Obstetric Care in Poor Settings in Ghana, India & Kenya:

Use of Qualitative and Quantitative methods

Samuel MillsEduard BosElizabeth LuleGNV RamanaRudolfo Bulatao

Report available at:

www.worldbank.org/hnppublications

Ghana - Kassena-Nankana District

India – Uttar Pradesh State

Nairobi, Kenya

A private clinic in the slums Pumwani hospital outside slums

Outline

Objectives

Background

Methods (quantitative & qualitative)

Main findings

Choice of method for evaluation

Objectives

1. To investigate recent maternal deaths to understand the level and causes of maternal mortality

2. To explore 3-delays resulting in maternal deaths• 1st Decision delay• 2nd Travel delay• 3rd Treatment delay

3. To assess the adequacy and quality of EmOC

4. To describe the utilization of antenatal and delivery services

Background Millennium Development Goal (MDG5)

• Reduce MMR by 75% between 1990 & 2015

Global estimates of maternal mortality remains unchanged (1990-2005)

• 0.4% annual decline instead of 5.5%

% of births with skilled attendant is another indicator for MDG5

However, access to quality emergency obstetric care is key to the reduction of maternal morbidity and mortality

Research Methods

Quantitative Methods

Household surveys• Socio-demographics• Assess utilization of ANC, delivery & postnatal

care, payments for obstetric care• 3-delays

Health facilities survey• Assessment of health facilities• Adequacy and quality of care

Verbal autopsy• Structured (estimate and causes of MMR)• Unstructured (contributory factors)

Qualitative Methods

Focus groups• Describe utilization of care• Community perspective• Cultural issues

In-depth interviews• Near misses were interviewed• Near misses are women who had life

threatening obstetric complications but survived

Sampling

Data type Northern Ghana Nairobi slums Uttar Pradesh state

Verbal autopsies and death narratives

516 deaths of females aged 12-49 in 2002-2004

289 deaths of females aged 12-49 in 2003-2005

283 deaths of females aged 12-44 in 2001-2004

In-depth interview (near misses)

28 cases in 2005 15 cases in 2005 49 cases in 2005

Health facility survey

All 8 facilities in district

25 facilities 128 facilities in 18 districts

Household survey 3,433 women whose pregnancies ended in 2004

1,927 women whose pregnancies ended in 2004-2005

13,645 women whose pregnancies ended in 2002-2004

Focus groups 18 groups (Previously done)

16 groups 20 groups

Sampling: In-depth interview

Ghana• Purposive sampling of near misses

• PS is a non-probability sampling• Sample with a purpose (not convenience)• Sample with a criteria in mind (age, sex etc)

District hospital• List names and addresses of all women who

experienced near misses in 2004• Trained interviewers visited the homes of these

women• Out of 33 cases, 28 were interviewed

Sampling: Focus groups

Ghana • District in N. Ghana with popu 142,000

Purposive sampling• 2 main languages (Kasem, Nankam)• 10 chiefdoms in district• 15 communities/villages selected• 18 homogenous groups selected

(source: Mills S, Bertrand JT. 2005. Use of Health Professionals for Obstetric Care in Northern Ghana. Studies in Family Planning 36(1): 45-56 )

Focus group procedure

Design focus group guide/consent form• Guide should be unstructured • Should generate long responses• eg tell me about, what are your views on…• Not what is your name (quantitative)

Community contact person assemble informants at agreed place and time

Research team• 2 moderators (female & male)• 2 assistants (female & male)• 1 transcriptionist

Focus group session

Introduction & administer informed consent 9-12 persons per group 45-90 mins per session Moderator/assistant and group of same sex Audio recorded

Olympus digital voice recorder DS 3000 Transcription of interviews

• Olympus DSS Pro transcription software & foot switch

Data analysis• Atlas.ti software

Focus group session

Successful in-depth interview/ focus groups• Informant or group does most of the

talking• Informant's responses are spontaneous &

relevant • Interviewer keeps questions short but

asks all relevant questions• Interviewer does not read the questions in

the guide verbatim• Interviewer follows up on leads

Study Findings

Ghana - Kassena-Nankana District

45 maternal deaths/516 female deaths 12,049 total live births

• MMRatio is 373 17 health facilities deaths

• Health facility MMRatio is 141 MMRatio decline in district

• 637 in 1995-1996

KND – Reasons for decline in MMR

Confluence of various research and communications activities over the decade • Community Health and Family Planning

Project Various reproductive health indicators have

improved• Infant mortality (129 in 1994 to 73 in 2003)• TFR (5.1 in 1994 to 4.1 in 2003)• No prim education (77% in 1993 to 51% in 2002)• African trad religion (70% in 1993 to 31% in 2002)

KND – Causes of maternal mortality

4.4

6.7

6.7

6.7

8.9

15.5

22.2

2.2

2.2

6.7

17.8

Anemia

HIV/AIDS

Malaria

Other indirect

Antepartum hemorrhage

Postpartum hemorrhage

Postpartum sepsis

Retained placenta

Obstructed labor

Complications of abortion

Other direct

Direct causes (71.1%) Indirect causes (28.9%)

Kenya - Nairobi slums

29 maternal deaths/289 female deaths

5,356 live births• MMRatio 630 maternal deaths per 100,000

live births

22 late maternal deaths (6wks-1yr)• 13 were due to HIV/AIDS deaths

Nairobi – Causes of maternal mortality

3.5

3.5

6.9

10.3

10.3

31

6.9

13.8

13.9

Anemia

Other indirect

HIV/AIDS

Ruptured uterus

Antepartum hemorrhage

Eclampsia

Postpartum hemorrhage

Postpartum sepsis

Complications of abortion

Direct causes (65.5%) Indirect causes (34.5%)

India – Uttar Pradesh

73 maternal deaths/275 female deaths

18,696 live births• MMRatio 409 maternal deaths per 100,000

live births

UP - Causes of maternal deaths

Direct Causes Indirect Causes Causes Unidentifiable

Hemorrhage

Obstructed/Prolonged Labor

Complications of Abortion

Postpartum Sepsis

Toxemia

Eclampsia

Miscarriage

Anemia

Cardiac Failure

Tuberculosis

Acute Renal Failure

Unidentifiable

27.2%

12.7%

10.9%

5.5%

5.5%

5.5%

1.8%

16.4%

7.3%

3.6%

1.8%

1.8%

UP - Time of Death

During 8-42 Days after Delivery

(14%)

Post-abortal(11%)

During Pregnancy

(15%)

During or Within Hours of Delivery

(51%)

During 1-7 Days after Delivery

(9%)

UP - Delays that Resulted in Deaths

Sudden deaths (delays not applicable) 10 cases Delays reported – 45 cases 18 of the 45 did not reach a health facility

All 3 delays interconnected

UP - Analysis of First Delay

Duration Number Percent

No Delay 16 36%

1-2 Hours 6 13%

3-24 Hours 5 11%

2-5 Days 10 23%

More than 5 Days 2 4%

Duration not clear 6 13%

Total 45 100%

Decision delay – time taken to make decision

Decision delay

20-year-old with no previous live birth

Our daughter-in-law had not been suffering from any disease throughout her pregnancy. The labor pain started at 6 p.m. and she had a stillbirth at home. Soon after delivery, she complained of severe backache. She asked for someone to massage her back. She slept after my mother gave her a massage. The next morning when the family members tried to wake her, they found her dead. Nobody knew when she had died during the night.

During the pregnancy she had swelling on her entire body. The swelling had aggravated during the last month of her pregnancy, along with blurring of vision at night. She was anemic and had experienced mild bleeding during delivery.

Time Gap between Decision to Seek Care and Reaching a Qualified Doctor/Health Facility

Duration Number

Within 2 Hours 19

3-6 Hours 3

7-9 Hours 2

3-5 Days 3

Total 27

UP - Analysis of Second Delay

Travel delay

32-year-old with two live births

My daughter-in-law fell ill when she was 9 months pregnant. Two days before her death, she was suffering from dysentery that is why she became very weak. At that time, except for me, neither her husband nor his brother was present in the house. When the labor pain started, my wife called the women in the neighborhood. An hour or two after that, she started feeling uncomfortable and died all of a sudden.

Here, in the village, the nearest road is 8 kilometers away and there is no means of transportation. By the time I tried to make transport arrangements, she died. There is an Anganwadi Center in the village, where an auxiliary nurse-nurse midwife comes once in six months. She was given tetanus toxoid injection once, after which she had fever. My son is a laborer in Mumbai.

UP - Analysis of Third Delay

Duration Number

No Delay 18

½ - 1 Hour 7

2-4 Hours 2

Total 27

Treatment delay

Treatment delay

35-year-old with five live births

She was at her parents' house for delivery. The pain had started at night, so we arranged for a jeep and took her to the district hospital and got her admitted there. There was considerable labor pain. She was restless with pain, but the baby was not being delivered. She was nine months pregnant. She was very weak and anemic.

The doctor demanded 10,000 rupees after admitting her and said that she was very anemic and a lot of blood would be needed for the operation. Then her brother said that their financial condition was not good. He requested the doctor to start the operation while he arranged for money. She continued suffering from severe pain, but, without payment, the doctor refused to operate on her. By the time we could arrange for money and return, it was too late and she had died. In this way, the mother and child both died in hospital.

All three delays

35-year-old with one live births

My sister-in-law had labor pains the whole night. There was no transport available during night. We showed to the auxiliary nurse-midwife in the morning and she referred her to government hospital. We took her to private nursing home where she was admitted and a stillborn baby was delivered after operation. Five days later she died in the hospital. She was given 6 bottles of blood and glucose drip.

She had swelling in her entire body. She was anemic because of frequent deliveries. Even after six deliveries, only one of her child has survived. The financial condition of her family is not good.

All three delays are interconnected

Compare findings of 3 settings

% Pregnant Women Receiving Obstetric Care

98

81

38

96

60

70

48

10

28

0 20 40 60 80 100

Any antenatal care

Four or more visits

Delivery care

Percent among those who had antenatal care

Ghana Kenya India

Barriers to obstetric care use

India • Preference for home deliveries • Public health facilities not adequately

equipped & staffed Ghana

• Preference for hospital delivery but• Long distance & lack of transport

• Kenya• Facilities are available in Nairobi but

• High hospital fees

Maternal Mortality Ratio

409

630

373

0 100 200 300 400 500 600 700

MMRatio

Deaths per 100,000 live births

Ghana

Kenya

India

Abortion MMRatio

45

200

58

0 50 100 150 200 250

Abortion deaths

Deaths per 100,000 live births

Ghana

Kenya

India

Abortion laws

India • Liberal

• to save woman’s life, mental health, rape/incest, fetal impairment, socio-economic reasons, contraceptive failure

Ghana • Similar to India but no induced abortion

for socio-economic reasons• Kenya

• Abortion is illegal except to save woman’s life

HIV/AIDS MMRatio

0

87

8

0 20 40 60 80 100

HIV/AIDS deaths

Deaths per 100,000 live births

Ghana

Kenya

India

Mix methods

In the evaluation of programs, use

• Quantitative methods to ascertain percentage increase or decrease of indicators of interest

• Qualitative methods to explain why the project was or was not successful

• Employ both for a meaningful evaluation!