Background
Methods
Study setting
Kaya district (Burkina Faso) | Kwale district (Kenya) | Ntchisi district (Malawi) | Chiúta district (Mozambique) | |
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District population
| 507,018 | 162,092 | 265,470 | 85,808 |
% of women of childbearing age
| 22.0 | 23.5 | 22.6 | 21.6 |
Number of health facilities
| 51 | 20 | 12 | 4 |
Primary health care facility
| 50 | 19 | 11 | 4 |
Referral district hospital
| 11 | 1 | 1 | 0 |
Median catchment area population per primary health care facility (range)
| 9,781 (2,382-25,934) | 5,651 (2,944-22,117) | 17,141 (7,346-47,794) | 21,881 (6,007-36,039) |
Research methodology
The needs assessment included: |
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1. A critical review of the MNCH policies in the four study countries through [30]: |
• document analysis of national, regional and local policies and guidelines, |
• semi-structured in-depth interviews with stakeholders at national, regional, and district levels and with health workers, and |
• focus group discussions with health workers and women and men from the local community |
2. A detailed quantitative situation analysis of existing MNCH services and care at the four study sites using routinely collected and available data on MNCH at national and study site level [29]. |
Checklist and interview guides to collect needs assessment data were developed. Data collection took place between December 2011 and April 2012 and was performed by project research staff. In-depth interviews and focus group discussions were audio recorded, transcribed and translated if needed. Qualitative data was analysed by extracting themes and triangulating. Quantitative data was entered in an Access database, and checked for errors by the lead partner (SL and HB). A descriptive analysis of the quantitative data was undertaken using SPSS 20. |
For each study site the development of a list of proposed interventions included the following process: | |||||||||||
• First, baseline assessment and stakeholders causal analysis workshop PPC findings were summarised in a SWOT analysis. The following characteristics and categories were assessed: | |||||||||||
o Characteristics of postpartum policies – category: postpartum policies | |||||||||||
o Characteristics of postpartum system – categories: health system organization, integration of PPC in other services (child clinic, HIV, FP, etc.), human resources, financial resources, PPC payment modalities for users/clients, and health information system | |||||||||||
o Characteristics of postpartum services – categories: facility-based PP services, community-based PP services, socio-cultural issues and access to PPC, geographic issues and access to PPC, financial issues and access to PPC, and access ‘in time’ to PPC | |||||||||||
o Characteristics of postpartum care – categories: technical effectiveness, patient centeredness, integration, continuity | |||||||||||
Example Kwale district, Kenya (Characteristics of postpartum services – facility-based PP services)
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Strengths
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Weaknesses
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Opportunities
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Threats
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Characteristics of postpartum services
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Facility-based PP services
| • none | • PPC is neglected compared to antenatal and childbirth care | • Framework to upgrade facility-based PPC services is available | • Understaffing | |||||||
• Health workers are not aware of importance of PPC | • Lack of interest among health facility staff | ||||||||||
• Health workers do not know guidelines on PPC | |||||||||||
• BEmOC services are in part not available at first line health facilities | |||||||||||
• Using the SWOT analysis results and internationally recognised evidence, problems and possible interventions to tackle these problems were identified. Problems were listed for four categories: health system, health services, health care and others. | |||||||||||
Example Kwale district, Kenya (Care)
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Problem identified regarding postpartum care in Kwale district
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Intervention proposed
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Care
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Attitude of health workers: lack of patient centred care, no respect for cultural beliefs and practices | • Train HWs on patient centred care and culturally appropriate behaviour and approaches | ||||||||||
Quality of care, poor skills of health workers | • Train HWs and establish regular supportive supervision of the HWs by district health management team. | ||||||||||
• Involvement of district QIT to improve quality of care and HW skills regarding PPC | |||||||||||
Postpartum care not felt as a priority among the health workers | • Sensitize HWs on the importance of PPC and train them on the contents of PPC | ||||||||||
Women discharged less than 24 h after delivery | • Upgrade logistical arrangements in the health HF to enable women to stay at least 24 h after they delivered. | ||||||||||
• Sensitize HWs and clients on the importance of staying at least 24 h at the HF before being discharged | |||||||||||
• Next the identified possible interventions were described in more detail by mentioning for each the challenges, opportunities and preconditions. Interventions were classified in four groups: (1) community-based interventions, (2) improvement of available PPC services, (3) integration of PPC for the mother in child clinics, and (4) interventions linking the community and health facility. | |||||||||||
Example Kwale district, Kenya (some interventions on improvement of available PPC services)
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Possible Intervention
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Challenges
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Opportunities
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Preconditions
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Improvement of available PPC services
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Improve BEmOC, PPC and other skills of health workers | • Availability of regular supportive supervision | • Availability of QIT to support improvement of quality of PPC | • none | ||||||||
Train health workers on patient-centred care and culturally adapted behaviour and approaches | • none | • none | • Trainers available | ||||||||
Sensitisation of health workers on importance of PPC for mother and newborn and PPC training | • Availability of regular supervision to support HWs to deliver PPC | • none | • Make arrangements to enable mother and newborn to stay at least 24 h after delivery | ||||||||
Dissemination of national guidelines and strategies regarding PPC among the health workers and training on PPC | • none | • Guidelines already available | • none | ||||||||
• Finally each of the above described interventions was assessed against a set of criteria. | |||||||||||
Example Kwale district, Kenya (some interventions on improvement of available PPC services)
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Possible interventions
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Criteria
1
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Inclusion in local MNCH policy | Acceptability | Evidence-base | Feasible/ realistic to implement: | Effectiveness | Sustainability (long-term) | ||||||
Financial | Human resources | Infrastructure, equipment & supplies | Health system | Referral structure | Supervision | ||||||
Improvement of available PPC services
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Improve BEmOC, PPC and other skills of health workers | +++ | +++ | ++ | + | + | ++ | ++ | ++ | ± | ++ | + |
Train health workers on patient-centred care and culturally adapted behaviour and approaches | + | + | + | + | + | + | + | + | + | ++ | |
Sensitizing of health workers on importance of PPC for mother and newborn and PPC training | +++ | - | ++ | ++ | ++ | +++ | + | ± | ± | ||
Dissemination of national guidelines and strategies regarding PPC among the health workers and training on PPC | +++ | ++ | + | ++ | ++ | +++ | +++ | + | ++ |
Ethics
Results
Needs assessment results
Selected and agreed upon packages of interventions
Study site | Selected interventions |
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Burkina Faso – Kaya district
| 1. Female community health worker support mother and infant during the postpartum period by: |
• conducting home visits | |
• providing individual counselling and group health education on danger signs (for mother and infant) | |
• identification of danger signs and referral if needed | |
• providing counselling on FP | |
2. Upgrade the delivery of immediate postpartum care in the health facilities with focus on the prevention, detection and management of postpartum haemorrhage and sepsis (in mother and newborn) and immediate postpartum FP | |
3. Integration of PPC (including FP counselling and provision) for the mother and newborn/infant in the child vaccination clinic | |
Kenya – Kwale district
| 1. Strengthening immediate postpartum care for mother and newborn by upgrading knowledge and skills of facility and community health workers on detection and management of common maternal and neonatal complications (danger signs counselling, detection and management), promotion of early breastfeeding, counselling and provision of family planning, and by providing postpartum home visits (conducted by the community health worker) |
2. Increase knowledge on and uptake of postpartum family planning during the first year after childbirth using the dialogue model approach at community and facility level. | |
Malawi - Ntchisi district
| 1. Strengthen clinical management of postpartum care during the postpartum period in the district hospital and health centres (using clinical mentorship and quality of care reviews) with focus on anaemia, sepsis, HIV screening and management, FP and nutrition for the mother and sepsis, pneumonia, feeding and growth monitoring for the infant |
2. Increase utilization of postpartum family planning through awareness raising by providing FP counselling at health facility and community level and by involving males | |
3. Strengthen community postpartum care management through home visits conducted by community volunteers and through the establishment and use of men’s, women’s and youth groups. Community volunteers will promote facility-based delivery and provide counselling on nutrition, hygiene, danger signs and FP for the mother and nutrition, immunisation, hygiene and danger signs for the infant. | |
Mozambique - Chiúta district
| 1. Mother and newborn/infant postpartum risk assessment and management at community and facility level upgraded during the postpartum period through early detection, treatment and referral of postpartum complication cases in health facilities and communities by using a risk assessment checklist. The assessment will focus on following risks, complications and conditions: for mother: sepsis, postpartum haemorrhage, mental/emotional status, anaemia, FP, exclusive breastfeeding and HIV/STI counselling and testing or follow-up, and for infant: sepsis, immunization and growth monitoring, exclusive breastfeeding and HIV/STI exposure. |
2. Scale-up access to and use of family planning through making immediate postpartum IUD insertion available at all district health facilities | |
3. Improve access to and use of maternal PPC and services by integrating maternal PPC in child clinics (growth monitoring and immunisation clinics) and by organising quarterly maternal and child health community outreach activities |