionnaires was used to assess the challenges being experienced by midwives during the implementation of the programme. RESULTS: The challenges identified included: shortage of staff, lack of cooperation from referral hospitals, lack of in-service training, problems with transportation of specimens to laboratories, lack of material resources, unavailability of Basic Antenatal Care programme guidelines and lack of management support. CONCLUSION: The challenges were the possible cause of the slow progress in the implementation of the programme. IMPLICATIONS FOR NURSING MANAGEMENT: The successful implementation of the new programme is dependent on support and guidance offered by the nurse manager to the staff at operational level. The manager should monitor and develop strategies to address and overcome challenges that hinder implementation of the Basic Antenatal Care programme.

Improved accessibility of emergency obstetrics and newborn care (EmONC) services for maternal and newborn health: a community based project.

BACKGROUND: Every year an estimated three million neonates die globally and two hundred thousand of these deaths occur in Pakistan. Majority of these neonates die in rural areas of underdeveloped countries from preventable causes (infections, complications related to low birth weight and prematurity). Similarly about three hundred thousand mother died in 2010 and Pakistan is among ten countries where sixty percent burden of these deaths is concentrated. Maternal and neonatal mortality remain to be unacceptably high in Pakistan especially in rural areas where more than half of births occur. METHOD/DESIGN: This community based cluster randomized controlled trial will evaluate the impact of an Emergency Obstetric and Newborn Care (EmONC) package in the intervention arm compared to standard of care in control arm. Perinatal and neonatal mortality are primary outcome measure for this trial. The trial will be implemented in 20 clusters (Union councils) of District Rahimyar Khan, Pakistan. The EmONC package consists of provision of maternal and neonatal health pack (clean delivery kit, emollient, chlorhexidine) for safe motherhood and newborn wellbeing and training of community level and facility based health care providers with emphasis on referral of complicated cases to nearest public health facilities and community mobilization. DISCUSSION: Even though there is substantial evidence in support of effectiveness of various health interventions for improving maternal, neonatal and child health. Reduction in perinatal and neonatal mortality remains a big challenge in resource constrained and diverse countries like Pakistan and achieving MDG 4 and 5 appears to be a distant reality. A comprehensive package of community based low cost interventions along the continuum of care tailored according to the socio cultural environment coupled with existing health force capacity building may result in improving the maternal and neonatal outcomes. The findings of this proposed community based trial will provide sufficient evidence on feasibility, acceptability and effectiveness to the policy makers for replicating and scaling up the interventions within the health system.

The importance of public sector health facility-level data for monitoring changes in maternal mortality risks among communities: the case of pakistan.

This paper illustrates the importance of monitoring health facility-level information to monitor changes in maternal mortality risks. The annual facility-level maternal mortality ratios (MMRs), complications to live births ratios and case fatality ratios (CFRs) were computed from data recorded during 2007 and 2009 in 31 upgraded public sector health facilities across Pakistan. The facility-level MMR declined by about 18%; both the number of Caesarean sections and the episodes of complications as a percentage of live births increased; and CFR based on Caesarean sections and episodes of complications declined by 29% and 37%, respectively. The observed increases in the proportion of women with complications among those who come to these facilities point to a reduction in the delay in reaching facilities (first and second delays; Thaddeus & Maine, 1994); the decrease in CFRs points to improvements in treating obstetric complications and a reduction in the delay in receiving treatment once at facilities (the third delay). These findings point to a decline in maternal mortality risks among communities served by these facilities. A system of woman-level data collection instituted at health facilities with comprehensive emergency obstetric care is essential to monitor changes in the effects of any reduction in the three delays and any improvement in quality of care or the effectiveness of treating pregnancy-related complications among women reaching these facilities. Such a system of information gathering at these health facilities would also help policymakers and programme mangers to measure and improve the effectiveness of safe-motherhood initiatives and to monitor progress being made toward achieving the fifth Millennium Development Goal.

Osteopathic physicians and international medical graduates in the rural primary care physician workforce.

BACKGROUND AND OBJECTIVES: Primary care physician (PCP) shortages are a longstanding problem in the rural United States. This study describes the 2005 supply of two important components of the rural PCP workforce: rural osteopathic (DO) and international medical graduate (IMG) PCPs. METHODS: American Medical Association (AMA) and American Osteopathic Association (AOA) 2005 Masterfiles were combined to identify clinically active, non-resident, non-federal physicians aged 70 or younger. Rural-Urban Commuting Area codes were used to categorize practice locations as urban, large rural, small rural, or isolated small rural. National- and state-level analyses were performed. PCPs included family physicians, general internists, and general pediatricians. RESULTS: DOs comprised 4.9% and IMGs 22.2% of the total clinically active workforce. However, they contributed 10.4% and 19.3%, respectively, to the rural PCP workforce, although their relative representation varied geographically. DO PCPs were more likely than allopathic PCPs to practice in rural places (20.5% versus 14.9%, respectively). IMG PCPs were more likely than other PCPs to practice in rural persistent poverty locations (12.4% versus 9.1%). The proportion of rural PCP workforce represented by DOs increased with increasing rurality and that of IMGs decreased. CONCLUSIONS: DO and IMG PCPs constitute a vital portion of the rural health care workforce. Their ongoing participation is necessary in addressing existing rural PCP shortages and handling the influx of newly insured residents as the Patient Protection and Affordable Care Act (ACA) comes into effect. The impact on rural DO and IMG PCP supply of ACA measures intended to increase their numbers remains to be seen.

Integrating evidence into policy and sustainable disability services delivery in western New South Wales, Australia: the 'wobbly hub and double spokes' project.

BACKGROUND: Policy that supports rural allied health service delivery is important given the shortage of services outside of Australian metropolitan centres. The shortage of allied health professionals means that rural clinicians work long hours and have little peer or service support. Service delivery to rural and remote communities is further complicated because relatively small numbers of clients are dispersed over large geographic areas. The aim of this five-year multi-stage project is to generate evidence to confirm and develop evidence-based policies and to evaluate their implementation in procedures that allow a regional allied health workforce to more expeditiously respond to disability service need in regional New South Wales, Australia. METHODS/DESIGN: The project consists of four inter-related stages that together constitute a full policy cycle. It uses mixed quantitative and qualitative methods, guided by key policy concerns such as: access, complexity, cost, distribution of benefits, timeliness, effectiveness, equity, policy consistency, and community and political acceptability. Stage 1 adopts a policy analysis approach in which existing relevant policies and related documentation will be collected and reviewed. Policy-makers and senior managers within the region and in central offices will be interviewed about issues that influence policy development and implementation. Stage 2 uses a mixed methods approach to collecting information from allied health professionals, clients, and carers. Focus groups and interviews will explore issues related to providing and receiving allied health services. Discrete Choice Experiments will elicit staff and client/carer preferences. Stage 3 synthesises Stage 1 and 2 findings with reference to the key policy issues to develop and implement policies and procedures to establish several innovative regional workforce and service provision projects. Stage 4 uses mixed methods to monitor and evaluate the implementation and impact of new or adapted policies that arise from the preceding stages. DISCUSSION: The project will provide policy makers with research evidence to support consideration of the complex balance between: (i) the equitable allocation of scarce resources; (ii) the intent of current eligibility and prioritisation policies; (iii) workforce constraints (and strengths); and (iv) the most effective, evidence-based clinical practice.