- Email: [email protected]
Designing feasible interventions for healthy pregnancies in low-resource settings
International Journal of Gynecology and Obstetrics 115 Suppl. 1 (2011) S37–S40
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
ARTICLE
Designing feasible interventions for healthy pregnancies in low-resource settings Shane A. Norris * MRC/Wits Developmental Pathways for Health Research Unit, Department of Pediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
article info
abstract
Keywords: Healthy pregnancy Interventions; Implementation Low-resource settings
In low-resource settings there is a need for effective interventions targeting women before and during pregnancy to improve their health outcomes and provide the best start to life for their infants. The aim of this paper is to provide an overview for designing, implementing, and evaluating such interventions. Drawing upon published literature and case studies, several key steps in the process of intervention design, implementation, and evaluation are identified. Pregnancy intervention studies in low-resource settings are challenging. Essential intervention process steps include: (1) selecting the optimal setting to pilot the intervention; (2) forming strong stakeholder collaborations; (3) identifying, understanding, and prioritizing community health problems; (4) facilitating the demand for intervention research and evidence utilization; (5) effectively implementing and evaluating the prototype intervention to provide evidence of effectiveness; and (6) planning with stakeholders for sustainability. Fundamental to any intervention for healthy pregnancies is the understanding that the process does not end with an evaluation study, but rather the end goal is to ensure successful interventions are sustainable, scalable, and integrated into health services. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The statistics are startling. Annually, up to 500 000 women die from causes related to pregnancy and childbirth [1,2], and 3.7 million children die before they are 1 month old worldwide [3]. Hemorrhage, HIV, infection, and hypertensive disorders account for over half of maternal deaths among women aged 15–44 years in low-income countries [4]. Preterm birth, asphyxia, and sepsis account for two-thirds of newborn deaths [5]. Most maternal deaths stem from emergencies that do not receive the rapid and adequate interventions they need. Younger mothers are particularly at risk. Compared with women aged 20–24 years, girls aged 12–14 years have a 5-fold increase in the likelihood of death; those aged 15–19 years are at twice the risk [6]. Improved maternal, newborn, and child health are essential for families to break out of crippling cycles of ill health that may otherwise continue across generations. New transgenerational cycles of risk are being understood; mothers who were stunted in childhood and later are obese may place themselves and their offspring at risk when they become pregnant because they are more likely to develop gestational diabetes, have obstructive labor, and confer risk for type 2 diabetes to their offspring [7]. These stark realities may seem insurmountable, but they highlight opportunities for interventions to save lives. Promoting the integration of programs may be one solution; for example, unifying maternal, newborn, child health initiatives within reproductive health and HIV/AIDS programs may be sensible, particularly in settings where resources have been ploughed into * Corresponding author. Shane Norris. MRC/Wits Developmental Pathways for Health Research Unit, Room 4L16, Medical School, 7 York Road, Parktown, 2146, South Africa. E-mail address: [email protected] (S. Norris).
creating infrastructure around HIV/AIDS services. Other solutions may include intervening before and during pregnancy by improving micronutrient status, promoting the access to prenatal care early and more regularly during pregnancy, and providing community health worker disseminated health education [8]. Whatever the intervention, designing and testing new ones targeted at pregnant women and their offspring, getting support from the local community, adhering to ethical standards, maintaining high participant retention rates, being able to measure the effect, and ensuring integration into existing services is not an effortless task in any setting, and may be more exigent in lowresource countries. The aim of this paper is to provide a practical overview to designing and implementing pregnancy interventions. 2. Intervention planning and development models Intervention models, for example the PRECEDE-PROCEED and Intervention Mapping models, provide explicit procedures to guide intervention conceptualization and development. In essence, the procedural steps include: (1) problem identification; (2) understanding the root causes of the health problem(s); (3) selecting which of these determinants should be translated into intervention or change goals; (4) mapping out the intervention objectives into specific and explicit activities; and (5) intervention implementation and evaluation [9–15]. 3. Identifying the problem Health challenges may or may not exist, depending on the perceptions of key informal and formal stakeholders. Often in rural areas, cultural beliefs, traditions, practices, poor education, and lack of data may hamper recognition of a health problem. Frequently
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
S38
S.A. Norris / International Journal of Gynecology and Obstetrics 115S1 (2011) S37–S40
Table 1 Checklist of actions to help define the problem Action
Task
Understand the evidence
Conduct a scientific literature review so as to identify local information and data within the community of interest. Collect additional formative data to supplement and fill in missing information highlighted by the literature review.
Identify possible intervention opportunities
Select a standard/reference population (regional, national, or international) for comparison with the local community/setting. Compare local data to the standard so as to identify health concerns and the intervention possibilities.
Understand the local setting
Describe the health concern according to who is affected, where, and why?. Scrutinize the root causes (medical, social, cultural, behavioral) so as to better inform the intervention.
Consensus
Come to a consensus with key stakeholders about which health concern is important and a priority with the aid of evidence from quantitative epidemiological data and qualitative community narratives.
Source: Lawn et al. The healthy newborn. A reference manual for program managers [17].
Table 2 Stakeholders: Who are they and why are they important to pregnancy interventions? Informal/community sector
Intersectoral sector
Formal sector
Who?
Traditional village leaders Youth group leaders Religious leaders Women’s groups
Teachers Local government officials Department of Transport
Community health workers, nurses, doctors District/regional medical officers Department of Health (regionally and nationally) Department of Education National Treasury Academic institutions NGOs and CBOs Funders
Why?
To understand what stakeholders consider to be critical community concerns. To promote ownership of the problem and provide potential solutions. To mobilize community resources and support for an intervention and evaluation study.
To mobilize resources to support the study. To foster demand for evidence that can drive policy. To provide information on planned projects that may be relevant to the study (for example, new roads).
To understand clinic staff perceptions of barriers and opportunities. To access local data to assist with problem identification and review of health service statistics. To promote ownership of the problem. To create a demand for the study and the data. To enable stakeholders to drive policy based on evidence.
How?
Community forums Focus groups In-depth interviews
Focus groups In-depth interviews
Collect data to address the gaps in understanding the problem. Provide data analysis support and feedback forums. Provide financial and logistic support.
Barriers?
Health problem may not be seen as a priority by the community. Conflict with traditional practices/beliefs. Lack of trust and support for the study in the community. Lack of resources and infrastructure to implement an intervention study.
Intersectoral stakeholders not identified. No established links with intersectoral sector stakeholders.
Overburdened clinic staff. Poor motivation and negative attitudes. No strong links with local government.
Source: Lawn et al. The healthy newborn. A reference manual for program managers [17].
referred to as a “needs assessment,” drawing upon available data, evidence from other interventions [16], and identifying gaps between what is observed and what is happening elsewhere (standard/reference population) can help identify opportunities for intervention priorities. Actual measurement of the magnitude of the problem is needed to harness recognition of the health problem within a community and among stakeholders; also, an understanding of the underlying cultural, social, and behavioral causes is also essential to formulate the pilot intervention. Health problems need to be defined by both observed evidence and from a stakeholder and community perspective. Interventions based exclusively on either will not be effective in the long term (Table 1). 4. Stakeholders Collaborating with stakeholders and the community early on, and throughout the intervention design and implementation process, can help increase demand for the study, foster shared ownership, assist with the identification of existing resources, and open opportunities for sustainability and integration into health
services (Table 2). Indeed, the community may in itself be a core component of the intervention to effect change and address a health problem [18]. 5. Evaluation of the intervention All the formative work (the evidence base) in the preceding steps is used to prioritize and support the development of an intervention prototype. Selecting the pilot community where the intervention prototype will be tested and evaluated is another crucial decision. Partnering with academic entities that have cohorts, demographic and health surveillance sites, or access to hospitals and clinics can prove useful in identifying the pilot community. Academic partners are often able to provide established and trusted relationships with communities and stakeholders, in depth understanding of community barriers and solutions, infrastructure, skilled staff, ethics application support and compliance with local guidelines and processes, and a platform that may be economical for nesting intervention studies within. The foundation for developing an evaluation framework is to ensure that the study team can articulate precisely and simply
S.A. Norris / International Journal of Gynecology and Obstetrics 115S1 (2011) S37–S40
S39
Table 3 Making Pregnancy Safer (MPS) intervention in Uganda Intervention design and implementation step
What the MPS intervention did
Key learning point
Stakeholders
Community forums Soroti district local government District health team and hospitals Ministry of Health Development partners NGOs World Health Organization UNICEF UNFPA
Partnerships were built early on so as to leverage funds to conduct the intervention, but also to share goals, resources, roles, and responsibilities.
Community assessment
Reproductive Health Needs Survey
The survey aided the identification of gaps and needs in responding to the problem of high maternal mortality in the district at both community and health facility level.
The health problem
Soroti MMR ratio was 885 per 100 000. Identified reasons included: failure to implement the policy of delivery of integrated Reproductive Health services, inadequacy of second line drugs for management of sepsis and malaria, understaffing in remote rural health units, poor knowledge on danger signs during pregnancy, and poor access to maternity services.
They compared local data with the MMR national average (504 per 100 000), which was able to assist with reaching consensus that maternal mortality was an opportunity gap and a priority.
Evaluation
MMR was halved to 221 per 100 000, which was 50% below the 2006 national MMR. Time taken for patients to reach referral hospitals was reduced from an average of 2 h to 30 min. The percentage of deliveries at health facilities increased from 19% to 41.4%. Attendance of prenatal care by pregnant women increased. Reproductive health awareness increased. More men accompanied wives for maternity services. Logistics, supplies, and training improved.
The success was largely due to the different stakeholder sectors working together on a common challenge and pooling resources that enabled cost-savings.
the goal, objectives, what interventions will achieve the objectives, where the interventions will be delivered, by whom, when, and how. Ensuring that each objective contributes to the overall goal and is linked to specific tasks and deliverables will assist the evaluation process [14]. It is important that the evaluation study also examines the cost-effectiveness, feasibility, and sustainability of the prototype. Embedded in the evaluation is monitoring, which will entail the ongoing collection of data to reflect project progress, quality assurance, budget expenditure, and provide process data (quantitative and qualitative) that will contribute to the impact evaluation. For successful monitoring and evaluation, selecting key indicators that will be measured is useful as it will assist with identifying the data sources for the indicators, how often they need to be collected and by whom, and the data analysis and reporting requirements. After the prototype intervention has been tested and evaluated, data reviewed by study partners and stakeholders, and the intervention improved, the process of implementation begins [14,16]. 6. Case study: Making Pregnancy Safer (MPS) intervention, Uganda The Soroti district in the eastern region of Uganda implemented a 5-year pregnancy intervention in 2001 that aimed to reduce the exceedingly high maternal mortality ratio (MMR) through improved access and utilization of quality reproductive health services. The intervention equipped doctors, nurses, and midwives with enhanced obstetric skills. The referral system from communities to Health Centers (HCs) to hospitals was improved. Communities were equipped with bicycle ambulances, HCs with radio transmission sets and motorized ambulances, and theatre facilities were improved at the referral hospital. Obstetric drugs starter packs were provided. These components were supplemented with public reproductive health education on the benefits of attending prenatal care, delivering in health units, avoiding early pregnancies, and
understanding responsible fatherhood. The information campaign also tackled cultural barriers and practices that hinder safe pregnancy practices such as over-reliance on Traditional Birth Attendants, use of herbs, and delays in seeking skilled medical attention when in labor (Table 3) [19]. The case study highlights that a pregnancy intervention in a lowresource setting can be successfully designed and implemented, but it also brings to the fore the enormous challenge of sustainability. Despite the effectiveness of the interventions and the commitment of the local government, equipment running expenses and replacement costs, ongoing staff training needs, community engagement costs, and scale-up barriers, pose real threats to the sustainability of the interventions. Furthermore, MPS monitoring and evaluation highlighted new health concerns, in particular, high infant mortality [19]. 7. Conclusion Good collaboration to facilitate data demand, stakeholder involvement, evidence utilization, and sound research practice can be invaluable in designing and implementing pregnancy interventions. Fundamental to an intervention is the understanding that the process does not end with an evaluation study, but rather the end goal is to ensure successful interventions are sustainable, scalable, and integrated into health services amid limited resources and emerging health challenges that may become prioritized. Conflict of interest statement The author has no conflict of interest to disclose. References 1. UNICEF. Progress for children: a report card on maternal mortality. www.unicef.org. http://www.unicef.org/publications/index_45454.html. Published 2008. 2. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010;375(9726):1609–23.
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3. You D, Wardlaw T, Salama P, Jones G. Levels and trends in under-5 mortality, 1990–2008. Lancet 2010;375(9709):100–3. 4. World Health Organization. Global burden of disease report: 2004 update. www.who.int. http://www.who.int/healthinfo/global_burden_disease/ GBD_report_2004update_full.pdf. Published 2008. 5. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010;375(9730):1969–87. 6. UNFPA. Fact sheet: Young people and Times of Change. www.unfpa.org. www.unfpa.org/public/cache/offonce/factsheets/young_people#fn09. Published 2009. Accessed 2011. 7. Yogev Y, Visser GH. Obesity, gestational diabetes and pregnancy outcome. Semin Fetal Neonatal Med 2009;14(2):77–84. 8. Global Health Council. Maternal, newborn, child and reproductive health. www.globalhealth.org. http://www.globalhealth.org/images/pdf/publications/ 2010_position_mnchfp.pdf. Published 2010. 9. Green LW, Kreuter MW. Health promotion planning: An educational and ecological approach, 3rd edition. Mountain View, CA, USA: Mayfield; 1999. 10. McKenzie JF, Smeltzer JL. Planning, implementing, and evaluating health promotion programs: A primer. 3rd edition. Boston, USA: Allyn and Bacon; 2001. 11. Jones SC, Donovan RJ. Does theory inform practice in health promotion in Australia? Health Educ Res 2004;19(1):1–14.
12. Young KT. Population health: Concepts and methods. 2nd edition. Oxford, UK: Oxford University Press; 2005. 13. Li Y, Cao J, Lin H, Li D, Wang Y, He J. Community health needs assessment with precede-proceed model: a mixed methods study. BMC Health Serv Res 2009;9:181. 14. Bartholomew KL, Parcel GS, Kok G, Gottlieb NH. Planning Health promotion programs: Intervention Mapping. San Francisco, USA: Jossey Bass; 2006. 15. Brug J, Oenema A, Ferreira I. Theory, evidence and Intervention Mapping to improve behavior nutrition and physical activity interventions. Int J Behav Nutr Phys Act 2005;2(1):2. 16. Helmink JH, Meis JJ, de Weerdt I, Visser FN, de Vries NK, Kremers SP. Development and implementation of a lifestyle intervention to promote physical activity and healthy diet in the Dutch general practice setting: the BeweegKuur programme. Int J Behav Nutr Phys Act 2010;7:49. 17. Lawn J, McCarthy BJ, Ross SR. The healthy newborn. A reference manual for program managers. http://www.care.org/careswork/whatwedo/health/hpub.asp. 18. Zoellner JM, Connell CC, Madson MB, Wang B, Reed VB, Molaison EF, et al. H.U.B city steps: methods and early findings from a community-based participatory research trial to reduce blood pressure among African Americans. Int J Behav Nutr Phys Act 2011;8:59. 19. World Health Organization. Making Pregnancy Safer: Implementing the MPS initiative in Soroti District, Uganda. www.who.int. http://www.afro.who.int/ index.php?option=com_docman&task=doc_download&gid=2320.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
ARTICLE
Designing feasible interventions for healthy pregnancies in low-resource settings Shane A. Norris * MRC/Wits Developmental Pathways for Health Research Unit, Department of Pediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
article info
abstract
Keywords: Healthy pregnancy Interventions; Implementation Low-resource settings
In low-resource settings there is a need for effective interventions targeting women before and during pregnancy to improve their health outcomes and provide the best start to life for their infants. The aim of this paper is to provide an overview for designing, implementing, and evaluating such interventions. Drawing upon published literature and case studies, several key steps in the process of intervention design, implementation, and evaluation are identified. Pregnancy intervention studies in low-resource settings are challenging. Essential intervention process steps include: (1) selecting the optimal setting to pilot the intervention; (2) forming strong stakeholder collaborations; (3) identifying, understanding, and prioritizing community health problems; (4) facilitating the demand for intervention research and evidence utilization; (5) effectively implementing and evaluating the prototype intervention to provide evidence of effectiveness; and (6) planning with stakeholders for sustainability. Fundamental to any intervention for healthy pregnancies is the understanding that the process does not end with an evaluation study, but rather the end goal is to ensure successful interventions are sustainable, scalable, and integrated into health services. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The statistics are startling. Annually, up to 500 000 women die from causes related to pregnancy and childbirth [1,2], and 3.7 million children die before they are 1 month old worldwide [3]. Hemorrhage, HIV, infection, and hypertensive disorders account for over half of maternal deaths among women aged 15–44 years in low-income countries [4]. Preterm birth, asphyxia, and sepsis account for two-thirds of newborn deaths [5]. Most maternal deaths stem from emergencies that do not receive the rapid and adequate interventions they need. Younger mothers are particularly at risk. Compared with women aged 20–24 years, girls aged 12–14 years have a 5-fold increase in the likelihood of death; those aged 15–19 years are at twice the risk [6]. Improved maternal, newborn, and child health are essential for families to break out of crippling cycles of ill health that may otherwise continue across generations. New transgenerational cycles of risk are being understood; mothers who were stunted in childhood and later are obese may place themselves and their offspring at risk when they become pregnant because they are more likely to develop gestational diabetes, have obstructive labor, and confer risk for type 2 diabetes to their offspring [7]. These stark realities may seem insurmountable, but they highlight opportunities for interventions to save lives. Promoting the integration of programs may be one solution; for example, unifying maternal, newborn, child health initiatives within reproductive health and HIV/AIDS programs may be sensible, particularly in settings where resources have been ploughed into * Corresponding author. Shane Norris. MRC/Wits Developmental Pathways for Health Research Unit, Room 4L16, Medical School, 7 York Road, Parktown, 2146, South Africa. E-mail address: [email protected] (S. Norris).
creating infrastructure around HIV/AIDS services. Other solutions may include intervening before and during pregnancy by improving micronutrient status, promoting the access to prenatal care early and more regularly during pregnancy, and providing community health worker disseminated health education [8]. Whatever the intervention, designing and testing new ones targeted at pregnant women and their offspring, getting support from the local community, adhering to ethical standards, maintaining high participant retention rates, being able to measure the effect, and ensuring integration into existing services is not an effortless task in any setting, and may be more exigent in lowresource countries. The aim of this paper is to provide a practical overview to designing and implementing pregnancy interventions. 2. Intervention planning and development models Intervention models, for example the PRECEDE-PROCEED and Intervention Mapping models, provide explicit procedures to guide intervention conceptualization and development. In essence, the procedural steps include: (1) problem identification; (2) understanding the root causes of the health problem(s); (3) selecting which of these determinants should be translated into intervention or change goals; (4) mapping out the intervention objectives into specific and explicit activities; and (5) intervention implementation and evaluation [9–15]. 3. Identifying the problem Health challenges may or may not exist, depending on the perceptions of key informal and formal stakeholders. Often in rural areas, cultural beliefs, traditions, practices, poor education, and lack of data may hamper recognition of a health problem. Frequently
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
S38
S.A. Norris / International Journal of Gynecology and Obstetrics 115S1 (2011) S37–S40
Table 1 Checklist of actions to help define the problem Action
Task
Understand the evidence
Conduct a scientific literature review so as to identify local information and data within the community of interest. Collect additional formative data to supplement and fill in missing information highlighted by the literature review.
Identify possible intervention opportunities
Select a standard/reference population (regional, national, or international) for comparison with the local community/setting. Compare local data to the standard so as to identify health concerns and the intervention possibilities.
Understand the local setting
Describe the health concern according to who is affected, where, and why?. Scrutinize the root causes (medical, social, cultural, behavioral) so as to better inform the intervention.
Consensus
Come to a consensus with key stakeholders about which health concern is important and a priority with the aid of evidence from quantitative epidemiological data and qualitative community narratives.
Source: Lawn et al. The healthy newborn. A reference manual for program managers [17].
Table 2 Stakeholders: Who are they and why are they important to pregnancy interventions? Informal/community sector
Intersectoral sector
Formal sector
Who?
Traditional village leaders Youth group leaders Religious leaders Women’s groups
Teachers Local government officials Department of Transport
Community health workers, nurses, doctors District/regional medical officers Department of Health (regionally and nationally) Department of Education National Treasury Academic institutions NGOs and CBOs Funders
Why?
To understand what stakeholders consider to be critical community concerns. To promote ownership of the problem and provide potential solutions. To mobilize community resources and support for an intervention and evaluation study.
To mobilize resources to support the study. To foster demand for evidence that can drive policy. To provide information on planned projects that may be relevant to the study (for example, new roads).
To understand clinic staff perceptions of barriers and opportunities. To access local data to assist with problem identification and review of health service statistics. To promote ownership of the problem. To create a demand for the study and the data. To enable stakeholders to drive policy based on evidence.
How?
Community forums Focus groups In-depth interviews
Focus groups In-depth interviews
Collect data to address the gaps in understanding the problem. Provide data analysis support and feedback forums. Provide financial and logistic support.
Barriers?
Health problem may not be seen as a priority by the community. Conflict with traditional practices/beliefs. Lack of trust and support for the study in the community. Lack of resources and infrastructure to implement an intervention study.
Intersectoral stakeholders not identified. No established links with intersectoral sector stakeholders.
Overburdened clinic staff. Poor motivation and negative attitudes. No strong links with local government.
Source: Lawn et al. The healthy newborn. A reference manual for program managers [17].
referred to as a “needs assessment,” drawing upon available data, evidence from other interventions [16], and identifying gaps between what is observed and what is happening elsewhere (standard/reference population) can help identify opportunities for intervention priorities. Actual measurement of the magnitude of the problem is needed to harness recognition of the health problem within a community and among stakeholders; also, an understanding of the underlying cultural, social, and behavioral causes is also essential to formulate the pilot intervention. Health problems need to be defined by both observed evidence and from a stakeholder and community perspective. Interventions based exclusively on either will not be effective in the long term (Table 1). 4. Stakeholders Collaborating with stakeholders and the community early on, and throughout the intervention design and implementation process, can help increase demand for the study, foster shared ownership, assist with the identification of existing resources, and open opportunities for sustainability and integration into health
services (Table 2). Indeed, the community may in itself be a core component of the intervention to effect change and address a health problem [18]. 5. Evaluation of the intervention All the formative work (the evidence base) in the preceding steps is used to prioritize and support the development of an intervention prototype. Selecting the pilot community where the intervention prototype will be tested and evaluated is another crucial decision. Partnering with academic entities that have cohorts, demographic and health surveillance sites, or access to hospitals and clinics can prove useful in identifying the pilot community. Academic partners are often able to provide established and trusted relationships with communities and stakeholders, in depth understanding of community barriers and solutions, infrastructure, skilled staff, ethics application support and compliance with local guidelines and processes, and a platform that may be economical for nesting intervention studies within. The foundation for developing an evaluation framework is to ensure that the study team can articulate precisely and simply
S.A. Norris / International Journal of Gynecology and Obstetrics 115S1 (2011) S37–S40
S39
Table 3 Making Pregnancy Safer (MPS) intervention in Uganda Intervention design and implementation step
What the MPS intervention did
Key learning point
Stakeholders
Community forums Soroti district local government District health team and hospitals Ministry of Health Development partners NGOs World Health Organization UNICEF UNFPA
Partnerships were built early on so as to leverage funds to conduct the intervention, but also to share goals, resources, roles, and responsibilities.
Community assessment
Reproductive Health Needs Survey
The survey aided the identification of gaps and needs in responding to the problem of high maternal mortality in the district at both community and health facility level.
The health problem
Soroti MMR ratio was 885 per 100 000. Identified reasons included: failure to implement the policy of delivery of integrated Reproductive Health services, inadequacy of second line drugs for management of sepsis and malaria, understaffing in remote rural health units, poor knowledge on danger signs during pregnancy, and poor access to maternity services.
They compared local data with the MMR national average (504 per 100 000), which was able to assist with reaching consensus that maternal mortality was an opportunity gap and a priority.
Evaluation
MMR was halved to 221 per 100 000, which was 50% below the 2006 national MMR. Time taken for patients to reach referral hospitals was reduced from an average of 2 h to 30 min. The percentage of deliveries at health facilities increased from 19% to 41.4%. Attendance of prenatal care by pregnant women increased. Reproductive health awareness increased. More men accompanied wives for maternity services. Logistics, supplies, and training improved.
The success was largely due to the different stakeholder sectors working together on a common challenge and pooling resources that enabled cost-savings.
the goal, objectives, what interventions will achieve the objectives, where the interventions will be delivered, by whom, when, and how. Ensuring that each objective contributes to the overall goal and is linked to specific tasks and deliverables will assist the evaluation process [14]. It is important that the evaluation study also examines the cost-effectiveness, feasibility, and sustainability of the prototype. Embedded in the evaluation is monitoring, which will entail the ongoing collection of data to reflect project progress, quality assurance, budget expenditure, and provide process data (quantitative and qualitative) that will contribute to the impact evaluation. For successful monitoring and evaluation, selecting key indicators that will be measured is useful as it will assist with identifying the data sources for the indicators, how often they need to be collected and by whom, and the data analysis and reporting requirements. After the prototype intervention has been tested and evaluated, data reviewed by study partners and stakeholders, and the intervention improved, the process of implementation begins [14,16]. 6. Case study: Making Pregnancy Safer (MPS) intervention, Uganda The Soroti district in the eastern region of Uganda implemented a 5-year pregnancy intervention in 2001 that aimed to reduce the exceedingly high maternal mortality ratio (MMR) through improved access and utilization of quality reproductive health services. The intervention equipped doctors, nurses, and midwives with enhanced obstetric skills. The referral system from communities to Health Centers (HCs) to hospitals was improved. Communities were equipped with bicycle ambulances, HCs with radio transmission sets and motorized ambulances, and theatre facilities were improved at the referral hospital. Obstetric drugs starter packs were provided. These components were supplemented with public reproductive health education on the benefits of attending prenatal care, delivering in health units, avoiding early pregnancies, and
understanding responsible fatherhood. The information campaign also tackled cultural barriers and practices that hinder safe pregnancy practices such as over-reliance on Traditional Birth Attendants, use of herbs, and delays in seeking skilled medical attention when in labor (Table 3) [19]. The case study highlights that a pregnancy intervention in a lowresource setting can be successfully designed and implemented, but it also brings to the fore the enormous challenge of sustainability. Despite the effectiveness of the interventions and the commitment of the local government, equipment running expenses and replacement costs, ongoing staff training needs, community engagement costs, and scale-up barriers, pose real threats to the sustainability of the interventions. Furthermore, MPS monitoring and evaluation highlighted new health concerns, in particular, high infant mortality [19]. 7. Conclusion Good collaboration to facilitate data demand, stakeholder involvement, evidence utilization, and sound research practice can be invaluable in designing and implementing pregnancy interventions. Fundamental to an intervention is the understanding that the process does not end with an evaluation study, but rather the end goal is to ensure successful interventions are sustainable, scalable, and integrated into health services amid limited resources and emerging health challenges that may become prioritized. Conflict of interest statement The author has no conflict of interest to disclose. References 1. UNICEF. Progress for children: a report card on maternal mortality. www.unicef.org. http://www.unicef.org/publications/index_45454.html. Published 2008. 2. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010;375(9726):1609–23.
S40
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3. You D, Wardlaw T, Salama P, Jones G. Levels and trends in under-5 mortality, 1990–2008. Lancet 2010;375(9709):100–3. 4. World Health Organization. Global burden of disease report: 2004 update. www.who.int. http://www.who.int/healthinfo/global_burden_disease/ GBD_report_2004update_full.pdf. Published 2008. 5. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010;375(9730):1969–87. 6. UNFPA. Fact sheet: Young people and Times of Change. www.unfpa.org. www.unfpa.org/public/cache/offonce/factsheets/young_people#fn09. Published 2009. Accessed 2011. 7. Yogev Y, Visser GH. Obesity, gestational diabetes and pregnancy outcome. Semin Fetal Neonatal Med 2009;14(2):77–84. 8. Global Health Council. Maternal, newborn, child and reproductive health. www.globalhealth.org. http://www.globalhealth.org/images/pdf/publications/ 2010_position_mnchfp.pdf. Published 2010. 9. Green LW, Kreuter MW. Health promotion planning: An educational and ecological approach, 3rd edition. Mountain View, CA, USA: Mayfield; 1999. 10. McKenzie JF, Smeltzer JL. Planning, implementing, and evaluating health promotion programs: A primer. 3rd edition. Boston, USA: Allyn and Bacon; 2001. 11. Jones SC, Donovan RJ. Does theory inform practice in health promotion in Australia? Health Educ Res 2004;19(1):1–14.
12. Young KT. Population health: Concepts and methods. 2nd edition. Oxford, UK: Oxford University Press; 2005. 13. Li Y, Cao J, Lin H, Li D, Wang Y, He J. Community health needs assessment with precede-proceed model: a mixed methods study. BMC Health Serv Res 2009;9:181. 14. Bartholomew KL, Parcel GS, Kok G, Gottlieb NH. Planning Health promotion programs: Intervention Mapping. San Francisco, USA: Jossey Bass; 2006. 15. Brug J, Oenema A, Ferreira I. Theory, evidence and Intervention Mapping to improve behavior nutrition and physical activity interventions. Int J Behav Nutr Phys Act 2005;2(1):2. 16. Helmink JH, Meis JJ, de Weerdt I, Visser FN, de Vries NK, Kremers SP. Development and implementation of a lifestyle intervention to promote physical activity and healthy diet in the Dutch general practice setting: the BeweegKuur programme. Int J Behav Nutr Phys Act 2010;7:49. 17. Lawn J, McCarthy BJ, Ross SR. The healthy newborn. A reference manual for program managers. http://www.care.org/careswork/whatwedo/health/hpub.asp. 18. Zoellner JM, Connell CC, Madson MB, Wang B, Reed VB, Molaison EF, et al. H.U.B city steps: methods and early findings from a community-based participatory research trial to reduce blood pressure among African Americans. Int J Behav Nutr Phys Act 2011;8:59. 19. World Health Organization. Making Pregnancy Safer: Implementing the MPS initiative in Soroti District, Uganda. www.who.int. http://www.afro.who.int/ index.php?option=com_docman&task=doc_download&gid=2320.