BACKGROUND: There is a growing movement, globally and in the Africa region, to reduce financial barriers to health care generally, but with particular emphasis on high priority services and vulnerable groups.
OBJECTIVE: This article reports on the experience of implementing a national policy to exempt women from paying for delivery care in public, mission and private health facilities in Ghana.
DESIGN: Using data from a complex evaluation which was carried out in 2005-2006, lessons are drawn which can inform other countries starting or planning to implement similar service-based exemption policies.
RESULTS: On the positive side, the experience of Ghana suggests that delivery exemptions can be effective and cost-effective, and that despite being universal in application, they can benefit the poor. However, certain 'negative' lessons are also drawn from the Ghana case study, particularly on the need for adequate funding, and for strong institutional ownership. It is also important to monitor the financial transfers which reach households, to ensure that providers are passing on benefits in full, while being adequately reimbursed themselves for their loss of revenue. Careful consideration should also be given to staff motivation and the role of different providers, as well as quality of care constraints, when designing the exemptions policy. All of this should be supported by a proactive approach to monitoring and evaluation.
CONCLUSION: The recent movement towards making delivery care free to all women is a bold and timely action which is supported by evidence from within and beyond Ghana. However, the potential for this to translate into reduced mortality for mothers and babies fundamentally depends on the effectiveness of its implementation.
OBJECTIVE: To evaluate the effect of a national referral system that aims to reduce maternal mortality rates through improving access to and the quality of emergency obstetric care in rural Mali (sub-Saharan Africa).
METHODS: A maternity referral system that included basic and comprehensive emergency obstetric care, transportation to obstetric health services and community cost-sharing schemes was implemented in six rural health districts in Kayes region between December 2002 and November 2005. In an uncontrolled 'before and after' study, we recorded all obstetric emergencies, major obstetric interventions and maternal deaths during a 4-year observation period (1 January 2003 to 30 November 2006): the year prior to the intervention (P-1); the year of the intervention (P0), and 1 and 2 years after the intervention (P1 and P2, respectively). The primary outcome was the risk of death among obstetric emergency patients, calculated with crude case fatality rates and crude odds ratios. Analyses were adjusted for confounding variables using logistic regression.
FINDINGS: The number of women receiving emergency obstetric care doubled between P-1 and P2, and the rate of major obstetric interventions (mainly Caesarean sections) performed for absolute maternal indications increased from 0.13% in P-1 to 0.46% in P2. In women treated for an obstetric emergency, the risk of death 2 years after implementing the intervention was half the risk recorded before the intervention (odds ratio, OR: 0.48; 95% confidence interval, CI: 0.30-0.76). Maternal mortality rates decreased more among women referred for emergency obstetric care than among those who presented to the district health centre without referral. Nearly half (47.5%) of the reduction in deaths was attributable to fewer deaths from haemorrhage.
CONCLUSION: The intervention showed rapid effects due to the availability of major obstetric interventions in district health centres, reduced transport time to such centres for treatment, and reduced financial barriers to care. Our results show that national programmes can be implemented in low-income countries without major external funding and that they can rapidly improve the coverage of obstetric services and significantly reduce the risk of death associated with obstetric complications.
BACKGROUND: Reducing maternal and perinatal mortality in sub Saharan Africa remains challenging and requires effective and context specific interventions.
OBJECTIVE: The aims of this paper were to demonstrate the impact of the community mobilisation of the Skilled Care Initiative (SCI) in reducing maternal and perinatal mortality and to describe the concept and implementation in order to guide replication and scaling up.
DESIGNS: A quasi experimental design was used to assess the extent to which the SCI was associated with increased institutional births, maternal and perinatal mortality reduction in an intervention (Ouargaye) versus a comparison (Diapaga) district. A geo-referenced census was conducted to retrospectively assess changes in outcomes and process measures. A detailed description of activities, rationale and timing of implementation were gathered from the SCI project officers and summarised. Data analyses included descriptive statistics and multivariate analyses.
RESULTS: At macro level, the main significant difference between Ouargaye and Diapaga districts was the scope and intensity of the community-based interventions implemented in Ouargaye. There was a temporal association relationship before and after the implementation of the demand-driven interventions and a remarkable 30% increase in institutional births in the intervention district compared to 10% increase in comparison district. There was a significant reduction of perinatal mortality rates (OR =0.75, CI 0.70-0.80) in intervention district and a larger decrease in maternal mortality ratios in intervention district, although statistical significance was not reached. A comprehensive framework of community mobilisation strategy is proposed to improve maternal and child health in poorest communities.
CONCLUSION: Controlling for the availability and quality of health services, working in partnership and effectively with communities, and not for them - hence characterising communities as not being empty vessels - can have impacts on outcomes. Here, in the district with a community mobilisation programme, there was a marked increase in institutional births and reductions in maternal and perinatal deaths.
OBJECTIVE: To audit intrapartum fetal and early neonatal deaths of infants weighing >or=2000 g in a regional hospital in western Tanzania.
METHODS: The 3-delays methodology was applied to a cohort of perinatal deaths from July 2002 to July 2004.
RESULTS: The overall perinatal mortality rate in the hospital was 38 per 1000 live births, and in just over half of these cases the birth weight was >or=2000 g. The leading clinicopathologic causes of death were birth asphyxia (19.0%), prolonged or obstructed labor (18.5%), antepartum hemorrhage (11.5%), and uterine rupture (9.0%). First delays occurred in 19.0% of the cases, second delays occurred in 21.5%, and third delays occurred in 72.5%.
CONCLUSION: For women who delivered in this hospital, most of the substandard care occurred after admission to the health facility. The improvement of institutional health care may have a significant impact on the decision to attend health institutions and, thereby, reduce first delays.
OBJECTIVES: The Skilled Care Initiative (SCI) was a comprehensive skilled attendance at delivery strategy implemented by the Ministry of Health and Family Care International in Ouargaye district (Burkina Faso) from 2002 to 2005. We aimed to evaluate the relationships between accessibility, functioning of health centres and utilisation of delivery care in the SCI intervention district (Ouargaye) and compare this with another district (Diapaga).
METHODS: Data were collected on staffing, equipment, water and energy supply for all health centres and a functionality index for health centres were constructed. A household census was carried out in 2006 to assess assets of all household members, and document pregnancies lasting more than 6 months between 2001 and 2005, with place of delivery and delivery attendant. Utilisation of delivery care was defined as birth in a health institution or birth by Caesarean section. Analyses included univariate and multivariate logistic regression.
RESULTS: Distance to health facility, education and asset ownership were major determinants of delivery care utilisation, but no association was found between the functioning of health centres (as measured by infrastructure, energy supply and equipment) and institutional birth rates or births by Caesarean section. The proportion of births in an institution increased more substantially in the SCI district over time but no changes were seen in Caesarean section rates.
CONCLUSION: The SCI has increased uptake of institutional deliveries but there is little evidence that it has increased access to emergency obstetric care, at least in terms of uptake of Caesarean sections. Its success is contingent on large-scale coverage and 24-h availability of referral for life saving drugs, skilled personnel and surgery for pregnant women.
BACKGROUND: In rural India, most births take place in the home, where high-risk care practices are common. We developed an intervention of behaviour change management, with a focus on prevention of hypothermia, aimed at modifying practices and reducing neonatal mortality. METHODS: We did a cluster-randomised controlled efficacy trial in Shivgarh, a rural area in Uttar Pradesh. 39 village administrative units (population 104,123) were allocated to one of three groups: a control group, which received the usual services of governmental and non-governmental organisations in the area; an intervention group, which received a preventive package of interventions for essential newborn care (birth preparedness, clean delivery and cord care, thermal care [including skin-to-skin care], breastfeeding promotion, and danger sign recognition); or another intervention group, which received the package of essential newborn care plus use of a liquid crystal hypothermia indicator (ThermoSpot). In the intervention clusters, community health workers delivered the packages via collective meetings and two antenatal and two postnatal household visitations. Outcome measures included changes in newborn-care practices and neonatal mortality rate compared with the control group. Analysis was by intention to treat. This study is registered as International Standard Randomised Control Trial, number NCT00198653. FINDINGS: Improvements in birth preparedness, hygienic delivery, thermal care (including skin-to-skin care), umbilical cord care, skin care, and breastfeeding were seen in intervention arms. There was little change in care-seeking. Compared with controls, neonatal mortality rate was reduced by 54% in the essential newborn-care intervention (rate ratio 0.46 [95% CI 0.35-0.60], p<0.0001) and by 52% in the essential newborn care plus ThermoSpot arm (0.48 [95% CI 0.35-0.66], p<0.0001). INTERPRETATION: A socioculturally contextualised, community-based intervention, targeted at high-risk newborn-care practices, can lead to substantial behavioural modification and reduction in neonatal mortality. This approach can be applied to behaviour change along the continuum of care, harmonise vertical interventions, and build community capacity for sustained development. FUNDING: USAID and Save the Children-US through a grant from the Bill & Melinda Gates Foundation.
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.
Inability to reduce neonatal and maternal mortality in poor countries is sometimes blamed on a lack of contextual knowledge about care practices and care-seeking behavior. There is a lack of knowledge about how to translate formative research into effective interventions to improve maternal and newborn health. We describe the findings of formative research and how they were used to inform the development of such an intervention in rural Nepal. Formative research was carried out in four parts. Part 1 involved familiarization with the study area and literature review, and parts 2, 3 and 4 involved community mapping, audit of health services, and qualitative and quantitative studies of perinatal care behaviors. Participatory approaches have been successful at reducing neonatal mortality and may be suitable in our context. Community mapping and profiling helped to describe the community context, and we found that community-based organizations often sought to involve the Female Community Health Volunteer in community mobilization. She was not routinely conducting monthly meetings and found them difficult to sustain without support and supervision. In health facilities, most primary care staff were in post, but doctors and staff nurses were absent from referral centers. Mortality estimates reflected under-reporting of deaths and hygiene and infection control strategies had low coverage. The majority of women give birth at home with their mother-in-law, friends and neighbors. Care during perinatal illness was usually sought from traditional healers. Cultural issues of shyness, fear and normalcy restricted women's behavior during pregnancy, birth and the postpartum period, and decisions about her health were usually made after communications with the family and community. The formative research indicated the type of intervention that could be successful. It should be community-based and should not be exclusively for pregnant women. It should address negotiations within families, and should tailor information to the needs of local groups and particular stakeholders such as mothers-in-law and traditional healers. The intervention should not only accept cultural constructs but also be a forum in which to discuss ideas of pollution, shame and seclusion. We used these guidelines to develop a participatory, community-based women's group intervention, facilitated through a community action cycle. The success of our intervention may be because of its acceptability at the community level and its sensitivity to the needs and beliefs of families and communities.
