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Synthesis of recent articles on knowledge gaps on maternal health, post agenda 2015, quality improvement of health services, fistula and adolescent health

March 20, 2015

Critical knowledge gaps on maternal healthcare

Kendall, T. (2015). Critical Maternal Health Knowledge Gaps in Low- and Middle-Income Countries for Post-2015: Researchers’ Perspectives. Women and Health Initiative Working Paper No. 2 Women and Health Initiative, Harvard T.H. Chan School of Public Health: Boston, MA. A meeting gathering 26 international maternal health researchers was conducted to capture the gaps and neglected areas for knowledge on maternal healthcare in low and middle- income countries. Three priorities of research were highlighted: 1) knowledge gaps that has to be addressed to reduce significantly maternal morbidity and mortality 2) maternal health issues that have been less paid attention from international organizations and academics 3) new challenges to be faced to improve maternal well-being 4) recommendations for approach in research.

Knowledge gaps that has to be addressed to reduce maternal morbidity and mortality: research to strengthen health system and improvement of quality of care. What has been the most raised by the respondent was the need for more implementation research to provide evidence on how to deliver efficiently the services, scale up and sustain interventions. More research on health system is needed especially for the delivery of basic and comprehensive emergency obstetric care and maternal health promotion. More researches need to be conducted to assess the effectiveness, feasibility, and equity impacts of health system interventions to increase and improve the quality and utilization of maternity healthcare services. More specifically in terms of quality of care, researches noted the need for more information about the quality o care, as well as to improve indicators and instruments for evaluating the quality of care.

Maternal health issues that have be less paid attention from international organizations and academics: Human resources and Disrespect and abuse during childbirth. For the issue of human resources, many elements were highlighted such as the availability, and quality of health workers, task shifting, training and supervision. There is a lack of evidence on how to develop, test, the feasibility of scaling up strategies to attract, deploy, and retain healthcare providers.Concerning, task shifting, implementation research must be conducted to assess how non-physician providers and different cadres can safely and effectively especially in rural and other settings with a low proportion of facility births. The Respondents identified two key topics for implementation research related to training: 1) introducing evidence-based practice and 2) increasing technical competence. And more Regarding, the leadership, the need for more evaluation of interventions to improve the managerial capacity at the facility and district level was raised.

New challenges to be faced to improve maternal wellbeing: Non communicable diseases and social and economic and social inequality. Three areas of research related to non-communicable diseases (NCD) were emphasized: (1) understanding the causes and develop effective treatments for NCD; (2) testing new treatments for cardiomyopathy and hypertension; (3) and measuring the prevalence of NCD. For the issue of social and economic inequality, two main area of researches were identified: (1) identification of metrics and a lack of evidence on social and economic inequality and vulnerability; (2) the development of more sophisticated measures to explain variation in quality of care and health outcomes and to track progress towards narrowing equity gaps.

Recommendations for approach in research: Finally, the respondents have made recommendations on how to conduct research to over come the knowledge gap in maternal health. They advocate for a more global health system thinking, being more sensitive to local context, more interdisciplinary team of researchers and more qualitative research.

Post Agenda 2015 on maternal and child health

Requejo, J. H., et al. Countdown to 2015 and beyond: fulfilling the health agenda for women and children. The objective of the article is to present the results of data collected in the 75 countdown countries to track the progress of MDG 4-5 indicators. The results show that despite progress they are still efforts to be conducted to improve the indicators related to MDG 4 and 5. The greatest coverage gaps observed are on planning, interventions addressing newborn mortality, and case management of childhood diseases. In terms of inequities, they are persistent. However, many countries have succeeded to reach the most vulnerable groups. For the future, improving the quality of data remains crucial in order to make decision-making. Under nutrition and child mortality have decreased substantially. Child mortality has reduced from 12.6 million in 1990 to 6.6 million in 2012. However, it did not decreased as faster as expected. Indeed, very few countdowns countries reach MDG4 in 2015.  The main causes of post-neonatal child deaths are preventable infectious diseases, pneumonia, diarrhoea and malaria.  In terms of the reduction of maternal mortality, the progress has been much slower. Sub-Saharan Africa is the region with the highest mortality with a ratio of maternal death of 500 or more deaths per 100 000 live births. Most maternal deaths occur during the intra-partum and immediate postpartum period.

Female workers

Uzondu et al. Female health workers at the doorstep: a pilot of community-based maternal, newborn, and child health service delivery in northern Nigeria. The objective of the article is to present the results of a pilot community-based maternal, newborn and child health service delivery in North of Nigeria. The pilot was conducted in 2011. The intervention has several components: the deployment of female health workers (CHEW) in remote areas, the CHWE do home visits, manage non complicated deliveries, refer in case of complications, counsel on family planning, provide integrated management of childhood illnesses provide drugs, supplies and consumables for basic health services. Using a quasi-experimental study design, the results indicate a 500% increase in rates of health post visits compared with 2010. Monthly antenatal care coverage in Kadawawa during the pilot period ranged from 11.9% to 21.3%, up from 0.9% to 5.8% in the preceding year. Facility-based deliveries more than doubled in Kadawawa compared with the preceding year (105 vs. 43 deliveries total, respectively). Challenges to implementation and scaling up of the intervention were identified: competence of CHEW, lack of training and supervision, difficulties in the supply chain of supplies, transportation issues (security, gender sensitive) for home visits and recruitment and retention of CHEWs. However, there was evidence of sustainability. The intervention received funds from different ministries.

Quality improvement approach in health services

Amina et al. Implementing a nationwide quality improvement approach in health services: The Moroccan “Quality Contest” experience. This paper aimed to present an innovative quality improvement intervention developed in Morocco and discuss its implementation. In 2005, Morocco opted for an intervention called “Quality Contest” (QC) targeting health centres, hospitals and health district offices and combining quality measurement with structures ranking, performance disclosure and reward system. The QC is organized every 18 months. After the self-assessment and external audit step, the participating structures are ranked according to their scores. Their performances are then disseminated and the highest performing structures are rewarded. The results showed an improvement in performance among participating structures, constructive exchange of successful experiences between structures, as well as communication of constraints, needs and expectations between MoH managers at central and local levels; the use of peer-auditors was appreciated as it enabled an exchange of best practices between auditors and audited teams but this was mitigated by the difficulty of ensuring their neutrality; and the recognition of efforts was appreciated but seemed insufficient to ensure a sense of justice and maintain motivation. Access full paper Implementing QC.

Amina et al. A systemic approach to quality improvement in public health services: The Moroccan “Quality Contest. This paper aimed to discuss the results of the first four years of implementation of a quality program called “Quality Contest” (QC). This program was implemented from 2007 onward to improve the quality of hospital services by the Moroccan Ministry of Health. The intervention, held every 18 months, combines several approaches (self-evaluation, external audits with feedback, hospital ranking, awards and performance disclosure) and focuses on the quality of management. The assessment tool used to evaluate the quality of hospital management consists of 80 items. In each contest, a score is attributed to each item based on the score given for self-evaluation and the score given by external auditors. The sum of these scores allows the global performance score of the hospital to be obtained. The results of the QC organized between 2007 and 2010 revealed that the hospitals participating in all the three contests had significantly improved their performance levels in terms of the quality of management. There was also a significant association between the number of times hospitals participated in the QC and the performance scores attained. Access full paper Systemic approach to QI in PH services.

Review: Use of maternal health services among adolescents

Shahabuddin et al. Use of maternal health services among adolescent women in Bangladesh. This scoping review of the literature aimed to understand the maternal health seeking behavior of adolescent women in Bangladesh. Seven electronic database were searched to identify articles related to Bangladeshi adolescent women’s use of maternal health services. In total 12 relevant studies were included in this review. 11 used quantitative methods and one used a mixed methods approach. All studies included married adolescent women only. Women with lower educational levels are less likely to seek skilled maternal health services than those with higher levels of education. Use of maternal health services are also less common among rural married adolescent women than women in urban areas. Being part of the richest bands of wealth, having had previous experiences of childbirth and higher women’s autonomy positively influence the use of skilled maternal health services among married adolescent women in Bangladesh. Antenatal care is a key predictor of the use of skilled birth attendants for delivery and postnatal care. This review recommends

to design and implement more maternal health related programs targeting rural and uneducated married adolescent women in Bangladesh and urges to conduct more qualitative investigations to broaden our understanding on maternal health seeking behavior of both married and unmarried adolescent women.

Holistic programme of fistula repair

Delamou et al. Good clinical outcomes from a 7-year holistic programme of fistula repair in Guinea. The objective of this article was to present and discuss the clinical outcomes of 7 years of work involving 2116 women repaired in three hospitals across the country. A retrospective cohort study using data abstracted from medical records for fistula repairs conducted from 2007 to 2013. The results shows that of the 2116 women who underwent surgical repair had vesicovaginal fistula (n = 2045, 97%) and 3% had rectovaginal fistula or a combination of both. Overall 1748 (83%) had a closed fistula and were continent of urine immediately after surgery. At discharge, 1795 women (85%) had a closed fistula and 1680 (79%) were dry, meaning they no longer leaked urine and/or faeces. One hundred and fifteen (5%) remained with residual incontinence despite fistula closure. Follow-up at 3 months was completed by 1663 (79%) women of whom 1405 (84.5%) had their fistula closed and 80% were continent. Twenty-one per cent were lost to follow-up. A routine programmatic repair for obstetric fistula in low resources settings can yield good outcomes. However, more efforts are needed to address loss to follow-up, sustain the results and prevent the occurrence and/or recurrence of fistula.