Obstetric Care in Poor Settings in Ghana, India & Kenya: Use of Qualitative and Quantitative methods...
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Transcript of Obstetric Care in Poor Settings in Ghana, India & Kenya: Use of Qualitative and Quantitative methods...
Obstetric Care in Poor Settings in Ghana, India & Kenya:
Use of Qualitative and Quantitative methods
Samuel MillsEduard BosElizabeth LuleGNV RamanaRudolfo Bulatao
Outline
Objectives
Background
Methods (quantitative & qualitative)
Main findings
Choice of method for evaluation
Objectives
1. To investigate recent maternal deaths to understand the level and causes of maternal mortality
2. To explore 3-delays resulting in maternal deaths• 1st Decision delay• 2nd Travel delay• 3rd Treatment delay
3. To assess the adequacy and quality of EmOC
4. To describe the utilization of antenatal and delivery services
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
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)
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
Sampling
Data type Northern Ghana Nairobi slums Uttar Pradesh state
Verbal autopsies and death narratives
516 deaths of females aged 12-49 in 2002-2004
289 deaths of females aged 12-49 in 2003-2005
283 deaths of females aged 12-44 in 2001-2004
In-depth interview (near misses)
28 cases in 2005 15 cases in 2005 49 cases in 2005
Health facility survey
All 8 facilities in district
25 facilities 128 facilities in 18 districts
Household survey 3,433 women whose pregnancies ended in 2004
1,927 women whose pregnancies ended in 2004-2005
13,645 women whose pregnancies ended in 2002-2004
Focus groups 18 groups (Previously done)
16 groups 20 groups
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
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 )
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
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
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
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
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)
KND – Causes of maternal mortality
4.4
6.7
6.7
6.7
8.9
15.5
22.2
2.2
2.2
6.7
17.8
Anemia
HIV/AIDS
Malaria
Other indirect
Antepartum hemorrhage
Postpartum hemorrhage
Postpartum sepsis
Retained placenta
Obstructed labor
Complications of abortion
Other direct
Direct causes (71.1%) Indirect causes (28.9%)
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
Nairobi – Causes of maternal mortality
3.5
3.5
6.9
10.3
10.3
31
6.9
13.8
13.9
Anemia
Other indirect
HIV/AIDS
Ruptured uterus
Antepartum hemorrhage
Eclampsia
Postpartum hemorrhage
Postpartum sepsis
Complications of abortion
Direct causes (65.5%) Indirect causes (34.5%)
India – Uttar Pradesh
73 maternal deaths/275 female deaths
18,696 live births• MMRatio 409 maternal deaths per 100,000
live births
UP - Causes of maternal deaths
Direct Causes Indirect Causes Causes Unidentifiable
Hemorrhage
Obstructed/Prolonged Labor
Complications of Abortion
Postpartum Sepsis
Toxemia
Eclampsia
Miscarriage
Anemia
Cardiac Failure
Tuberculosis
Acute Renal Failure
Unidentifiable
27.2%
12.7%
10.9%
5.5%
5.5%
5.5%
1.8%
16.4%
7.3%
3.6%
1.8%
1.8%
UP - Time of Death
During 8-42 Days after Delivery
(14%)
Post-abortal(11%)
During Pregnancy
(15%)
During or Within Hours of Delivery
(51%)
During 1-7 Days after Delivery
(9%)
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
UP - Analysis of First Delay
Duration Number Percent
No Delay 16 36%
1-2 Hours 6 13%
3-24 Hours 5 11%
2-5 Days 10 23%
More than 5 Days 2 4%
Duration not clear 6 13%
Total 45 100%
Decision delay – time taken to make decision
Decision delay
20-year-old with no previous live birth
Our daughter-in-law had not been suffering from any disease throughout her pregnancy. The labor pain started at 6 p.m. and she had a stillbirth at home. Soon after delivery, she complained of severe backache. She asked for someone to massage her back. She slept after my mother gave her a massage. The next morning when the family members tried to wake her, they found her dead. Nobody knew when she had died during the night.
During the pregnancy she had swelling on her entire body. The swelling had aggravated during the last month of her pregnancy, along with blurring of vision at night. She was anemic and had experienced mild bleeding during delivery.
Time Gap between Decision to Seek Care and Reaching a Qualified Doctor/Health Facility
Duration Number
Within 2 Hours 19
3-6 Hours 3
7-9 Hours 2
3-5 Days 3
Total 27
UP - Analysis of Second Delay
Travel delay
32-year-old with two live births
My daughter-in-law fell ill when she was 9 months pregnant. Two days before her death, she was suffering from dysentery that is why she became very weak. At that time, except for me, neither her husband nor his brother was present in the house. When the labor pain started, my wife called the women in the neighborhood. An hour or two after that, she started feeling uncomfortable and died all of a sudden.
Here, in the village, the nearest road is 8 kilometers away and there is no means of transportation. By the time I tried to make transport arrangements, she died. There is an Anganwadi Center in the village, where an auxiliary nurse-nurse midwife comes once in six months. She was given tetanus toxoid injection once, after which she had fever. My son is a laborer in Mumbai.
UP - Analysis of Third Delay
Duration Number
No Delay 18
½ - 1 Hour 7
2-4 Hours 2
Total 27
Treatment delay
Treatment delay
35-year-old with five live births
She was at her parents' house for delivery. The pain had started at night, so we arranged for a jeep and took her to the district hospital and got her admitted there. There was considerable labor pain. She was restless with pain, but the baby was not being delivered. She was nine months pregnant. She was very weak and anemic.
The doctor demanded 10,000 rupees after admitting her and said that she was very anemic and a lot of blood would be needed for the operation. Then her brother said that their financial condition was not good. He requested the doctor to start the operation while he arranged for money. She continued suffering from severe pain, but, without payment, the doctor refused to operate on her. By the time we could arrange for money and return, it was too late and she had died. In this way, the mother and child both died in hospital.
All three delays
35-year-old with one live births
My sister-in-law had labor pains the whole night. There was no transport available during night. We showed to the auxiliary nurse-midwife in the morning and she referred her to government hospital. We took her to private nursing home where she was admitted and a stillborn baby was delivered after operation. Five days later she died in the hospital. She was given 6 bottles of blood and glucose drip.
She had swelling in her entire body. She was anemic because of frequent deliveries. Even after six deliveries, only one of her child has survived. The financial condition of her family is not good.
All three delays are interconnected
% Pregnant Women Receiving Obstetric Care
98
81
38
96
60
70
48
10
28
0 20 40 60 80 100
Any antenatal care
Four or more visits
Delivery care
Percent among those who had antenatal care
Ghana Kenya India
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
Maternal Mortality Ratio
409
630
373
0 100 200 300 400 500 600 700
MMRatio
Deaths per 100,000 live births
Ghana
Kenya
India
Abortion MMRatio
45
200
58
0 50 100 150 200 250
Abortion deaths
Deaths per 100,000 live births
Ghana
Kenya
India
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
HIV/AIDS MMRatio
0
87
8
0 20 40 60 80 100
HIV/AIDS deaths
Deaths per 100,000 live births
Ghana
Kenya
India
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!