Facility-based active management of the third stage of labour: assessment of quality in six countries in sub-Saharan Africa.

OBJECTIVE: To assess the quality of facility-based active management of the third stage of labour in Ethiopia, Kenya, Madagascar, Mozambique, Rwanda and the United Republic of Tanzania. METHODS: Between 2009 and 2012, using a cross-sectional design, 2317 women in 390 health facilities were directly observed during the third stage of labour. Observers recorded the use of uterotonic medicines, controlled cord traction and uterine massage. Facility infrastructure and supplies needed for active management were audited and relevant guidelines reviewed. FINDINGS: Most (94%; 2173) of the women observed were given oxytocin (2043) or another uterotonic (130). The frequencies of controlled cord traction and uterine massage and the timing of uterotonic administration showed considerable between-country variation. Of the women given a uterotonic, 1640 (76%) received it within three minutes of the birth. Uterotonics and related supplies were generally available onsite. Although all of the study countries had national policies and/or guidelines that supported the active management of the third stage of labour, the presence of guidelines in facilities varied across countries and only 377 (36%) of 1037 investigated providers had received relevant training in the previous three years. CONCLUSION: In the study countries, quality and coverage of the active management of the third stage of labour were high. However, to improve active management, there needs to be more research on optimizing the timing of uterotonic administration. Training on the use of new clinical guidelines and implementation research on the best methods to update such training are also needed.

Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa.

BACKGROUND: Poor quality of care at health facilities is a barrier to pregnant women and their families accessing skilled care. Increasing evidence from low resource countries suggests care women receive during labor and childbirth is sometimes rude, disrespectful, abusive, and not responsive to their needs. However, little is known about how frequently women experience these behaviors. This study is one of the first to report prevalence of respectful maternity care and disrespectful and abusive behavior at facilities in multiple low resource countries. METHODS: Structured, standardized clinical observation checklists were used to directly observe quality of care at facilities in five countries: Ethiopia, Kenya, Madagascar, Rwanda, and the United Republic of Tanzania. Respectful care was represented by 10 items describing actions the provider should take to ensure the client was informed and able to make choices about her care, and that her dignity and privacy were respected. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Clinical observers' open-ended comments were also analyzed to identify examples of disrespect and abuse. RESULTS: A total of 2164 labor and delivery observations were conducted at hospitals and health centers. Encouragingly, women overall were treated with dignity and in a supportive manner by providers, but many women experienced poor interactions with providers and were not well-informed about their care. Both physical and verbal abuse of women were observed during the study. The most frequently mentioned form of disrespect and abuse in the open-ended comments was abandonment and neglect. CONCLUSIONS: Efforts to increase use of facility-based maternity care in low income countries are unlikely to achieve desired gains if there is no improvement in quality of care provided, especially elements of respectful care. This analysis identified insufficient communication and information sharing by providers as well as delays in care and abandonment of laboring women as deficiencies in respectful care. Failure to adopt a patient-centered approach and a lack of health system resources are contributing structural factors. Further research is needed to understand these barriers and develop effective interventions to promote respectful care in this context.

Using Young Mothers' Clubs to Improve Knowledge of Postpartum Hemorrhage and Family Planning in Informal Settlements in Nairobi, Kenya.

Women living in Nairobi's informal settlements face a higher risk of maternal death than those living elsewhere in the country, and have limited knowledge of actions they can take to improve their chances of survival during pregnancy and childbirth. As one strategy to reach this high risk group, Jhpiego has implemented young mothers' clubs (YMCs). These clubs comprise mothers aged 18-30 who come together on a weekly basis to share experiences and solutions to their challenges while receiving health education from health facility staff and community health workers (CHWs). The aim of this study was to assess whether the YMC strategy could be used to improve participants' knowledge of postpartum hemorrhage (PPH), positive behavior around childbirth, and family planning. Participants in nine YMCs (n = 193) across four informal settlements were interviewed to assess their knowledge of safe motherhood topics before and after a series of eight health education sessions. Data were analyzed with the McNemar test to determine significance of change in knowledge pre- and post-intervention. The largest improvements were observed in knowledge about what to include in a birth plan, with correct responses increasing from 32 to 73% (p < 0.001), 58-93% (p < 0.001), 36-66% (p < 0.001), 58-85% (p < 0.001), and 64-88% (p < 0.001) for identifying a birth companion, budget, skilled birth attendant, emergency supplies, and place of birth, respectively. Less substantial improvements were observed in knowledge of danger signs of PPH (up 10% from 77%, p = 0.003). Although knowledge of actions to take in the event of bleeding after delivery did significantly improve, final knowledge scores remained low--knowledge to urinate increased from 14 to 28% (p < 0.001) and to breastfeed from 12 to 24% (p = 0.005). Even though the vast majority of respondents (84%) knew before the intervention that a woman should space pregnancy by at least 2 years after delivery, there was an increase to 94% after the sessions (p = 0.008). Overall, participants demonstrated significant improvements in knowledge of safe motherhood and family planning topics, suggesting that the materials and methods used were generally effective for improving knowledge among this high risk group.

Improving adherence to family planning guidelines in Kenya: an experiment.

QUALITY PROBLEM: Research in Kenya in the mid-1990s suggested poor quality family planning services and limited access to services. Clinical guidelines for family planning and reproductive health were published in 1991 and updated in 1997, but never widely distributed. CHOICE OF SOLUTION: Managers and trainers chose intensive, district-level training workshops to disseminate guidelines and update health workers on guideline content and best practices. INTERVENTION: Training workshops were held in 41 districts in 1999. Trainees were instructed to update their untrained co-workers afterwards. As a reinforcement, providers in randomly selected areas received a 'cascade training package' of instructional materials and training tips. Providers in 15 randomly selected clinics also received 'supportive supervision' visits as a second reinforcement. EVALUATION METHODOLOGY: A cluster-randomized experiment in 72 clinics assessed the overall impact of the training and the marginal benefits of the two reinforcing activities. Researchers and trainers created several dozen indicators of provider knowledge, attitudes, beliefs and practices. Binomial and multivariate analyses were used to compare changes over time in indicators and in aggregated summary scores. Data from patient interviews were analysed to corroborate provider practice self-reports. Cost data were collected for an economic evaluation. RESULTS: Post-test data collected in 2000 showed that quality of care and access increased after the intervention. The cascade training package showed less impact than supportive supervision, but the former was more cost-effective. LESSONS LEARNED: Service delivery guidelines, when properly disseminated, can improve family planning practices in sub-Saharan Africa.

Medicina familiar en Inglaterra / Family medicine in England

La medicina familiar es un especializacion nueva en Colombia, pero bien establecida desde hace 40 anos en Inglaterra. Si se tienen en cuenta los recursos financieros y profesionales del pais, conviene examinarla y extraer lo mejor y lo mas pertinente para Colombia