"Practice so that the skill does not disappear": mixed methods evaluation of simulator-based learning for midwives in Uganda.

BACKGROUND: Postpartum hemorrhage and neonatal asphyxia are leading causes of maternal and neonatal mortality, respectively, that occur relatively rarely in low-volume health facilities in sub-Saharan Africa. Rare occurrence of cases may limit the readiness and skills that individual birth attendants have to address complications. Evidence suggests that simulator-based training and practice sessions can help birth attendants maintain these life-saving skills; one approach is called "low-dose, high-frequency" (LDHF). The objective of this evaluation is to determine the facilitating factors and barriers to participation in LDHF practice, using qualitative and quantitative information. METHODS: A trial in 125 facilities in Uganda compared three strategies of support for LDHF practice to improve retention of skills in prevention and treatment of postpartum hemorrhage and neonatal asphyxia. Birth attendants kept written logs of their simulator-based practice sessions, which were entered into a database, then analyzed using Stata to compare frequency of practice by the study arm. The evaluation also included 29 in-depth interviews and 19 focus group discussions with birth attendants and district trainers. Transcripts were entered in Atlas.ti software for coding, then analyzed using content analysis to identify factors that motivated or discouraged simulator-based practice. RESULTS: Practice log data indicated that simulator-based practice sessions occurred more frequently in facilities where one or two practice coordinators helped schedule and lead the practice sessions and in health centers compared to hospitals. The qualitative data suggest that birth attendants who practiced more were motivated by a desire to maintain skills and be prepared for emergencies, external recognition, and establishing a set schedule. Barriers to consistent practice included low staffing levels, heavy workloads, and a sense that competency can be maintained through routine clinical care alone. Some facilities described norms around continuing education and some did not. CONCLUSIONS: Designating practice coordinators to lead their peers in simulator-based practice led to more consistent skills practice within frontline health facilities. Ongoing support, scheduling of practice sessions, and assessment and communication of motivation factors may help sustain LDHF practice and similar forms of continuing professional development. TRIAL REGISTRATION: Registered with clinicaltrials.gov #NCT03254628 on August 18, 2018 (registered retrospectively).

Expanding the Single-Visit Approach for Cervical Cancer Prevention: Successes and Lessons From Burkina Faso.

BACKGROUND: Cervical cancer accounts for 23% of cancer incidence and 22% of cancer mortality among women in Burkina Faso. These proportions are more than 2 and 5 times higher than those of developed countries, respectively. Before 2010, cervical cancer prevention (CECAP) services in Burkina Faso were limited to temporary screening campaigns. PROGRAM DESCRIPTION: Between September 2010 and August 2014, program implementers collaborated with the Ministry of Health and professional associations to implement a CECAP program focused on coupling visual inspection with acetic acid (VIA) for screening with same-day cryotherapy treatment for eligible women in 14 facilities. Women with larger lesions or lesions suspect for cancer were referred for loop electrosurgical excision procedure (LEEP). The program trained providers, raised awareness through demand generation activities, and strengthened monitoring capacity. METHODS: Data on program activities, service provision, and programmatic lessons were analyzed. Three data collection tools, an individual client form, a client registry, and a monthly summary sheet, were used to track 3 key CECAP service indicators: number of women screened using VIA, proportion of women who screened VIA positive, and proportion of women screening VIA positive who received same-day cryotherapy. RESULTS: Over 4 years, the program screened 13,999 women for cervical cancer using VIA; 8.9% screened positive; and 65.9% received cryotherapy in a single visit. The proportion receiving cryotherapy on the same day started at a high of 82% to 93% when services were provided free of charge, but dropped to 51% when a user fee of $10 was applied to cover the cost of supplies. After reducing the fee to $4 in November 2012, the proportion increased again to 78%. Implementation challenges included difficulties tracking referred patients, stock-outs of key supplies, difficulties with machine maintenance, and prohibitive user fees. Providers were trained to independently monitor services, identify gaps, and take corrective actions. CONCLUSIONS: Following dissemination of the results that demonstrated the acceptability and feasibility of the CECAP program, the Burkina Faso Ministry of Health included CECAP services in its minimum service delivery package in 2016. Essential components for such programs include provider training on VIA, cryotherapy, and LEEP; provider and patient demand generation; local equipment maintenance; consistent supply stocks; referral system for LEEP; non-prohibitive fees; and a monitoring data collection system.

Experiences with and expectations of maternity waiting homes in Luapula Province, Zambia: a mixed-methods, cross-sectional study with women, community groups and stakeholders.

BACKGROUND: Luapula Province has the highest maternal mortality and one of the lowest facility-based births in Zambia. The distance to facilities limits facility-based births for women in rural areas. In 2013, the government incorporated maternity homes into the health system at the community level to increase facility-based births and reduce maternal mortality. To examine the experiences with maternity homes, formative research was undertaken in four districts of Luapula Province to assess women's and community's needs, use patterns, collaboration between maternity homes, facilities and communities, and promising practices and models in Central and Lusaka Provinces. METHODS: A cross-sectional, mixed-methods design was used. In Luapula Province, qualitative data were collected through 21 focus group discussions with 210 pregnant women, mothers, elderly women, and Safe Motherhood Action Groups (SMAGs) and 79 interviews with health workers, traditional leaders, couples and partner agency staff. Health facility assessment tools, service abstraction forms and registers from 17 facilities supplied quantitative data. Additional qualitative data were collected from 26 SMAGs and 10 health workers in Central and Lusaka Provinces to contextualise findings. Qualitative transcripts were analysed thematically using Atlas-ti. Quantitative data were analysed descriptively using Stata. RESULTS: Women who used maternity homes recognized the advantages of facility-based births. However, women and community groups requested better infrastructure, services, food, security, privacy, and transportation. SMAGs led the construction of maternity homes and advocated the benefits to women and communities in collaboration with health workers, but management responsibilities of the homes remained unassigned to SMAGs or staff. Community norms often influenced women's decisions to use maternity homes. Successful maternity homes in Central Province also relied on SMAGs for financial support, but the sustainability of these models was not certain. CONCLUSIONS: Women and communities in the selected facilities accept and value maternity homes. However, interventions are needed to address women's needs for better infrastructure, services, food, security, privacy and transportation. Strengthening relationships between the managers of the homes and their communities can serve as the foundation to meet the needs and expectations of pregnant women. Particular attention should be paid to ensuring that maternity homes meet quality standards and remain sustainable.

Wheelchair services and use outcomes: A cross-sectional survey in Kenya and the Philippines.

BACKGROUND: The World Health Organisation recommends that services accompany wheelchair distribution. This study examined the relationship of wheelchair service provision in Kenya and the Philippines and wheelchair-use-related outcomes. METHOD: We surveyed 852 adult basic manual wheelchair users. Participants who had received services and those who had not were sought in equal numbers from wheelchair-distribution entities. Outcomes assessed were daily wheelchair use, falls, unassisted outdoor use and performance of activities of daily living (ADL). Descriptive, bivariate and multivariable regression model results are presented. RESULTS: Conditions that led to the need for a basic wheelchair were mainly spinal cord injury, polio/post-polio, and congenital conditions. Most Kenyans reported high daily wheelchair use (60%) and ADL performance (80%), while these practices were less frequent in the Philippine sample (42% and 74%, respectively). Having the wheelchair fit assessed while the user propelled the wheelchair was associated with greater odds of high ADL performance in Kenya (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.6, 5.1) and the Philippines (OR 2.8, 95% CI 1.8, 4.5). Wheelchair-related training was associated with high ADL performance in Kenya (OR 3.2, 95% CI 1.3, 8.4). In the Philippines, training was associated with greater odds of high versus no daily wheelchair use but also odds of serious versus no falls (OR 2.5, 95% CI 1.4, 4.5). CONCLUSION: Select services that were associated with some better wheelchair use outcomes and should be emphasised in service delivery. Service providers should be aware that increased mobility may lead to serious falls.

Use of a design challenge to develop postural support devices for intermediate wheelchair users.

The provision of an appropriate wheelchair, one that provides proper fit and postural support, promotes wheelchair users' physical health and quality of life. Many wheelchair users have postural difficulties, requiring supplemental postural support devices for added trunk support. However, in many low- and middle-income settings, postural support devices are inaccessible, inappropriate or unaffordable. This article describes the use of the design challenge model, informed by a design thinking approach, to catalyse the development of an affordable, simple and robust postural support device for low- and middle-income countries. The article also illustrates how not-for-profit organisations can utilise design thinking and, in particular, the design challenge model to successfully support the development of innovative solutions to product or process challenges.

Erratum: Wheelchair services and use outcomes: A cross-sectional survey in Kenya and the Philippines.

[This corrects the article DOI: 10.4102/ajod.v6i0.318.].

Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa.

BACKGROUND: Poor quality of care at health facilities is a barrier to pregnant women and their families accessing skilled care. Increasing evidence from low resource countries suggests care women receive during labor and childbirth is sometimes rude, disrespectful, abusive, and not responsive to their needs. However, little is known about how frequently women experience these behaviors. This study is one of the first to report prevalence of respectful maternity care and disrespectful and abusive behavior at facilities in multiple low resource countries. METHODS: Structured, standardized clinical observation checklists were used to directly observe quality of care at facilities in five countries: Ethiopia, Kenya, Madagascar, Rwanda, and the United Republic of Tanzania. Respectful care was represented by 10 items describing actions the provider should take to ensure the client was informed and able to make choices about her care, and that her dignity and privacy were respected. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Clinical observers' open-ended comments were also analyzed to identify examples of disrespect and abuse. RESULTS: A total of 2164 labor and delivery observations were conducted at hospitals and health centers. Encouragingly, women overall were treated with dignity and in a supportive manner by providers, but many women experienced poor interactions with providers and were not well-informed about their care. Both physical and verbal abuse of women were observed during the study. The most frequently mentioned form of disrespect and abuse in the open-ended comments was abandonment and neglect. CONCLUSIONS: Efforts to increase use of facility-based maternity care in low income countries are unlikely to achieve desired gains if there is no improvement in quality of care provided, especially elements of respectful care. This analysis identified insufficient communication and information sharing by providers as well as delays in care and abandonment of laboring women as deficiencies in respectful care. Failure to adopt a patient-centered approach and a lack of health system resources are contributing structural factors. Further research is needed to understand these barriers and develop effective interventions to promote respectful care in this context.

Women's use of private and government health facilities for childbirth in Nairobi's informal settlements.

The private sector's role in increasing the use of maternal health care for the poor in developing countries has received increasing attention, yet few data exist for urban slums. Using household-survey data from 1,926 mothers in two informal settlements in Nairobi, Kenya, collected in 2006, we describe and examine the factors associated with women's use of private and government health facilities for childbirth. More women gave birth at private facilities located in the settlements than at government facilities, and one-third of the women gave birth at home or with the assistance of a traditional birth attendant. In multivariate models, women's education, ethnic group, and household wealth were associated with institutional deliveries, especially in government hospitals. Residents in the more disadvantaged settlement were more likely than those in the better-off settlement to give birth in private facilities. In urban areas, maternal health services in both the government and private sectors should be strengthened, and efforts made to reach out to women who give birth at home.

Women's satisfaction with delivery care in Nairobi's informal settlements.

OBJECTIVE: To quantify women's satisfaction with delivery care in informal settlements of Nairobi, Kenya, and to determine characteristics of women and delivery care associated with satisfaction. DESIGN: Household survey data analysis of 1266 women who delivered in health facilities in 2004 or 2005. SETTING: Two densely populated informal settlements 7 and 12 km from Nairobi's center, where residents work primarily in the nearby industrial area or in the informal sector. Outcome Satisfaction was assessed by whether women would recommend the delivery care facility and deliver there again. RESULTS: Over half (56%) of women would both recommend and deliver again in the same facility. In multivariate analysis, women's satisfaction with delivery care was associated with greater provider empathy (OR = 3.68, 95% CI 2.27, 5.97). Women's satisfaction with delivery care was also associated with the pregnancy having been wanted (OR = 2.75, 95% CI 1.82, 4.14) or mistimed vs. unwanted. Women delivering at private facilities in the settlement near the industrial area were more satisfied than women delivering at private facilities in the more distant and marginalized settlement (OR = 2.12, 95% CI 1.45, 3.09). The association of women's satisfaction and provider empathy was stronger among women who experienced complications compared to those who did not. CONCLUSION: Health providers should be sensitized to the finding that unintended pregnancy is associated with lower satisfaction with delivery care. Maternal health programmes should focus on increasing provider empathy, especially for women who experience complications, in both private and government health facilities.

Couples counseling at an abortion clinic: a pilot study.

BACKGROUND: Nearly half of all pregnancies in the United States (US) are unintended. Nonuse, incorrect or inconsistent use of contraception may be related to limited support of male partners. Partners often accompany women seeking abortions to the clinic, representing an opportunity for health providers to engage them. This pilot study estimates the proportion of abortion patients accompanied by a male partner, the proportion agreeing to couples counseling and describes couples' experiences with the counseling. STUDY DESIGN: At a Baltimore clinic providing abortion, after preliminary qualitative research we recorded the number of patients who came with partners and accepted couples counseling in a 3-month period and sought feedback on the couples counseling in questionnaires from women, partners and the counselor. The counseling session consisted of giving information about the procedure and counseling regarding choices of a post-abortion contraceptive method and related topics that the woman and/or partner might raise. RESULTS: Overall, 27% of 774 patients came with their male partner, 28% with someone else and 45% alone. Fewer African-Americans (23%) came with a male partner, compared to 35% each among Whites and Hispanics (p<.001). Among all couples, 42% (n=88) accepted couple counseling. Many women (77%) and partners (59%) completing questionnaires (n=66) had expected the partner to be involved in the clinic visit. The patients appreciated having the partner's support, having an informed partner with whom to communicate and being able to share decision making. CONCLUSION: Over a quarter of patients to an abortion clinic came with a partner without any advance notice of the availability of couple counseling, and a sizable minority of these couples accepted couple counseling. Those who had the counseling evaluated it favorably.

Factors associated with religious congregation members' support to people living with HIV/AIDS in Kumasi, Ghana.

Physical, social and economic constraints often limit the ability of people living with HIV/AIDS to meet their basic needs. Community members are a valuable source of support for people living with HIV/AIDS, although little is known about the types of support they provide or how to mobilize this support. To examine this issue, a survey of 1200 members of 6 religious congregations was conducted in Kumasi, Ghana. A fifth of congregation members reported providing some support to people with HIV/AIDS in the last 6 months, mostly through prayer, financial support, and counseling. Factors associated with providing support include having heard a congregation or tribal chief speaking about HIV/AIDS, collective efficacy related to HIV/AIDS, and perceived risk of becoming infected with HIV. To enhance support to people with HIV/AIDS, programs should involve community leaders and encourage dialogue on ways to address the epidemic.