Using spatial analysis and GIS to improve planning and resource allocation in a rural district of Bangladesh.

The application of a geographic information system (GIS) in public health is relatively common in Bangladesh. However, the use of GIS for planning, monitoring and decision-making by local-level managers has not been well documented. This assessment explored how effectively local government health managers used maps with spatial data for planning, resource allocation and programme monitoring. The United States Agency for International Development-funded MaMoni Health Systems Strengthening project supported the introduction of the maps into district planning processes in 2015 and 2016. GIS maps were used to support the prioritisation of underserved unions (the lowest administrative units) and clusters of disadvantaged communities for the allocation of funds. Additional resources from local government budgets were allocated to the lowest performing unions for improving health facility service readiness and supervision. Using a mixed-methods approach, the project evaluated the outputs of this planning process. District planning reports, population-based surveys, local government annual expenditure reports and service availability and utilisation data were reviewed. The goal was to determine the degree to which district planning teams were able to use the maps for their intended purpose. Key informant interviews were conducted with upazila (subdistrict) managers, elected government representatives and service providers to understand how the maps were used, as well as to identify potential institutionalisation scopes. The project observed improvements in health service availability and utilisation in the highest priority unions in 2016. Quick processing of maps during planning sessions was challenging. Nevertheless, managers and participants expressed their satisfaction with the use of spatial analysis, and there was an expressed need for more web-based GIS both for improving community-level service delivery and for reviewing performance in monthly meetings. Despite some limitations, the use of GIS maps helped local health managers identify health service gaps, prioritise underserved unions and monitor results.

Global Burden, Epidemiologic Trends, and Prevention of Intrapartum-Related Deaths in Low-Resource Settings.

Intrapartum-related neonatal deaths include live-born infants who die in the first 28 days of life from neonatal encephalopathy or die before onset of neonatal encephalopathy and have evidence of intrapartum injury. A smaller portion of the population in poorer countries has access to basic obstetric and postnatal care causing neonatal mortality rates to be higher. Presence of a skilled birth attendant and provision of basic emergency obstetric care can reduce intrapartum birth asphyxia by 40%. With the announcement of Sustainable Development Goals and global Every Newborn Action Plan, there is hope that interventions around continuum of care will save lives.

'Midwives are the backbone of our health system': lessons from Afghanistan to guide expansion of midwifery in challenging settings.

BACKGROUND: over the last decade Afghanistan has made large investments in scaling up the number of midwives to address access to skilled care and the high burden of maternal and newborn mortality. OBJECTIVE: at the request of the Ministry of Public Health (MOPH) an evaluation was undertaken to improve the pre-service midwifery education programme through identification of its strengths and weaknesses. The qualitative component of the evaluation specifically examined: (1) programme strengths; (2) programme weaknesses; (3) perceptions of the programme's community impact; (4) barriers to provision of care and challenges to impact; (5) perceptions of the recently graduated midwife's field experience, and (6) recommendations for programme improvement. DESIGN: the evaluation used a mixed methods approach that included qualitative and quantitative components. This paper focuses on the qualitative components which included in-depth interviews with 138 graduated midwives and 20 key informants as well as 24 focus group discussions with women. SETTING: eight provinces in Afghanistan with functioning and accredited midwifery schools between June 2008 and November 2010. PARTICIPANTS: midwives graduated from one of the two national midwifery programmes: Institute of Health Sciences and Community Midwifery Education. Key informants comprised of stakeholders and female residents of the midwives catchment areas. FINDINGS: midwives described overall satisfaction with the quality of their education. Midwives and stakeholders perceived that women were more likely to use maternal and child health services in communities where midwives had been deployed. Strengths included evidence-based content, standardised materials, clinical training, and supportive learning environment. Self-reported aspects of the quality education in respect to midwives empowerment included feeling competent and confident as demonstrated by respect shown by co-workers. Weaknesses of the programme included perceived low educational requirement to enter the programme and readiness of programmes to commence education. Insecurity and geographical remoteness are perceived as challenges with clients' access to care and the ability of midwives to make home visits. KEY CONCLUSIONS: the depth of midwives' contribution in Afghanistan - from increased maternal health care service utilisation to changing community's perceptions of women's education and professional independence - is overwhelmingly positive. Lessons learned can serve as a model to other low resource, post-conflict settings that are striving to increase the workforce of skilled providers.

Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar

Background: In Myanmar a large proportion of antenatal and intrapartum care in rural areasis provided by skilled birth attendants (SBAs), this study assessed the coverage by these healthworkers of all births, their adherence to service guidelines, and community opinion on the antenataland delivery care they give in two rural health centres in Pathein Township, Ayeyarwaddy Regionto identify the challenges and improve antenatal and intrapartum service delivery provided by theSBAs.Method: A structured questionnaire was used to interview 304 women who had infants under oneyear of age, and in-depth interviews were held with 12 SBAs and 10 community members.Results: Of the 304 pregnancies, 93% had received antenatal care (ANC); 97% of these werecovered by SBAs at an average 15 weeks’ gestation. The average frequency of ANC visits was 9.Rates of home and hospital deliveries were 84.5% and 13.8% respectively. Among home deliveries,use rate of SBA was 51.4%, while for postnatal care, 31.3% was given by unskilled providers(traditional birth attendants (TBAs) 17.5%, auxiliary midwives (AMWs),13.8%). Multivariate analysisshowed that interviewees aged 30 years and below (OR=0.468, P=0.046), with an education atprimary level and below that of husband (OR=0.391, P=0.007) or not residing in the village of therural/station health centre (OR=0.457, P=0.011) were significantly less likely to use SBAs. Thecategories of supervision, referral, and health education activities of SBAs were not in line withservice guidelines. The main reasons were lack of access and community acceptance of TBAs.Conclusion: Heavy workload, geographical location, transportation and financial concerns weremajor challenges for SBAs, along with community compliance and mutual coordination. Goodcommunication and service management skills were important to overcome these challenges.