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Improving facility-based quality for maternal and neonatal care is the key to reducing morbidity and mortality rates in low- and middle-income countries. Recent guidance from WHO and others has produced a large number of indicators to choose from to track quality. To explore how to translate complex global maternal and neonatal health standards into actionable application at the facility level. We applied a two-step process as an example of how the 352 indicators in WHO’s 2016 Standards for Improving Quality of Maternal and Newborn Care in Health Facilities might be reduced to only those with the strongest evidence base, associated with outcomes, and actionable by facility managers. We applied Hill criteria and assessed whether indicators were within the control of facility managers. We next conducted a rapid review of supporting literature and applied GRADE analysis, retaining those with scores of ‘moderate’ or ‘high’. To understand the utility and barriers to measuring this limited set of indicators in practice, we undertook a case study of hypothetical measurement application in two districts in Bangladesh, interviewing 25 clinicians, managers, and other stakeholders. From the initial 352 indicators, 56 were retained. The 56 indicators were used as a base for interviews. Respondents emphasized the practical challenges to the use of complex guides and the need for parsimonious and actionable sets of quality indicators. This work offers one way to move towards a reduced quality indicator set, beginning from current WHO guidance. Despite study limitations, this work provides evidence of the need for reduced and evidence-based sets of quality indicators if guides are to be used to improve quality in practice. We hope that future research will build on and refine our efforts. Measuring quality effectively so that evidence guides and improves practice is the first step to assuring safe maternal and neonatal care. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the study was to assess continuation rates and satisfaction among post-partum intrauterine device (PPIUD) accepters.Methods: This prospective observational study comprised 591 Zambian women who underwent PPIUD insertion at sites of the Society for Family Health, Lusaka, Zambia. The women were contacted 6-12 months after PPIUD insertion and asked to return to the clinic for interview and examination. If the IUD strings were not visible, an ultrasound was performed. Participants were asked about their satisfaction with the PPIUD. Main outcome measures were short-term PPIUD continuation and reported complications according to time of insertion.Results: Of 591 women enrolled, 305 women attended the follow-up appointment for interview and examination, giving a power of 80% to estimate an expulsion rate of 10 ± 5%. The IUD was inserted within 10 min of placental delivery (post-placental insertion) in 24.3% of participants (n = 74) and within 48 h (immediate post-partum insertion) in 71.1% of participants (n = 217). The total expulsion rate was 5.6%. Expulsion rates for post-placental and immediate post-partum insertions were 10.8% and 4.1%, respectively. No significant difference in expulsion rates was found (p = 0.10). Of those with an expulsion, 76.5% (n = 13) recognised that it had occurred. There were no reported complications, and 94.1% of women reported being satisfied or very satisfied with their PPIUD (n = 287).Conclusions: Overall, expulsion rates were lower than previously reported, particularly for immediate post-partum insertions. Attention to high fundal placement at insertion is a likely explanation for the low expulsion rates. Contrary to conventional wisdom, these low expulsion rates indicate that previous notions regarding insertion timing may not be accurate. Satisfaction levels were also favourable. PPIUD can be safe, acceptable and feasible in an African setting. [ABSTRACT FROM AUTHOR]

Background: In Kenya, as in many low-income countries, the private sector is an important component of health service delivery and of providing access to preventive and curative health services. The Tunza Social Franchise Network, operated by Population Services Kenya, is Kenya's largest network of private providers, comprising 329 clinics. Franchised clinics are only one source of family planning (FP), and this study seeks to understand whether access to a franchise increases the overall use or provides another alternative for women who would have found FP services in the public sector.Methods: A quasi-experimental study compared 50 catchment areas where there is a Tunza franchise and no other franchised provider with 50 purposively matched control areas within 20 km of each selected Tunza area, with a health facility, but no franchised facility. Data from 5609 women of reproductive age were collected on demographic and socioeconomic status, FP use, and care-seeking behavior. Multivariate logistic regression, with intervention and control respondents matched using coarsened exact matching, was conducted.Results: Overall modern contraceptive use in this population was 53 %, with 24.8 % of women using a long-acting or permanent method (LAPM). There was no significant difference in odds of current or new FP use by group, adjusted for age. However, respondents in Tunza catchment areas are significantly more likely to be LAPM users (adj. OR = 1.49, p = 0.015). Further, women aged 18-24 and 41-49 in Tunza catchment areas have a significantly higher marginal probability of LAPM use than those in control areas.Conclusions: This study indicates that access to a franchise is correlated with access to and increased use of LAPMs, which are more effective, and cost-effective, methods of FP. While franchised facilities may provide additional points of access for FP and other services, the presence of the franchise does not, in and of itself, increase the use of FP in Kenya. [ABSTRACT FROM AUTHOR]

Background: Nepal has high unmet need for family planning and low use of intrauterine devices (IUDs). While clients' attitudes toward the IUD are known in a variety of contexts, little is known about providers' knowledge and perceptions of the IUD in developing countries. Nepal's liberal IUD service provision policies allow the opportunity to explore provider knowledge and perceptions across cadres and sectors. This research contributes to an understanding of providers' IUD perceptions in low-resource environments, and increases evidence for IUD task-sharing and private sector involvement. Methods: A questionnaire was administered to 345 nurses and auxiliary nurse midwives (ANMs) affiliated with the private Mahila Swastha Sewa (MSS) franchise, public sector, or private non-franchise sector. All providers had been trained in TCu 380A IUD insertion and removal. The questionnaire captured providers' IUD experience, knowledge, and perceived barriers to recommendation. Descriptive, multivariate linear, and multinomial logistic regression was conducted, comparing providers between cadre and sector. Results: On average, providers answered 21.5 of 35 questions correctly, for a score of 61.4%. Providers scored the lowest on IUD medical eligibility, answering 5.9 of 14 questions correctly. Over 50% of providers were able to name the four side effects most frequently associated with the IUD; however, one-third of all providers found at least one of these side effects unacceptable. Adjusted results show that cadre does not significantly impact provider's IUD knowledge scores or side effect perceptions. Public sector affiliation was associated with higher knowledge scores regarding personal characteristic eligibility and more negative perceptions of two normal IUD side effects. IUD knowledge is significantly associated with provider's recent training and employment at multiple facilities, and side effect perceptions are significantly associated with client volume, range of family planning methods, and region. Conclusions: Provider knowledge and attitudes towards IUD provision are similar across cadre and sector, supporting WHO task-sharing guidelines and validating Nepal's family planning policies. However, overall provider knowledge is low. We recommend that providers need to receive further training and support to improve knowledge, manage side effects, and recognize women in periods of high unmet need - such as post-partum or post-abortion women - as suitable candidates for IUDs. [ABSTRACT FROM AUTHOR]

Background: The majority of social marketing programs are intended to reach the poor. It is therefore essential that social marketing organizations monitor the health equity of their programs and improve targeting when the poor are not being reached. Current measurement approaches are often insufficient for decision making because they fail to show a program's ability to reach the poor and demonstrate progress over time. Further, effective program equity metrics should be benchmarked against a national reference population and consider exposure, not just health outcomes, to measure direct results of implementation. This study compares two measures of health equity, concentration indices and wealth quintiles, using a defined reference population, and considers benefits of both measures together to inform programmatic decision making. Methods: Three datasets from recent cross-sectional behavioral surveys on malaria, HIV, and family planning from Nepal and Burkina Faso were used to calculate concentration indices and wealth quintiles. Each sample was standardized to national wealth distributions based on recent Demographic and Health Surveys. Wealth quintiles were generated and concentration indices calculated for health outcomes and program exposure in each sample. Chi-square and t-tests were used to assess statistical significance of results. Results: Reporting wealth quintiles showed that recipients of Population Services International (PSI) interventions were wealthier than national populations. Both measures indicated that desirable health outcomes were usually concentrated among wealthier populations. Positive and significant concentration indices in all three surveys indicated that wealth and program exposure were correlated; however this relationship was not necessarily linear. In analyzing the equity of modern contraceptive use stratified by exposure to family planning messages in Nepal, the outcome was equitable (concentration index = 0.006, p = 0.68) among the exposed, while the wealthy were more likely to use modern contraceptives (concentration index = 0.071, p < 0.01) among the unexposed. Conclusions: Using wealth quintiles and concentration indices together for equity monitoring improves usability of findings for decision making. Applying both metrics, and analyzing equity of exposure along with health outcomes, provides results that have statistical and programmatic significance. Benchmarking equity data against national data improves generalizability. This approach benefits social marketers and global health implementers to improve strategic decision making and programs' ability to reach the poor. [ABSTRACT FROM AUTHOR]

Little consensus exists about how to measure quality of care in abortion. Our purpose is to (a) provide common language for healthcare quality definitions, frameworks and measurement; (b) synthesize literature about quality measurement in abortion; and (c) present criteria for quality metric development. Quality includes effectiveness, patient centeredness, timeliness, efficiency and equity of care. Information about structure, process and outcomes of care is used to measure quality. We do not have good evidence about expected population-level health and behavioral outcomes associated with improving abortion service quality. Abortion patients overwhelmingly report high satisfaction with services, but it is not clear if their satisfaction indicates high-quality care. Guidance exists for quality metric selection; measures must focus on priority topics, be scientifically sound and be feasible. Technical quality standards and clinical guidelines exist, but we lack a standard set of quality metrics. Partners in the Abortion Service Quality Initiative (https://asq-initiative.org/) are collaborating to develop the first-ever global standard for measuring abortion service quality in low- and middle-income countries, both in and out of health care facilities. Standardized and validated quality metrics would move our field forward and contribute to quality improvement activities and, ultimately, to improved health outcomes for women and families. IMPLICATIONS: We define quality of health care, synthesize the evidence about quality of care in abortion and advocate for standardized and validated quality metrics to improve health outcomes for women. [ABSTRACT FROM AUTHOR]