Journal Club: Oct. 3
Posted by Lance Gravlee on October 1st, 2008 in Journal club |
This week Nikki D’Errico will moderate a discussion of:
Mayhew, M., Hansen, P. M., Peters, D. H., Edward, A., Singh, L. P., Dwivedi, V. et al. (2008). Determinants of Skilled Birth Attendant Utilization in Afghanistan: A Cross-Sectional Study. American Journal of Public Health, 98(10), 1849.
As usual, a PDF of the article is available from the journal club page. Due to renovations in our alternate meeting space, we’ll continue to meet in the Diaspora Room (Turlington 1350) for now. Please join us on Friday at 11:45 a.m.—and feel free to leave your comments about the article here.
One Response
Mayhew et al.’s study of Skilled Birth Attendant (SBAs) Utilization in Afghanistan attempts to pinpoint the reasons which explain why some women in the country are using SBAs while others are not. Their article begins with a brief statistical history of maternal mortality, situated within a discussion of the major causes of maternal and neonatal mortality and the presence of barriers standing in the way of the utilization of health services.
A cross-sectional study was completed within all of the 33 provinces in Afghanistan during the months of June through September 2004. Data was collected from women living in “catchment areas” of the country, defined as being located within a 90-minute walk of the local health facilities. 617 health facilities were surveyed in the country, representing 25 facilities per province. A team of 1 man and 1 woman (“qualified doctors and nurses”) was deployed to randomly selected villages to conduct interviews. The authors analysis uses data from 9,917 respondents.
In homes, questions sought to find out about individual wealth, access to motorized transportation, location of the home to the health facility, literacy of the post-parturient woman, and whether or not anyone in her family had ever visited the health facility.
In the health care facilities, data was taken on availability of basic equipment and emergency equipment, types of workers present, existence of user fees, and presence of community health workers and traditional birth attendants working in the catchment area of the health facility.
The data collected revealed that only 13% of respondent’s births were attended by an SBA. The individual factors of note include literacy and wealth of the respondent. The researchers also found that women aged 30 to 39 were less likely to have their births attended by an SBA. Geographic proximity to the health center also strongly impacted the presence of an SBA in that women living with a 60-minute walk to the facility were more likely to utilize SBAs. Finally, factors relating to the health facilities themselves were important, but not as important as individual or geographic factors. The availability of a female doctor or midwife played the largest role in utilization of SBAs, while presence of traditional birth attendants, quality of antenatal care, and availability of emergency obstetrical care equipment did not seem to have any influence. The presence of fees for curative services at the health care facility was reported to be a significant factor in utilization of SBAs as well.
Finally, the article provides suggestions for future research, and recommendations for increasing the attendance of SBAs at births in Afghanistan. The authors recommend removing user fees at health facilities, or providing vouchers or gifts for services. They also suggest the implementation of community grants to provide transportation of parturient women to the health center. Long term recommendations include addressing the literacy problem among women in Afghanistan (6% of women are literate), and increasing the proportion of female doctors and midwives at health centers, by increasing training to local females in rural areas. Acknowledging the breadth of this task, the authors also suggest that providing birth related training to community health workers might prove effective in the interim.
Questions and thoughts for tomorrow’s meeting:
1) The authors provide a general list of causes for maternal and neonatal mortality in developing countries, ranging from preventable factors, to more complicated, acute problems during birth. How might increasing the presence of SBAs during birth influence mortality based on the list provided? Do you think their presence is an adequate response to the plethora of diverse causes of mortality? Their conclusion is that 78% of maternal deaths in 2002 could have been prevented with adequate obstetric care. Do you think increasing SBAs at birth would accomplish this task?
2) There is little discussion of the scope of the training of doctors, midwives, and more importantly, community health workers, and alternative birth attendants. Do you find this to be a weakness in their argument? Do you think the perceived competence of doctors, nurses, midwives and community health workers plays a role here?
3) Do you think this study, which took place in Afghanistan, accurately dealt with culture specific realities in the country? How might they have been glossed over? Do you see areas for improvement?
4) The authors recommend removing user fees at health facilities. The user fees were not neonatal specific, but for curative services in general. Do you see any negative impacts that might arise from implementing this suggestion?