1. Obstetric Care in Poor Settings in Ghana, India & Kenya: Use of Qualitative and Quantitative methods Samuel Mills Eduard Bos Elizabeth Lule GNV Ramana Rudolfo Bulatao

2. Report available at: www.worldbank.org/hnppublications

3. Ghana - Kassena-Nankana District

4. India – Uttar Pradesh State

5. Nairobi, Kenya A private clinic in the slums Pumwani hospital outside slums

6. Outline  Objectives  Background  Methods (quantitative & qualitative)  Main findings  Choice of method for evaluation

7. 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

8. 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

9. Research Methods

10. 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)

11. 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

12. Sampling

13. 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

14. 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 )

16. 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

17. 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

18. 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

19. Study Findings

20. 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

21. 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)

22. KND – Causes of maternal mortality

23. 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

24. Nairobi – Causes of maternal mortality

25. India – Uttar Pradesh  73 maternal deaths/275 female deaths  18,696 live births MMRatio 409 maternal deaths per 100,000 live births

26. 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% 1.8% 16.4% 7.3% 3.6% 1.8%

27. 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%)

28. 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

29. UP - Analysis of First Delay DurationNumberPercent No Delay1636% 1-2 Hours613% 3-24 Hours511% 2-5 Days1023% More than 5 Days24% Duration not clear613% Total45100% Decision delay – time taken to make decision

31. Time Gap between Decision to Seek Care and Reaching a Qualified Doctor/Health Facility DurationNumber Within 2 Hours19 3-6 Hours3 7-9 Hours2 3-5 Days3 Total27 UP - Analysis of Second Delay

33. UP - Analysis of Third Delay DurationNumber No Delay18 ½ - 1 Hour7 2-4 Hours2 Total27 Treatment delay

35. All three delays are interconnected

36. Compare findings of 3 settings

37. % Pregnant Women Receiving Obstetric Care

38. 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

39. Maternal Mortality Ratio

40. Abortion MMRatio

41. 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

42. HIV/AIDS MMRatio

43. 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!