Continuing high maternal mortality ratios, especially in Africa, and high discrepancies between richer and poorer households in relation to access to maternal health care and maternal health status have focussed attention on the importance of reducing financial barriers to skilled care. This PhD compares the findings of two evaluations of national policies exempting women from user fees for deliveries, conducted in Ghana in 2005-6 and in Senegal in 2006-7. The detailed findings from each evaluation are presented as well as the broad lessons learnt from what are similar (but not identical) policies with similar goals, both of which were implemented in poorer regions initially but then scaled up, using national resources.  Both demonstrate the potential of fee exemption policies to increase utilisation.  The cost per additional associated delivery was $62 (average) in Ghana and $21 (normal delivery) and $457 (caesarean section) in Senegal. However, despite reducing direct costs for women (from $195 to $153 for caesareans and from $42 to $34 for normal deliveries in Ghana), in neither country were delivery fees costs reduced to zero.  This was linked to a number of important factors, including inadequate budgets (in Ghana) and failure to adequately reimburse lower level providers (in Senegal).  The study also highlights the need to address quality of care and geographical access issues alongside fee exemption. While there has been a lot of debate over the relative merits of different targeting approaches and design of policies to reduce financial barriers to health care (maternal and general), the Ghana and Senegal evaluations suggest the details of implementation and their interaction with contextual factors can be more significant than design of the policy per se.

While significant progress has been made towards improving health outcomes in low-resource settings, unacceptably high maternal mortality remains a problem. Efforts to improve maternal mortality in low-resource settings did not yield intended results. One hypothesized reason for insufficient maternal mortality progress is poor interpersonal quality of care during childbirth at health facilities. Qualitative studies support the assumptions of quality of care frameworks that connect structural inputs (e.g. drugs and supplies, equipment, human resources) to interpersonal quality. However, there is no quantitative evidence for this relationship. Further, although maternal health researchers developed quantitative tools to measure interpersonal quality of care, the construct is mainly operationalized as a single, bipolar dimension, measured as respectful maternity care (good care) or disrespect and abuse (poor care). To address these limitations, this dissertation used an epidemiologic perspective to test the underlying assumptions of quality of care frameworks and to create a robust measure of interpersonal quality of care. This dissertation consists of three parts: an empirical study to test the hypothesis that structural inputs have a positive effect on interpersonal quality of care; a systematic review of the literature of instruments measuring the construct of interpersonal quality of care and their reliability, validity, and dimensionality; and an empirical study to assess the dimensionality and construct validity of the Maternal Health Interpersonal Quality Scale, a measure of interpersonal quality of care. The first empirical study did not find meaningful associations between HIV structural inputs and maternal health structural inputs and interpersonal quality of care during childbirth. These results do not support the assumptions of quality of care frameworks nor qualitative evidence linking structural inputs and interpersonal quality of care. The systematic review suggested that the construct of interpersonal quality of care is not well-defined, that few instruments met psychometric standards for adequate reliability and validity, and that studies that assessed the instruments were generally of poor quality. The second empirical study found that interpersonal quality of care formed a two-dimensional, correlated structure, with one dimension measuring respectful maternity care and one dimension measuring disrespect and abuse. Overall, this dissertation used an epidemiologic lens to address an implementation problem in maternal health. While there is a need to improve interpersonal quality of care during childbirth, in order to impact change and to avoid implementation failure, it is imperative to ensure interventions have a strong evidence base and to use validated measures of the construct.

Thesis (Ph. D.)--University of Washington, 2001. / Vita. Includes bibliographical references (leaves 252-263).

Thesis (Ph. D.)--University of Oklahoma, 1994. / Includes bibliographical references (leaves 315-343).

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Background: Since the launch of the Safe Motherhood Initiative in 1987, the global community has called for reductions in maternal mortality in the developing world. However, reliable methods for assessing levels and trends in maternal deaths, particularly at a district level, are lacking. In increasingly-diverse countries like Indonesia, it is essential for national and local decision-makers to have timely figures to inform programmatic efforts. Aims: The aim of this PhD is to develop and pilot a community-based surveillance system (‘Surveillance by Key Informants’/SKI). The objective is a proof of principle of SKI’s reliability and feasibility, and to verify the potential for routine use at a district level in Indonesia. Methods: This PhD is comprised of two methodological studies, both designed and implemented in Serang and Pandeglang Districts of Banten Province, Indonesia, between 2004 and 2008. The Maternal Death from Informant/the Maternal Death Follow on Review (MADE-IN/MADE-FOR) method comprises retrospective, community-based surveillance of maternal deaths, involving two local informant networks. The experience from MADE-IN/MADE-FOR was used to create a prospective surveillance system (SKI), using the same networks but re-designed for routine use by district authorities. Results: MADE-IN/MADE-FOR found a high level both of maternal mortality (435 deaths per 100,000 live births) and of indirect causes (43%). The SKI findings show the considerable potential of this new approach. The two informant networks together captured about 91% of births and 92% of deaths. In general, the local stakeholders accepted SKI as a useful and realistic system for them to continuously capture local vital events. Conclusions: In a country like Indonesia where civil registration is lacking, SKI could be used to capture deaths and births in the immediate term, with MADE-IN/MADE-FOR used as a periodic census of all maternal deaths. Both approaches can provide the basis for more detailed follow-up of deaths, and so ultimately help to inform reductions in maternal mortality.

No description available.

名古屋大学博士学位論文 学位の種類 : 博士(医学)(課程) 学位授与年月日:平成25年3月25日 江啓発氏の博士論文として提出された

This thesis has explored the implementation of the primary health care strategy in Ghana, focusing on the Maternal Child Health program, one of main components of the strategy and the program that seems to have been most widely implemented in the country. / The analysis has been concerned primarily with identifying the obstacles to the implementation of this strategy in rural areas of the country, where levels of utilization and participation have been found to be lower than what was hoped for by the government. It does this by using data collected through in-depth interviews and participant observation in three rural villages of the country. / The findings reveal that a complex range of interrelated factors influence or deter women from utilizing and participating in the MCH program.

Research has shown that there is a problem in the delivery of quality care in maternal and child health services in Zambia. The 1996 Zambia demographic and health survey estimated maternal mortality rate as high as 649 per 100,000 live birth, with this reason among others, human resource constraints and low number of supervised antenatal clinics, deliveries and postnatal clinics by skilled personnel as some of the reasons for the high maternal mortality. Selected studies identify the role of a clinical nurse specialist in advanced midwifery and neonatology who has acquired the knowledge and practical skills to bring about the desired impact of quality care in safe mother hood in order to bring down the high maternal mortality rates. In order to achieve this, the government needs to integrate the advanced midwifery and neonatology clinical nurse specialist in the health system. It was the purpose of the study to inquire into the feasibility of integration of the advanced midwifery and neonatology clinical nurse specialist in the Ndola District Health system .