1200 100 p m Agenda Welcome and Update Allison Campbell Instructor and Interim Program Lead UBC Midwifery Program Agenda Factors Affecting the U se of M idwifery S ervices in Remote Nepal ID: 780045
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Slide1
Meeting
Thursday, February 22, 2018
12:00 – 1:00
p
m
Slide2AgendaWelcome and UpdateAllison Campbell, Instructor
and Interim Program LeadUBC Midwifery Program
Slide3Agenda
Slide4Factors Affecting the Use of Midwifery Services in Remote Nepal
SFU doctoral research February 22, 2018
Cathy Ellis, BFA, RM, MSc, doctoral candidate
Slide5BackgroundUse of Skilled birth attendants (SBAs) less in rural areas than urban areas: 67.7% urban compared to 46.8% rural (NHDS, 2016).Mountainous area 43.3% uses SBA, Lowest quintile 33.9% use SBA Gov’t of Nepal has trained providers in skilled birth attendance and set up birthing centers in rural areas but they are under-utilized. No midwives to date.
Gov’t has begun to educate professional midwives but it is not known how they will function optimally (
SBA Policy, 2006)
Slide6Nepal Situation MMR is decreasing, correspondent to lower fertility rate, but without skilled care in rural areas may not be able to decrease further: 258 [158 – 425] per 100,000 live births (
WHO, 2015). Perinatal mortality rate 36 per 1000 births in rural area and 27 per 1000 births in urban (NDHS, 2016)
Only 35% of births are registered with the state
Slide7My role A partner with Midwifery Society of Nepal in providing midwifery skills refresher workshops and mentoring for rural and remote midwives and nurses since 2007. We involve UBC midwifery students through credit course and global placements.
A doctoral researcher working with local midwife partners to learn about and increase ‘enabling factors’ for safe birthing for women in remote areas.
Slide8Research objectivesTo assess attitudes and practices around birth and how this affects mothers’ and families’ willingness to use skilled attendants in healthcare facilities;
To assess the readiness of Nepal’s rural heath system to provide services to parturient women;
To discover the links between mothers’ perceptions around birth and their use of the health system.
Slide9Research questions1. What are the factors (barriers, facilitators) women report that affect their use of skilled birth attendants in rural and remote Nepal?
2. What are the barriers to establishing skilled care at birth in rural and remote settings?
3. What are the gaps in skill sets and enabling factors in health care facilities to providing culturally acceptable and safe birth attendance?
Slide10Research design‘Concurrent mixed methods’ research
involves: (Creswell, 2009)
Concurrent embedded design (Creswell, 2009)Participant and site
observation (Bernard, 2002)Semi-structured Interviews in and around
6 remote health facilitiesWHO Service Availability and Readiness Assessment Survey (6 birthing facilities)
Skilled Birth A
ttendant skills surveys (12 nurses)
Slide11Interviews n=67
In 6
sites
Mothers
FCHVs; Shamans
Mat
Care Workers
Participant observation
While
travelling
In Birthing centers and hospitals
In homes
WHO System
Survey
n=6
Hospital
n=1
Primary Health Centers n=2
Rural Birthing Centers n=3
SBA
Survey
(nurses) n=12
Hospital
n= 4
Primary Health Centers n=4
Rural Birthing centers n=4
Mixed Methods Study: Sept. to Dec. 2016
Slide12InterviewsResearch questions: What are the factors (barriers, facilitators) women report that affect their use of skilled birth attendants in rural and remote
Nepal?
What are the barriers to establishing skilled care at birth in rural and remote settings?
Slide13Translation methodInterview questions for mothers/families and Nepalese-only speaking health workers have been translated into Nepalese
and pre-tested using ‘WHO Process of forward-backward translation and adaptation of instruments’.
http://www.who.int/substance_abuse/research_tools/translation/en
/
Slide14Demographics of Mothers for Interviews
Slide15Analysis of interviewsThematic analysis (1) discover themes and sub-themes, (2) decide which main themes are important, (3) build hierarchies of themes or code books, and (4) link themes into a theoretical model (Ryan & Bernard, 2003).
NVIVO
for a second tool for thematic analysis. If different discovery techniques are used with the same set of data,
more themes may be found.
Slide16Cost and
Distance
Human Resources
Provision of Services
Socio-cultural
Remote area
Lack of roads, transportation
Lack of people to help mother to health facility
Cost to be carried to facility
AAMA program as
incentive
Being a local maternal care worker
Cooperation among staff
Incentives for mat care workers
Mat care workers satisfaction
Quality of care of ANC
Skilled care at birth
Safety in hospital for complications
Enabling factors such as adequate buildings, space, supplies
Fear, reluctance to use facility birth
Monitoring, evaluation of facilities or HR
Mother, family satisfaction with services
Shortage of materials/supplies
Birth planning preparedness
Dealing with blood and pollution problems
Education or awareness of services
Feel confident to deliver at home
Personal Agency
Respect and cultural humility
Shame and shyness
Son preference
Traditional birthing practices
Traditional midwives and TBAs
Role of shamans
Themes from Semi-structured Interviews
Slide17Credibility and DependabilityCredibility: descriptions must be recognized as accurate by participants (Chilisa, 2012). Dependability (is data analysis reliable?). If study were to be done again, would they find the same answers?
Slide18Using two surveys:To assess the readiness of Nepal’s rural heath system to provide services to parturient women;
What are the barriers to establishing skilled care at birth in rural and remote settings?
What are the gaps in skill sets and enabling factors in health care facilities to providing culturally acceptable and safe birth attendance?
Slide191. Skilled Birth Attendance (SBA) SurveyA skilled birth attendant enhancement project assessed skills and needs in some areas of Nepal (Gov’t of Nepal and Nick Simon Institute).I assessed 12 nurses in the research area. Each individual assessment took 4 hours, with 4 to 8 hours ‘gap training’ following the assessment.
Found poor capacity in managing eclampsia, shock due to PPH and
vacuum, especially if not recently trained.
Slide202. WHO Service Availability and Readiness Assessment SurveyCheck-list examining infrastructure, communications such as phone for referrals, lab facilities, basic equipment, supplies, medications.
Added respectful childbirth questions including companion during delivery, choice of labour and birthing positions. Earthquake affected area; most basic supplies available
Did not assess abortion availability
Slide21Linking Findings of Mixed MethodsTo discover the links between mothers’ perceptions around birth and their use of the health system:
Mothers judged quality of care by way they were treated, and by doctor and supplies availability; birthing centers basic care only
Few deliveries, few human resources, lack of mentoring led to poor skill performance (rural birthing centers)Some birthing centers were not accessible nor had 24 hr. skilled care available
Slide22Closing CommentsAllison Campbell