Written by: Nick Pearson, Managing Director, Jacaranda Health

The following originally appeared on Jacaranda Health’s blog. It is posted here with permission

Imagine waiting for six hours for antenatal visit, only to be seen by a nurse who doesn’t have time to answer questions about your pregnancy, or doesn’t bother to treat you with respect. A recent Kenyan government survey indicated that bad patient experience is one of the major reasons that women in Kenya avoid giving birth in hospitals and other birth facilities. The vast majority of women who participated in Jacaranda’s field research in Nairobi complained of long waits, poor treatment from nurses, crowded labor wards, and difficulty getting education and birth-preparedness counseling.

If you have any doubts about the pervasiveness or the detrimental effects of this problem, read the eye-opening “Failure to Deliver: Violations of Women’s Human Rights in Kenyan Health Facilities,” by the Kenya Federation of Women’s lawyers, or USAID’s powerful “Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth: Report of a Landscape Analysis.”

This issue of poor service is one of the biggest hurdles to increasing delivery in facilities. Jacaranda aims to change that dynamic by providing care that is respectful and responsive to the needs of mothers. One of the most interesting ways we’re meeting this goal is by following the lead of organizations like the design consultancy IDEO and the Mayo Clinic, who advocate for a principle known as “patient-centered design.”

Patients draw their ideal waiting room

Patient-centered design reflects the notion that healthcare can be more responsive and respectful if providers engage patients in the design process. It sounds straightforward, but patient-centered design is far from the norm; this really is a new frontier in healthcare. Some of the best hospitals in the States are starting to do it; both Kaiser Permanente and the Mayo Clinic have crack teams of designers who work with clinicians and patients to design friendlier, more effective care. A greater focus on the patient results in improvements like physical spaces that encourage recovery, scripts and settings for better doctor-patient interaction, and better ways to exchange information during nurse shift changes. For an example see: http://www.ideo.com/work/nurse-knowledge-exchange/.

Here in Kenya, Jacaranda Health has approached patient-centered design in a similar way. Over the last year and a half, we have held design sessions with groups of prospective patients and nurses to get their help in developing our model of care. In these sessions, we borrow from the playbook of design firms like IDEO, using tools like brainstorming, role-playing and sketching to develop basic prototypes of potential tools and solutions.

The result is not only deeper knowledge of our patients and insights about the most effective ways to provide care, but a patient experience designed by patients for patients. Our patient-centered design process has led to a number of additions to our standard services, including:

• Greeters to guide patients through the delivery process;
• A performance-review process that evaluates our nurses not only on clinical quality, but also on patient satisfaction and respect;
• Group birth-preparedness education and Q+A sessions, led by community health workers in our waiting rooms; and
• Strategies to better accommodate fathers during antenatal-care visits.

Clients give feedback on audio presentations for birth preparedness

As is the case with everything we do, our patient-design process is intentionally a work in progress. Each phase of Jacaranda’s growth will offer us more opportunities to seek ideas from our patients and learn how we can serve them better. Involving our patients in designing their own care gives Jacaranda a competitive advantage over other facilities. But just as importantly, it lets the women of Nairobi design the maternity care they want, so that more of them will seek skilled care, resulting in healthier outcomes for mothers and babies.

In the maternal and reproductive health fields, we often discuss the importance of involving men. While there is certainly evidence that male involvement can lead to better health outcomes, there are potential downsides that are rarely discussed.

A new report from PlusNews investigates prevention of mother-to-child transmission of HIV (PMTCT) in Kenya and finds some possible drawbacks to involving men in certain situations:

There is limited research into the area of gender-based violence following HIV-testing, but a presentation by the NGO, the Sonke Gender Justice Network, at the 2010 International AIDS Society conference in Vienna, Austria, reported that women’s experiences upon disclosing their status to their male partners were often “complex and positive”: some studies reported violence levels of up to 14 percent, while others stated that about half of HIV-positive women said their partners reacted supportively to the disclosure.

 

According to Beatrice Misoga, PMTCT programme officer with the AIDS Population Health Integrated Assistance (APHIA Plus), gender-based violence is more common in discordant relationships where the man is HIV-negative. “Male involvement has helped realize success with PMTCT programmes where it has been applied because prevention of mother to child transmission is a family issue, but yes, there have been challenges in certain aspects like the possibility of gender-based violence targeting women and more so in a situation where the male partner is not willing to be part of it.”

This week on the MHTF blog:

1. Melinda Gates answers questions as she travels in Bangladesh
2. Ana Langer welcomed the MHTF to Harvard on GlobalMama
3. A focus on promoting Respectful Maternity Care is emerging
4. Emily Puckart on MaiMwana and community death reviews

Some reading for the weekend:

1. WHO, budget shortfalls, and organizational restructuring
2. Progress on PMTCT in sub-Saharan Africa
3. Solar suitcases provide electricity and light in maternity wards

The second and third installments of Melinda Gates’ answers to reader questions are now available.

Topics include access to contraceptives in Bangladesh:

Bangladesh has made huge improvements in getting women access to contraceptives since its independence 40 years ago. The program has consistently maintained strong support from the highest levels of government and society, and has had great success tapping into the tremendous amount of latent demand for contraceptives. Nearly half of Bangladeshi women use modern contraceptives today, up from just five percent in 1975. The average number of births per woman has dropped correspondingly, from 6.3 to 2.3 over the same period. We often talk about all the benefits that stem from getting women access to family planning tools, but Bangladesh went to great lengths to prove this hypothesis.

Involving women in decision making:

One of the best parts of my job is that I get to travel to places like Bangladesh to talk to women about their lives. I learn so much from them. Some of the most extraordinary innovations in health and development in recent decades have come from simple conversations that start with asking people what they need. I particularly like to ask mothers what they dream about for their children’s futures, and the answer is almost always the same wherever I go. They want their children to grow up healthy, and they want to be able to send them to school.

And dealing with corruption:

It’s unfortunate and true that Bangladesh is perceived to be one of the world’s most corrupt countries. The Bangladeshis I have met have told me that they feel this in small ways on a fairly regular basis. Because the problem is systemic, it’s hard for them to go against the tide. One doctor I met with yesterday told me that nobody pays attention to traffic lights since you can buy your way out of a ticket for a small fee and because if you don’t run the red light, “everyone else will and you’ll never get to your destination.” Obviously, these unnecessary surcharges on everyday life and other forms of corruption are a major impediment to faster economic growth and it’s something the government and others must address.

Dr. Ana Langer has written a post on our Medscape blog, GlobalMama, that describes the future outlook for the MHTF:

Our partners were virtually unanimous in calling for more educational opportunity for those interested in maternal health, especially from low-resource settings. So the next phase of the MHTF will prioritize education…Implementation research emerged as another critical need especially the quality of maternal health care.

Read more here (free registration may be required).

Last week, we linked to an opportunity to submit questions fro Melinda Gates and Nick Kristoff as Ms. Gates travels throughout Bangladesh. This week, Impatient Optimists has posted the first of the responses. A second installment will be published soon.

Her responses from part one include thoughts on how people of average means can make a difference and monitoring progress on Gates funded projects:

I believe that each of us can do important and meaningful work to make the world a better place. It’s not about the money. It’s about using whatever resources you have at your fingertips to try to improve the world.

The foundation is data-driven in everything we do, from making grants to estimating and evaluating their impact. For example, here in Bangladesh, we are funding several research studies to better understand which viruses and bacteria cause the most cases of pneumonia. Only by generating solid data will we be able to make well-informed decisions. And, of course, we need to know if our work is having impact. Measurement and evaluation is built into every single grant so we can analyze the results of programs that we fund.

Check back later for the second installment!

Written by: EngenderHealth

The following originally appeared on the White Ribbon Alliance blog. It is posted here with permission

Pregnancy and childbirth are momentous events in the lives of women and families everywhere, but also moments of intense vulnerability. A woman’s relationship with her maternity providers is vitally important during this time, particularly because of the essential lifesaving health services they can offer her. Women’s experiences with such caregivers can both empower and comfort, providing memories of childbearing that stay with them for a lifetime and are shared with other women. Unfortunately, evidence suggests that in too many instances women instead experience lasting damage and emotional trauma, and these memories too are shared with other women.

That is why EngenderHealth is partnering with the White Ribbon Alliance to promote the Respectful Maternity Care campaign. The Respectful Maternity Care campaign aims to raise awareness of the disrespectful treatment that many women experience in seeking and receiving maternity care. For advocacy purposes, the campaign has developed a charter laying out the Universal Rights of Childbearing Women. All these rights are grounded in international human rights instruments.

Photo credit: M. Tuschman/EngenderHealth

EngenderHealth has long advocated for the need to address clients’ rights and providers needs by promoting quality services that address sexual and reproductive rights, particularly informed and voluntary decision making. In order to make quality health care a reality, EngenderHealth has developed quality improvement approaches and tools, including COPE for Maternal Health Services (which has been used to improve health services in more than 45 countries).

Two assumptions inform the COPE process:

• Recipients of health care services are not passive patients waiting to be seen by experts, but are autonomous health care consumers, or clients, responsible for making decisions about their own health care and who deserve – indeed, have a right to – high-quality care. They have the right to information, access to services, informed and voluntary decision-making, safe services, privacy and confidentiality, and last but not least to dignity, comfort and respect.
• Health care staff desire to perform their duties well, but without facilitative supervision and management, information, training and development and supplies equipment and appropriate infrastructure, they cannot deliver the high-quality services to which clients are entitled.

Unless health workers and facilities provide respectful high quality services, women will be reluctant to seek skilled care, may never return for follow-up, and will not recommend such services to their friends and neighbors. This has very important implications – not only for women and their families but for health care facilities, national governments and all those engaged in efforts to improve maternal and newborn health and survival.

On the other hand, satisfied clients of high quality services often become de facto spokespeople, as they help spread the word about the excellent care they received and advise others to seek the same. This positive feedback loop can help save lives.

For more information about other tools and approaches to improve maternity care, visit: www.engenderhealth.org.

Traditional leaders and project staff participating in the project

Written by: Emily Puckart, Program Associate, Maternal Health Task Force

Supported by the Maternal Health Task Force, MaiMwana piloted a project to strengthen the current Maternal Death Review system in Malawi through a village-level program of maternal death audits. The project used community Maternal Death Review (MDR) teams based in health facilities in the Mchinji district to collect information regarding maternal deaths. The MDR teams worked with the deceased woman’s community, in collaboration with health workers, in order to learn more about the causes and circumstances surrounding each woman’s death. Information was then shared between MDR teams around the district in order to form comprehensive strategies to prevent future maternal deaths. By including health workers, health facilities, community leaders, and community members in their pilot, MaiMwana was able to target every level of care where a pregnant woman might seek assistance. This comprehensive view towards improving the care of pregnant women is vital to decreasing the number of maternal deaths.

The pilot project provided important data to MaiMwana, as well as valuable information for other community organizations trying to implement similar programs in other districts or countries. The team from MaiMwana described their assessment of the project:

An assessment was conducted after piloting the Community focused maternal death reviews. The findings were: the process has created more awareness on maternal health issues to the community, it provides interaction between health workers and the community, and the community can identify a maternal death, problems and solutions. The success in the community-focused interventions depended on traditional leaders’ participation, as custodians of culture. Involvement of different professionals in health service assists to identify gaps in provision of health services and addressing them adequately at all levels.

Below are a number of documents that resulted from the MHTF funded program at MaiMwana:

This week on the MHTF blog:

1. Ask Melinda Gates a question about maternal and child health as she travels in Bangladesh
2. The top ten highlights for maternal health in 2011 from Women Deliver
3. Project updates from CIESAS and ICDDR,B

Some reading for the weekend:

1. Taking action to promote respectful maternity care
2. Case studies on taking mhealth projects to scale
3. An assessment of quality maternal and neonatal care in Albania, Turkmenistan and Kazakhstan
4. Portable ultrasounds saving lives

Written by: ICDDR,B

Nine Knowledge Translation Briefs are finalized after a continuous rigorous external and internal review process. These Knowledge Translation Briefs are now available on the Knowledge Translation in Maternal Health web-page under the Reproductive Health Programme on the icddr,b web-site.

A web page on Research Policy Communication Cell will be available on the DGHS website under the Ministry of Health and Family Welfare (MOHFW) from next month. This is the outcome of another icddr,b project Enhancing capacity to apply research evidence in policy making for reproductive health in Bangladesh. The Knowledge Translation Briefs developed from our project will also be available on this Research Policy Communication Cell webpage.

We are in the process of institutionalizing the Knowledge Translation Brief Writing course materials for researchers at icddr,b. During the process of conducting the KT writing course and finalizing the KT briefs, we worked individually with researchers from across icddr,b which has helped us in institutionalization of the course materials among researchers at icddr,b.

In addition, a special one-hour session of the KT Brief writing course was delivered to a group of twenty policy makers and program managers in the Training of Trainers (ToT) workshop as a complementto another icddr,b project.

One of the MHTF researchers participated in the “MHTF Buzz meeting” at Tarrytown, New York from October 3-5, 2011, in which thought leaders and stakeholders were brought together to discuss and debate the tough questions facing the field of maternal health today. She presented the challenges their project started out to address, turning point, and the questions moving forward in the maternal health field they found along the way.

Five Knowledge Translation Briefs, as outcome of the project were displayed and distributed in the meeting which was much appreciated by participants.

MHTF researchers are planning to attend the Second Global Symposium on Health Systems Research will be held in Beijing from 31 October to 3 November, 2012 and are planning to submit an abstract on Knowledge Translation in Maternal Health to share their experiences in this area in this international conference.