'What gets measured gets managed': revisiting the indicators for maternal and newborn health programmes.

BACKGROUND: The health of women and children are critical for global development. The Sustainable Development Goals (SDG) agenda and the Global Strategy for Women's, Children's, and Adolescent's Health 2016-2030 aim to reduce maternal and newborn deaths, disability, and enhancement of well-being. However, information and data on measuring countries' progress are limited given the variety of methodological challenges of measuring care around the time of birth, when most maternal and neonatal deaths and morbidities occur. MAIN BODY: In 2015, the World Health Organization launched Mother and Newborn Information for Tracking Outcomes and Results (MoNITOR), a technical advisory group to WHO. MoNITOR comprises 14 independent global experts from a variety of disciplines selected in a competitive process for their technical expertise and regional representation. MoNITOR will provide technical guidance to WHO to ensure harmonized guidance, messages, and tools so that countries can collect useful data to track progress toward achieving the Sustainable Development Goals. SHORT CONCLUSION: Ultimately, MoNITOR will provide technical guidance to WHO to ensure harmonized guidance, messages, and tools so that countries can collect useful data to track progress toward achieving the Sustainable Development Goals.

What happened to the IUD in Ghana?

The intrauterine contraceptive device (IUD) is a safe and reversible contraceptive method that requires little effort on the part of the user. Once inserted, it offers 10 years of protection against pregnancy. However, its use in Ghana has stagnated in relation to other contraceptive methods. An exploratory study was, therefore, conducted to examine the client, provider and system characteristics that affect the demand for IUD. Data were gathered through secondary analysis, in-depth interviews, focus group discussions and simulated client survey. The stagnating demand for IUD is attributed to clients' perceptions and rumours about IUD. The fear of excessive bleeding and weight loss discourages potential users. The product design was also perceived to be unacceptable. Demand creation for the IUD has been poor and the number of providers with practical experience of insertion is insufficient. Contrary to the belief that providers' bias contributes to the decline in use, findings show that providers have a favourable attitude towards the product.

Female genital cutting practices in Burkina Faso and Mali and their negative health outcomes.

Observations of the types of female genital cutting and possible associated gynecological and delivery complications were undertaken in 21 clinics in rural Burkina Faso and in four rural and four urban clinics in Mali. Women who came to the clinics for services that included a pelvic exam were included in the study, and trained clinic staff observed the presence and type of cut and any associated complications. Ninety-three percent of the women in the Burkina Faso clinics and 94 percent of the women in the Mali clinics had undergone genital cutting. In Burkina Faso, type 1 (clitoridectomy) was the most prevalent (56 percent), whereas in Mali the more severe type 2 cut (excision) was the most prevalent (74 percent); 5 percent of both samples had undergone type 3 cutting (infibulation). Logistic regression analyses show significant positive relationships between the severity of genital cutting and the probability that a woman would have gynecological and obstetric complications.

PIP: This study examines the type of female genital cutting and its possible associated gynecological and delivery complications among females in Burkina Faso and Mali, Africa. Included in the study were women who came to 21 clinics in rural Burkina Faso and in four rural and four urban clinics in Mali seeking medical services that include a pelvic exam. Trained clinical staff observed the presence and type of cut and any associated complications. It was observed that 93% of the women in Burkina Faso and 94% in Mali had undergone genital cutting. The most prevalent type of female genital cutting in Burkina Faso is clitoridectomy, which is 56% among women observed. In Mali, excision was the most prevalent (74%). About 5% of both samples had undergone type 3 cutting, which is the infibulation. Furthermore, there exist a significant relationship between the severity of genital cutting and the possibility of gynecological and obstetric complications.

Indicators for measuring the quality of family planning services in Nigeria.

This article presents the Situation Analysis approach as a means of collecting data that can be used to assess the quality of care provided by family planning service-delivery points (SDPs), and describes the quality of services offered in Nigeria. Elements of the quality of services provided at 181 clinical service-delivery points in six states of Nigeria are described. The substantive results from the study suggest that although most of the 181 service points sampled are functional, the quality of care being provided could be improved. Illustrative scores for these indicators and elements of the Bruce-Jain framework are given. By comparison with contraceptive prevalence surveys, the Situation Analysis approach is still in its early stages. Some methodological issues are raised here and future directions for strengthening the validity and applicability of the approach are discussed.

PIP: Baseline data for a situation analysis of family planning programs in Nigeria was collected from 181 clinical service delivery points (SDPs) in six of Nigeria's 30 states. The variety of instruments described by Fisher et al. were used and modified for the Nigerian context in a workshop setting in 1992. Data was collected during March and April 1992. The sample represented over 10% of SDPs nationally and the public SDPs were stratified by type and represented almost 50% of the family planning SDPs within the 6 states. A modified version of the Bruce-Jain framework was used in the analysis: interpersonal relations, choice of method, provider-client information exchange, technical competence, and mechanisms to assure continuity of care. There were eight interpersonal indicators. Findings showed that 97% of clients received a friendly greeting, but only 33% were probed about whether clients had questions. There was visual and auditory privacy for only 71% of SDPs. Over 75% had at least curtained off areas for examinations. 13% had no private areas at all. 39% reported no waiting time, and 39% reporting a waiting time of under 30 minutes. Busy SDPs had the shortest waits. New clients had a mean duration of 33 minutes for interaction with staff. Resupply or check-ups averaged 19 minutes. Public SDPs had shorter visit times. Less busy SDPs had longer visits. The number of methods available averaged 4.5 per SDP but varied by state. 3.5 methods/client were the mean number of methods mentioned to the 121 new clients. 28% learned about only one method. 55% of the 128 new clients had a method choice before counseling was initiated. About 22% of those not voluntarily reporting a preference were asked a preference. Equal amounts of information on each method were not provided. Limited information was provided on how to use, side effects, effectiveness, and contraindications. Few IEC aids were used, and those were primarily contraceptive samples (86% of cases). Groups health talks were a common method of imparting contraceptive information.

Using situation analysis data to assess the functioning of family planning clinics in Nigeria, Tanzania, and Zimbabwe.

Situation analyses conducted in Nigeria. Tanzania, and Zimbabwe have revealed problems in the functioning of many of the subsystems of family planning service delivery, namely in supplies of commodities; in facilities and equipment; in staffing and training; in information, education, and communication; and in record keeping. Although a clear pattern of clinic use exists, in that only a few service-delivery points provide contraceptive services to the majority of new family planning acceptors in the three countries, an attempt to explain how clinics with more clients differ from those that are visited less frequently revealed only a weak association between subsystem functioning and use.

PIP: Family planning specialists analyzed subsystem data and the pattern of clinic use from family planning clinics in Nigeria, Tanzania, and Zimbabwe to illustrate how situation analysis can help program managers identify service delivery problems, possible remedial actions, and needs in a clear manner and evaluate specific interventions to improve the quality of family planning services. The Nigerian study included service delivery points in only 6 states. The Tanzanian and Zimbabwean studies included service delivery points countrywide. The researchers examined the functioning of family planning subsystems. They found considerable problems in supplies of contraceptive methods, in facilities and equipment, in staffing and training, in IEC (information, education, and communication), and in record keeping. In Nigeria, just 37% of service delivery points had disposable gloves. Only 56% of facilities had adequate water available in the examination area. In Zimbabwe, 84% and 86% of service delivery points did not have IUDs and injectables, respectively, which limited contraceptive choice. Tanzania had the most problems with subsystem functioning. Few service delivery points in any country provided contraceptive services to most new clients. Thus, there is much room to expand family planning services in most facilities which have few clients. A weak positive association existed between subsystem functioning and use, so the researchers could not explain the variation in number of new acceptors by level of subsystem functioning. They suggested a return visit to a few service delivery points, for a longer stay, as a way to learn ways the active facilities differ from the inactive facilities.

Future directions for family planning operations research: towards a greater appreciation of psychosocial issues.

PIP: In the past, operations research has played a significant role in providing donor agencies and family planning program managers with information to guide the development of services most likely to reduce fertility. As family planning programs have become more established, however, the focus of operations research has shifted from an emphasis solely on outcome variables such as contraceptive usage to consideration of psychosocial and quality of care variables. There is new awareness that aspects of the service delivery system itself determine client transactions (proximate psychosocial variables), which in turn affect client satisfaction and contraceptive use. Such aspects include choice of contraceptive methods, client education and counseling, providers' technical competence, client-staff relations, mechanisms to encourage continuity of use, eligibility restrictions, provider bias, and an appropriate constellation of services. Increasing emphasis is being placed on operations research to guide the process of introduction of new contraceptive technologies (e.g., Norplant) into family planning programs. Finally, there is greater appreciation of the need in operations research for nonexperimental, qualitative data collection methods such as focus group discussions, in-depth unstructured interviews, and direct observation techniques, as well as multi-level analyses that reflect the perspectives of both providers and users. As family planning programs become more complex, the disciplines of organizational psychology and sociology should be drawn upon for theoretical and methodological guidance.^ieng

Menstrual experiences and beliefs: a multicountry study of relationships with fertility and fertility regulating methods.

PIP: Knowledge is needed about what women generally experience (behavior and beliefs about sexual, personal, social, and dietary factors) during menstruation as baseline data. Data were obtained from a WHO non nationally representative sample of 5322 parous women from 14 cultural groups between 1973 to 1980 and a subsample of 500 women with detailed daily diaries from 10 countries (Egypt, India, Indonesia, jamaica, Korea, Mexico, Pakistan, Philippines, UK, and Yugoslavia). This study identified and analyzed 1) critical variables through principal component analysis and varimax rotation, 2) clusters of types of women with particular menstrual experiences and particular beliefs, and 3) the relationship between demographic variables and the 2 resultant cluster and the relationship between beliefs and experiences. Factor analysis resulted in the identification of 6 factors and 13 variables which accounted for more than 65% of the variance: amount of bleeding, activity during the last menstrual period, mood during last menstrual period, discomfort during last menstrual period, predictability, and blood characteristics (smell and color). Beliefs that explained more than 53% of the estimated variance were bathing behavior during menstruation, fertility and femininity issues, interpretations and implications of menstruation, and beliefs about not washing hair or body during menstruation. Alpha estimates of reliability for the belief ranged from .33 to .73, and for behavior the range was .40 to .59. The cluster analysis of type of persons identified 3 groups of women: type I (26.4%) who experienced low blood loss the first day and had a long duration of bleeding; type II (52.3%) who had a short duration of bleeding; and type III (21.2%) who had the heaviest bleeding and longest duration of bleeding. The cluster analysis of women's belief types indicated 9 profiles. For instance, Type 2 women tended to believe that menstruation is dirty but prefer more blood loss. Belief Profiles 3, 4, 5, 8, and 9 are consistently represented and profiles 1, 2, 6, and 7 show wide variability. 7 demographic factors were found to be significantly related to belief clusters: country of residence, religion, literacy, age, work environment, social status, and rural vs. urban area. There was evidence, for instance, that type 2 women were overrepresented in the use of modern methods, and that Belief Profile 1, which represents 10.23% of the sample, showed 17.86% using modern methods. The findings show that Belief Profile 1 persons who disagreed with many items were the most likely to use modern methods and have smaller family sizes. Beliefs, which reflect socialization according to demographic variables, appear to affect choice of methods and family size.^ieng

Community participation in national family planning programs: some organizational issues.

Increasing the involvement of communities in implementing national family planning programs has been advocated as a means of increasing the acceptability, availability, and sustainability of services provided. This article reviews the nature and extent of community participation in the national programs of Bangladesh, China, the Republic of Korea, the Philippines, and Thailand by analyzing the structures and processes through which participation is organized. Across all five countries a similar pattern of participation has emerged in which a community-based delivery system is supported by the involvement of community leaders in activities that promote family planning. Active participation in planning and management functions is, however, virtually nonexistent. This limited form of participation is attributed to the bureaucratic organization of national family planning programs that seek to implement policies with explicit demographic goals. Given these goals and organizational structures, however, the pattern of organizing participation observed is probably the most appropriate. Consequently, policymakers should be wary of expecting greater involvement by community members in program implementation activities or in contributing resources unless consideration is given to reorienting the goals and organizing programs that meet needs that are directly relevant to families and communities.

Organizing community participation in family planning projects in South Asia.

"Community participation" is a popular phrase with policymakers but the operational implications of putting the idea into practice are not clearly understood. This paper presents the findings from a comparative analysis of seven case studies of community participation projects implemented by the nongovernmental Family Planning Associations (FPAs) of India, Bangladesh, Pakistan, Sri Lanka, and Nepal. The analysis focuses on the interactions between staff and communities and assesses the extent to which the organization of the FPAs encourages and enables participation in project implementation. The results suggest that, despite the policy rhetoric seeking greater community involvement and self-reliance in program implementation, FPAs most commonly use participation as a means to generate new demand for services by presenting family planning in a manner that is acceptable and appropriate to the communities involved.

Physicians' views of periodic abstinence methods: a study in four countries.

A study of the knowledge, perceptions, and behavioral intentions of physicians regarding periodic abstinence (PA) methods was undertaken in Mauritius, Peru, the Philippines, and Sri Lanka. Most respondents considered PA to be useful, although even the PA providers prescribed mainly non-PA methods. Detailed knowledge of PA methods was not evident, but most physicians were willing to initiate general discussion about PA with patients. Physicians favored methods perceived as "scientific" and "modern," which primarily prevent pregnancy and secondarily avoid other health risks. When carefully presented as "scientific" and "modern," methods presented to medical audiences may find acceptance and be more likely to result in referral.

PIP: This study attempts to assess the level of knowledge about periodic abstinence methods and willingness to communicate that knowledge to patients among a sample of 375 physicians from 4 developing countries: Mauritius, Peru, the Philippines, and Sri Lanka. For purposes of this study, periodic abstinence includes the calendar method (rhythm), the Billings method (ovulation method), the temperature method (basal body temperature), and the sympto-thermal method (temperature and cervical mucus observation). 54% of the doctors interviewed did not provide periodic abstinence services. 67% were male, 60% were over 40, 92% were not strongly Catholic, and 42% were general practitioners. Older doctors, female doctors, and strongly Catholic doctors were most likely to provide periodic abstinence services. 54% of providers were general practitioners, 46% were gynecologists, and 36% were clinicians. Both providers and nonproviders were most likely to recommend the pill or the IUD as a contraceptive method. The calendar method was the most commonly provided abstinence method. Providers, in general, had more knowledge about abstinence methods than did nonproviders, but even providers were deficient in knowledge about methods that they did not supply. Of the 3 main abstinence methods, the calendar method was perceived as most traditional, the Billings method as most modern. The sympto-thermal method was perceived as modern but also as "artificial." On a scale of 1 to 7 from bad/nonscientific to good/scientific, the pill scored highest (6.4), while the temperature, Billings, and calendar methods scored 5.2 or 5.1. 47% of all the physicians surveyed said that they would not recommend periodic abstinence to their patients. The majority said that they would respond to inquiries about these methods but would not initiate discussions about them. Among nonproviders, 12% said they would seek future training, but 17% said they had no future plans for either training or service.