No longer giving life through death.

Pragmatic approaches to safe motherhood consider the needs of both clients and providers: the sociological and physical environments within which a woman lives and moves through to reach a level of care that fulfills her health needs; and the conditions of formal and traditional health care systems within which a health care provider works and moves through to reach a level of professional satisfaction and quality care that fulfills her/his needs and responsibilities. These movements toward higher levels of 'care' are interdependent; without one, the other falters. Clients and providers are partners in this 'dance' of health. Five approaches employed by the MotherCare Project shape maternal health programs. Presented in geometric form, they each describe movements leading client and provider to more satisfying positions in receiving and giving health care, respectively. Strategies to enhance these movements are the subject of the subsequent chapters of this supplement.

Improving the quality of service delivery in Nigeria.

This study evaluates the effect of a nurse training program in family planning counseling skills on the quality of service delivery at the clinic level, as well as its impact on client compliance with prearranged appointments. The study used a quasi-experimental design to compare certified nurses who received six weeks of family planning technical training with certified nurses who, in addition to the technical training course, received a three-day course in counseling skills. Data were collected through client exit interviews, expert observation, and inspection of medical record abstracts. Trained nurses performed better than their untrained counterparts in the quality-of-care areas investigated--interpersonal relations, information giving, counseling, and mechanisms for encouraging continuity. The likelihood that clients will attend follow-up visits was also found to improve when they were attended by trained professionals. Short-term counseling training can significantly improve the quality of care provided by family planning workers, as well as client compliance with follow-up appointments.

PIP: In 1989, researchers evaluated the impact of a 3 day course in counseling and interpersonal communication skills for family planning nurses in Ogun State, Nigeria on quality of service delivery and on client compliance with follow up appointments. They interviewed 480 clients, observed 39 nurses, and examined the medical records of 1001 clients who visited the 8 clinics. 97% of clients who spoke to a trained nurse felt the nurse earnestly listened whereas only 66% of those who spoke with an untrained nurse felt this (p.001). Further clients tended to be more comfortable with trained nurses than with untrained nurses (97% vs. 76%; p.001). Moreover trained nurses provided clear explanations to 94% of clients while untrained nurses did so to only 76% of clients (p.001). In addition, trained nurses were better at demonstrating the use of a contraceptive (p.001), repeating instructions for methods (p.05), asking if clients had more questions (p.05), and referring to booklets or leaflets about methods (p.05). They intended to schedule a follow up visit with clients who used a method for the 1st time (96% vs. 78%; p.001). In fact, clients of trained nurses were 2 times as likely to return than those of untrained nurses (84% vs. 44%; p.001). Moreover, of clients who chose to use the IUD at the 1st visit, 85% of those attended to by a trained nurse returned for follow up appointments compared to only 30% of those attended to by an untrained nurse (p.001). The corresponding percentages for those who chose an oral contraceptive were 91% and 70% p.001). The findings revealed that the training course did indeed improve the quality of family planning service delivery and client compliance. In fact, counseling training most likely provided even greater advantages than the study suggested since untrained nurses interacted with the trained nurses socially and on the job. Moreover they were also inquisitive about what methods their trained colleagues used.

Mass media family planning promotion in three Nigerian cities.

Television promotion of family planning and clinic sites in three cities of Nigeria--Ilorin, Ibadan, and Enugu--played a significant role in 1985-88 in increasing the number of new acceptors at family planning clinics in each city. Family planning skits, prepared with advice and support from the local service providers, were included in existing popular entertainment shows. Questions asked in a recall survey among the exposed population in Enugu and Ibadan revealed that about half of those surveyed in both cities had seen the television episodes. Of those who had watched, 79 and 99 percent, respectively, recalled the family planning messages, and 69 and 88 percent, respectively, recalled specific clinic sites mentioned. Following the media promotion, the number of new clinic clients per quarter in Ilorin increased almost fivefold (in the original clinics evaluated); in Enugu, the number of new clients per month more than doubled; and in Ibadan, the number of new clients increased threefold. Use of entertainment through this "enter-educate approach" is a promising technique that can be replicated in different settings to encourage new clients to seek family planning services.