Experiences with facility-based maternal death reviews in northern Nigeria.

OBJECTIVE: To evaluate the effectiveness of the maternal death review (MDR) system and process in improving quality of maternal and newborn health care in northern Nigeria. METHODS: A combination of quantitative and qualitative methods was used, including review of MDR forms and of health management information system data on maternal deaths (MDs), as well as semi-structured interviews with members of 11 MDR committees. RESULTS: Facility-based MDRs were initiated in 75 emergency obstetric and newborn care facilities in northern Nigeria and were initially conducted in the 33 hospitals; however, the process stopped after some time and had to be revitalized. Main reasons were transfer of key members of MDR committees, lack of supportive supervision, and shortage of staff. Ninety-three (12.1%) of 768 identified MDs were recorded on MDR forms and 52 (6.7%) had been reviewed. MDRs resulted in improved quality of care, including mobilization of additional resources. Challenges were fear of blame, shortage of staff, transfer of MDR team members, inadequate supportive supervision, and poor record keeping. CONCLUSION: MDR requires teamwork, commitment, and champions at health facility level to spearhead the process. MDR needs to be institutionalized in the Ministry of Health, which provides oversight, policy guidance, and support, including supportive supervision.

Young people's perception of sexual and reproductive health services in Kenya.

BACKGROUND: Addressing the Sexual and Reproductive Health (SRH) needs of young people remains a big challenge. This study explored experiences and perceptions of young people in Kenya aged 10-24 with regard to their SRH needs and whether these are met by the available healthcare services. METHODS: 18 focus group discussions and 39 in-depth interviews were conducted at health care facilities and youth centres across selected urban and rural settings in Kenya. All interviews were tape recorded and transcribed. Data was analysed using the thematic framework approach. RESULTS: Young people's perceptions are not uniform and show variation between boys and girls as well as for type of service delivery. Girls seeking antenatal care and family planning services at health facilities characterise the available services as good and staff as helpful. However, boys perceive services at health facilities as designed for women and children, and therefore feel uncomfortable seeking services. At youth centres, young people value the non-health benefits including availability of recreational facilities, prevention of idleness, building of confidence, improving interpersonal communication skills, vocational training and facilitation of career progression. CONCLUSION: Providing young people with SRH information and services through the existing healthcare system, presents an opportunity that should be further optimised. Providing recreational activities via youth centres is reported by young people themselves to not lead to increased uptake of SRH healthcare services. There is need for more research to evaluate how perceived non-health benefits young people do gain from youth centres could lead to improved SRH of young people.

Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.

BACKGROUND: Addressing the sexual and reproductive health (SRH) needs of young people remains a challenge for most developing countries. This study explored the perceptions and experiences of Health Service Providers (HSP) in providing SRH services to young people in Kenya. METHODS: Qualitative study conducted in eight health facilities; five from Nairobi and three rural district hospitals in Laikipia, Meru Central, and Kirinyaga. Nineteen in-depth interviews (IDI) and two focus group discussions (FGD) were conducted with HSPs. Interviews were tape recorded and transcribed. Data was coded and analysed using the thematic framework approach. RESULTS: The majority of HSPs were aware of the youth friendly service (YFS) concept but not of the supporting national policies and guidelines. HSP felt they lacked competency in providing SRH services to young people especially regarding counselling and interpersonal communication. HSPs were conservative with regards to providing SRH services to young people particularly contraception. HSP reported being torn between personal feelings, cultural and religious values and beliefs and their wish to respect young people's rights to accessing and obtaining SRH services. CONCLUSION: Supporting youth friendly policies and competency based training of HSP are two common approaches used to improve SRH services for adolescents. However, these may not be sufficient to change HSPs' attitude to adolescents seeking help. There is need to address the cultural, religious and traditional value systems that prevent HSPs from providing good quality and comprehensive SRH services to young people. Training updates should include sessions that enable HSPs to evaluate how their personal and cultural values and beliefs influence practice.

Monitoring and evaluation of skilled birth attendance: a proposed new framework.

BACKGROUND: The maternal mortality ratio (MMR) and proportion of births attended by skilled attendants are the two indicators selected to measure progress towards the achievement of MDG five. By the year 2015, the international community aims to have achieved a 75% reduction in MMR and 90% coverage of women having a skilled attendant at birth. In spite of the importance of this indicator, there is little consistency in how this is monitored and evaluated. This paper provides a review of the literature on the approaches and conceptual frameworks for evaluating progress with skilled birth attendance (SBA). The applicability of current frameworks is reviewed and a new simplified framework for monitoring and evaluation of SBA is proposed. METHODS: We searched electronic databases, internet, publications and databases of organisations. We hand searched reference lists of key papers, using search terms such as skilled attend*, maternal health, maternal mortality, midwi*, health professional, impact*, monitor* and evaluat*. FINDINGS: there were 44 potentially relevant articles from PUBMED, three from Scopus, seven from WHO, two from UNFPA, one obtained via hand search and one via personal communication. A total of 27 publications were found to be relevant after a review of their abstracts. Of these, 17 were on SBA and maternal mortality, and 10 were on monitoring and evaluation of SBA. Of the publications on monitoring and evaluation of SBA, two studies assessed global coverage of SBA, eight studies evaluated specific programmes and three of these had a 'conceptual framework'. CONCLUSIONS: No standard framework to evaluate progress made in ensuring increased coverage with skilled birth attendance currently exists. There are three published conceptual frameworks, each of which has valuable and workable components as well as limitations. A simplified systems approach to the Monitoring and Evaluation of SBA using structure, process and outcome criteria is proposed.

Motorcycle ambulances for referral of obstetric emergencies in rural Malawi: do they reduce delay and what do they cost?

OBJECTIVES: To assess whether motorcycle ambulances placed at rural health centers are a more effective method of reducing referral delay for obstetric emergencies than a car ambulance at the district hospital, and to compare investment and operating costs with those of a 4 wheel drive car ambulance at the district hospital. METHODS: Motorcycle ambulances were placed at 3 remote rural health centers in Malawi. Data were collected over a 1-year period, from October 2001 to September 2002, using logbooks, cashbooks, referral forms, and maternity registers. RESULTS: Depending on the site, median referral delay was reduced by 2-4.5 hours (35%-76%). Purchase price of a motorcycle ambulance was 19 times cheaper than for a car ambulance. Annual operating costs were US dollars 508, which was almost 24 times cheaper than for a car ambulance. CONCLUSIONS: In resource-poor countries motorcycle ambulances at rural health centers are a useful means of referral for emergency obstetric care and a relatively cheap option for the health sector.

Practice points in utilizing local volunteers in community health projects.

Community volunteers are recruited for many health intervention projects. There are various motivations for the use of the volunteers and these include: the desire to reduce financial costs of projects/programmes; to encourage community ownership; ensure long-term sustainability of the health intervention; and to empower local communities through training offered the project. Health intervention measures working with community volunteers should not be implemented without due consideration of issues regarding mobilization and engagement, skills and motivation of the volunteers and their effectiveness and efficiency towards the attainment of the project goals. This paper discusses some tips that should be considered when community volunteers are used in resource-limited situations.