Sickle cell disease: time for a targeted neonatal screening programme.

Ireland has seen a steady increase in paediatric sickle cell disease (SCD). In 2005, only 25% of children with SCD were referred to the haemoglobinopathy service in their first year. A non-funded screening programme was implemented. This review aimed to assess the impact screening has had. All children referred to the haemoglobinopathy service born in Ireland after 2005 were identified. Data was collected from the medical chart and laboratory system. Information was analysed using Microsoft Excel. 77 children with SCD were identified. The median age at antibiotic commencement in the screened group was 56 days compared with 447 days in the unscreened group, p = < 0.0003. 22 (28%) of infants were born in centre's that do not screen and 17 (81%) were over 6 months old at referral, compared with 14 (21%) in the screened group. 6 (27%) of those in the unscreened group presented in acute crisis compared with 2 (3%) in the screened population. The point prevalence of SCD in Ireland is 0.2% in children under 15 yr of African and Asian descent. We identified delays in referral and treatment, which reflect the lack of government funded support and policy. We suggest all maternity units commence screening for newborns at risk of SCD. It is a cost effective intervention with a number needed to screen of just 4 to prevent a potentially fatal crisis.

Paediatric umbilical cord blood transplantation.

Umbilical cord blood is being used increasingly as a source of haematopoietic stem cells for transplantation because of rapid availability, and the unavailability of a HLA matched adult donor for some patients. This study reports the characteristics and outcomes of 15 patients who have undergone umbilical cord blood transplantation (UCBT) in Ireland between 1998 and 2009. The median total nucleated cell and CD34+ doses post-processing were 6.5 x 107cells/kg and 1.8 x 105 cells/kg, respectively. Median neutrophil recovery time was 30 days (range, 14-44). Median platelet recovery time was 46.5 days (range, 35-148). 33.3% of patients developed acute cutaneous graft-versus-host disease (GVHD) grade I-II. Three patients died of transplant-related toxicity and two died of leukaemic relapse. We conclude that, with a satisfactory stem cell dose, UCBT offers a high chance of engraftment with acceptable toxicity, and should be regarded as a favourable option in selected patients when satisfactory bone marrow or peripheral blood stem cell donors are not available.

Risk of airborne transmission in an operating theatre containing four ultraclean air units.

This study shows that a single, large, operating theatre (barn) containing four ultraclean operating units (cabins), was highly effective in reducing the number of airborne bacteria in the operating fields providing all occupied ultraclean cabins were functioning correctly. The air flows and bacterial counts during operations within the cabins met the current standard for ultraclean systems (HTM 2025 1994) and there was no evidence of mixing of air between cabins. It is, however, recommended that air flows are regularly checked for compliance with the standard. If failure occurs in any single ultraclean unit, surgery in that cabin should cease as contaminated air may enter from the barn and surrounding cabins. Routine microbiological sampling should not be necessary providing there is no evidence of filter leakage. An operating theatre with several ultraclean operating tables in a single room would appear to be a viable proposition for the future. Considerable savings are likely in revenue costs as much of the air is reused and support services are shared.

A fifteen-year review of female sterilization by minilaparotomy under local anesthesia in Kenya.

This paper is a comprehensive review of literature concerning the Kenyan experience with female sterilization through minilaparotomy under local anesthesia (ML/LA). A composite picture from analysis of several studies that include some 12,000 clients since 1979 reveals an average Kenyan user to be 31-34 years old (SD 4.9) with 5.9-6.8 children (SD 1.7-1.8). In up to 96% of cases, the indication for choosing sterilization is personal socio-economic considerations. The majority of clients (97%-99%) report satisfaction with their choice of sterilization at the first follow-up visit, and 96-99% state that they would recommend the method to others. The operation takes an average of 14 min (SD 4.5-5.3) "skin-to-skin" through a 2.5.2.8 cm incision (SD 0.5). A mean of 18 cm3 of 1% lignocaine is used (SD 2.7). Most clients (76.4%) have no post-operative complaints; those who do have any complaints report minor transitory problems. Similarly, most clients (96%) have moderate, little, or no peri-operative pain, but 1.9%-5% report much pain. The intra-operative and early complication rate is 0.9%. Some 3.3% of clients suffer at least one complication, some multiple, and the complication rate at 6 weeks is 4.1%, with major complications occurring in 0.7% of cases, and minor complications in 3.4%. The crude failure rate is 0.4% in the first year and 0.1% in the second year, when corrected for luteal phase pregnancies, which account for 50% of all "failures," the actual failure rate is 0.2% in the first year and 0.1% in the second year both for interval and postpartum procedures. This literature review finds outpatient ML/LA to be a relatively safe, simple, effective, and well-accepted option for most Kenyan couples seeking contraception that is intended to be permanent. Counseling, adequate client assessment, and voluntarism have been shown to be essential elements, not only for client satisfaction and avoidance of possible future regret, but also for technical ease of the operative procedure. Recommendations that derive from the Kenya experience are made.

COPE: helping to improve the quality of family planning services in Africa.

PIP: The Association of Voluntary Surgical Contraception (AVSC) had developed a new process for family planning providers to improve the quality of services. The Client Oriented, Provider Efficient, or COPE, process was created in response to problems facing family planning delivery sites throughout sub-Saharan Africa. Frequently, clients are forced to wait for hours, only 1 nurse is placed on duty during the busiest times, in some urban sites family planning facilities are inadequately identified, and several clinics lack private consulting areas. Family planning pamphlets and posters may be locked away while clients in the waiting room sit idly for hours. Developing their own plans of action under the COPE process, local staff members assess their own services by means of a problem identification checklist and a client interview form. First, their goals related to client satisfaction and efficiency are evaluated; then providers are guided in conducting a client flow analysis to identify where clients wait the longest. Applying the COPE process for problem solving requires minimal material resources of some flipchart paper, a few pens, and some photocopied sheets and training of a few hours over 3 days. Facilitators visit sites to guide staff through the COPE process. In Kenya, several organizations initially coached by AVSC are replicating the process in multiple sites. Currently AVSC is planning to deliver seminars for its field staff, regional family planning coordinators, and outside agencies. A manual explaining the COPE process is also under development. Follow-up visits to 11 sites 6-12 months after the introduction of the COPE process indicated that 59% of the problems originally identified had been solved. 76% of the solvable problems were rectified. Clinics achieved decreases in time ranging from 18 to 74 minutes in 5 of the 6 sites where waiting times had been considered excessive.^ieng

Improving service quality.

PIP: This paper describes the Client Oriented, Provider Efficient (COPE) Services, a new initiative of the Family Planning Association of Kenya (FPAK) for improving services to its clients, and for increasing contraceptive prevalence rate. Developed by the Association for Voluntary Surgical Contraception International, COPE has proved to be successful in improving quality of clinic services in Kenya since its introduction into FPAK clinics in 1989. It works by helping family planning service providers in various FPAK clinics become more aware of expressed as well as implied/perceived needs of their clients through the application of its set of tools: self-assessment, client interviews, client flow analysis, and plan of action. Due to its success, a lot of family planning provision organizations in Kenya are interested in incorporating COPE quality improvement tools.^ieng

Not for women only: child-spacing clubs for Malawian men.

PIP: Even though men in many cultures throughout the world determine whether their wives and/or sex partners will use contraception, family planning information and services in Africa are not targeted to men. Services are instead traditionally presented within the context of maternal and child health. Staff from Mulanje Mission Hospital in rural Malawi, however, with the limited support of AVSC, have gotten many men involved in the family planning process. AVSC began working in Malawi in 1989 at the request of the Christian Health Association of Malawi (CHAM). CHAM is an umbrella organization for mission hospitals throughout the country which collectively provide 40% of the nation's health care. Working with CHAM and the Malawi Ministry of Health, AVSC has focused upon education and training to increase the awareness of service providers and counselors about family planning, including long-term and permanent methods. Mulanje staff first visited Man to Man, an initiative of Banja La Misogolo, a nongovernmental organization, involving men in child spacing. Pleased with what they saw, staff members returned to the hospital and organized a child-spacing club which subsequently organized educational seminars for thirty male hospital staff. Staff soon began conducting one-day seminars in villages and at a tea estate. 320 men actively participated in the workshops, with many requesting additional learning opportunities. Most men knew little about family planning and very few had heard about tubal occlusion or vasectomy. A significant number of men attributed their lack of involvement in family planning to the fact that they were not included in counseling and education in the past. News of the successful meetings spread to other villages which, in turn, requested visits from the child-spacing club. Mulanje staff now have far more requests than they can accommodate. This project has reached Malawian men and women with only a small amount of funding from AVSC; AVSC has provided educational materials and gasoline for vehicles. A second mission hospital has started a similar club which AVSC will also support. The success of the club and its seminars demonstrate how eager men are to learn about contraception and how it can improve the lives of their families. The time has come to acknowledge the important male role in family planning.^ieng

Using self-assessment to improve the quality of family planning clinic services.

A follow-up study was conducted to evaluate the effect of a self-assessment technique called COPE (client-oriented, provider-efficient) on the quality of family planning clinic operations in Africa. In 1991 the Association for Voluntary Surgical Contraception revisited 11 clinics where it had introduced COPE from five to 15 months earlier. Changes that had occurred as a result of the COPE intervention were assessed by (1) determining how many of the clinic problems identified by staff at the COPE introduction had been solved; (2) comparing the results of a second client-flow analysis with the initial analysis; and (3) interviewing service providers to obtain their opinions of the effects of COPE. Of the problems identified by staff nearly three-fourths of those that could be solved internally were solved. The study revealed improvements in the quality of care provided as well as increased staff involvement in solving clinic problems.

PIP: The association for Voluntary Surgical Contraception (AVSC) had developed a family planning (FP) clinic operations assessment approach called COPE: client oriented and provider efficient. The COPE method were employed in 11 sites in Ghana, Kenya, Nigeria, and Uganda and evaluated 5-15 months after implementation. COPE aims to improve client services through change in the organization, by continually revising plans and services, and by evaluating outcomes. The focus is not on outcome or distributional statistics, but on qualitative and quantitative data on the process of service delivery. Cope meets the criteria of using multiple methods, being flexible in research design, and being simple. The 4 main components of COPE are as follows: 1) self-assessment; 2) client interviews (10); 3) client-flow analysis (CFA); and 4) plan of action. COPE is currently integrating into its methodology the routine for follow-up evaluation visits by COPE facilitators. Evaluation of COPE implementation took into consideration the number of problems solved or addressed since the introduction of COPE, the results of the client-flow analysis, and the results of interviews of providers. The lack of baseline information on client satisfaction prevented analysis of changes. The instruments of evaluation included a table of lists of problems and proposed staff solutions, several CFA summary sheets, and a structured interview questionnaire for service providers involved with COPE. AVSC staff found that the proportion of solvable problems that were solved varied by site and ranged from 33-75%. It appeared that the level of dedication of service providers and the interest, cooperation, and involvement of administration determined the disparity in problems solved. There were 109 problems identified at all sites and 59% solved. 73% of the problems did not call for outside help. 88% of these solvable problems were solved or partly solved or had attempts at solutions. The cases involved a need for more training of staff in FP the lack of a forum to discuss FP, the lack of directional signs to the FP unit, the long client waiting times, the inadequacy of FP supplies, and the incompleteness of records. Positive results of COPE centered on decreased waiting times, improved morale and staffing, and increased satisfaction. Lessons learned and future directions are given.

Client flow analysis: a practical management technique for outpatient clinic settings.

Client flow analysis (CFA) is a practical technique to help address one of the most frequently cited causes of patient disquiet with quality of health services--waiting times. It allows clinic managers and workers to look at the way that clients and patients move through the clinic. It gives information on waiting times, time spent in contact with different service providers, bottle-neck areas in services and staff utilization patterns. It is a technique which is simple, quickly performed, cost effective, easy to learn and easily transferrable. This paper gives two illustrative examples of sites where CFA has been initiated in Africa--a free-standing family planning clinic and a provincial hospital outpatient clinic. Waiting times were reduced by over one-half and by one-third, respectively. By reducing waiting times for clients and patients and addressing some of the problems of staff time allocation, the quality of clinic operations can be improved for both providers and clients.

Introducing quality assurance to health service delivery--some approaches from South Africa, Ghana and Kenya.

The following report combines the contributions of four health care professionals engaged in quality improvement activities in three different areas of Africa--Ghana in West Africa, Kenya in the East, and the Republic of South Africa. These reports provide current and vivid accounts of the impact of quality assurance and quality improvement activities on areas of change in each country's rapidly expanding health care system.

Unmet family planning demand: evidence from two sites in Kenya.

PIP: A study was undertaken in Kenya to assess 1) the family planning (FP) needs of women in the perinatal period, 2) whether these needs are recognized by staff, 3) the postpartum demand for FP information and services, and 4) the barriers to addressing client needs. Data were collected from interviews with 400 prenatal clients, 200 postpartum women, 400 child welfare clinic attenders, and 69 staff members. More than a third of the clients desired no more children. A further 22%, 33%, and 28% of the three client groups, respectively, wished to delay their next pregnancy for more than four years. Over 88% of the prenatal, 93% of the postpartum, and 84% of the child welfare clients wanted to use FP. The staff was generally aware of the women's desire for information, but they underestimated the need for information in the immediate postpartum period. Information from the child welfare mothers indicated that by six months postpartum 75% of the women are at risk of pregnancy, and, by 12 months, 83% are at high risk of pregnancy. Therefore, women need FP services by six months postpartum. Even though most of the postpartum women wanted to receive a method before discharge from the maternity ward, very few received any FP services during their stay. The clients felt uncomfortable raising the issue with the maternity staff, and the staff felt constrained by a lack of knowledge although they recognized the need and wanted to be able to provide adequate services. Based on this study, it is recommended that 1) FP services be available in all parts of a hospital; 2) maternity ward staff, in particular, be trained to provide FP services; 3) a team approach to FP services be developed; 4) staff be more pro-active in identifying potential clients; and 5) maternal/child health and FP services be fully integrated to provide FP services in a private setting for all clinic attenders.^ieng