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      Availability and Quality of Family Planning Services in the Democratic Republic of the Congo: High Potential for Improvement

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          Abstract

          A few facilities provided good access to and quality of family planning services, particularly urban, private, and higher-level facilities. Yet only one-third offered family planning services at all, and only 20% of these facilities met a basic measure of quality. Condoms, oral contraceptives, and injectables were most available, whereas long-acting, permanent methods, and emergency contraception were least available. Responding to the DRC's high unmet need for family planning calls for substantial expansion of services.

          Abstract

          A few facilities provided good access to and quality of family planning services, particularly urban, private, and higher-level facilities. Yet only one-third offered family planning services at all, and only 20% of these facilities met a basic measure of quality. Condoms, oral contraceptives, and injectables were most available, whereas long-acting, permanent methods, and emergency contraception were least available. Responding to the DRC's high unmet need for family planning calls for substantial expansion of services.

          Abstract

          Objective:

          To determine the availability and quality of family planning services within health facilities throughout the Democratic Republic of the Congo (DRC).

          Methods:

          Data were collected for the cross-sectional study from April 2014 to June 2014 by the Ministry of Public Health. A total of 1,568 health facilities that reported data to the National Health Information System were selected by multistage random sampling in the 11 provinces of the DRC existing at that time. Data were collected through interviews, document review, and direct observation. Two dependent variables were measured: availability of family planning services (consisting of a room for services, staff assigned to family planning, and evidence of client use of family planning) and quality of family planning services (assessed as “high” if the facility had at least 1 trained staff member, family planning service delivery guidelines, at least 3 types of methods, and a sphygmomanometer, or “low” if the facility did not meet any of these 4 criteria). Pearson's chi-square test and odds ratios (ORs) were used to test for significant associations, using the alpha significance level of .05.

          Results:

          We successfully surveyed 1,555 facilities (99.2%) of those included in the sample. One in every 3 facilities (33%) offered family planning services as assessed by the index of availability, of which 20% met all 4 criteria for providing high-quality services. Availability was greatest at the highest level of the health system (hospitals) and decreased incrementally with each health system level, with disparities between provinces and urban and rural areas. Facilities in urban areas were more likely than in rural areas to meet the standard for high-quality services ( P<.001). Public facilities were less likely than private facilities to have high-quality services ( P=.02). Among all 1,555 facilities surveyed, 14% had at least 3 types of methods available at the time of the survey; the most widely available methods were male condoms, combined oral contraceptive pills, and progestin-only injectable contraceptives.

          Conclusion:

          Availability and quality of family planning services in health facilities in the DRC remain low, with inequitable distribution of services throughout the country. To improve access to and use of family planning, efforts should focus on improving availability and quality at lower health system levels and in rural areas where the majority of the population lives.

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          Most cited references 21

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          Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence.

          Infant and under-5 childhood mortality rates in developing countries have declined significantly in the past 2 to 3 decades. However, 2 critical indicators, maternal and newborn mortality, have hardly changed. World leaders at the United Nations Millennium Summit in September 2000 agreed on a critical goal to reduce deaths of children <5 years by two thirds, but this may be unattainable without halving newborn deaths, which now comprise 40% of all under-5 deaths. Greater emphasis on wide-scale implementation of proven, cost-effective measures is required to save women's and newborns' lives. Approximately 99% of neonatal deaths take place in developing countries, mostly in homes and communities. A comprehensive review of the evidence base for impact of interventions on neonatal health and survival in developing-country communities has not been reported. This review of community-based antenatal, intrapartum, and postnatal intervention trials in developing countries aimed to identify (1) key behaviors and interventions for which the weight of evidence is sufficient to recommend their inclusion in community-based neonatal care programs and (2) key gaps in knowledge and priority areas for future research and program learning. Available published and unpublished data on the impact of community-based strategies and interventions on perinatal and neonatal health status outcomes were reviewed. Evidence was summarized systematically and categorized into 4 levels of evidence based on study size, location, design, and reported impact, particularly on perinatal or neonatal mortality. The evidence was placed in the context of biological plausibility of the intervention; evidence from relevant developed-country studies; health care program experience in implementation; and recommendations from the World Health Organization and other leading agencies. A paucity of community-based data was found from developing-country studies on health status impact for many interventions currently being considered for inclusion in neonatal health programs. However, review of the evidence and consideration of the broader context of knowledge, experience, and recommendations regarding these interventions enabled us to categorize them according to the strength of the evidence base and confidence regarding their inclusion now in programs. This article identifies a package of priority interventions to include in programs and formulates research priorities for advancing the state of the art in neonatal health care. This review emphasizes some new findings while recommending an integrated approach to safe motherhood and newborn health. The results of this study provide a foundation for policies and programs related to maternal and newborn health and emphasizes the importance of health systems research and evaluation of interventions. The review offers compelling support for using research to identify the most effective measures to save newborn lives. It also may facilitate dialogue with policy makers about the importance of investing in neonatal health.
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            Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery.

            We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006. This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined. Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20. Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.
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              Measuring client satisfaction and the quality of family planning services: A comparative analysis of public and private health facilities in Tanzania, Kenya and Ghana

              Background Public and private family planning providers face different incentive structures, which may affect overall quality and ultimately the acceptability of family planning for their intended clients. This analysis seeks to quantify differences in the quality of family planning (FP) services at public and private providers in three representative sub-Saharan African countries (Tanzania, Kenya and Ghana), to assess how these quality differentials impact upon FP clients' satisfaction, and to suggest how quality improvements can improve contraceptive continuation rates. Methods Indices of technical, structural and process measures of quality are constructed from Service Provision Assessments (SPAs) conducted in Tanzania (2006), Kenya (2004) and Ghana (2002) using direct observation of facility attributes and client-provider interactions. Marginal effects from multivariate regressions controlling for client characteristics and the multi-stage cluster sample design assess the relative importance of different measures of structural and process quality at public and private facilities on client satisfaction. Results Private health facilities appear to be of higher (interpersonal) process quality than public facilities but not necessarily higher technical quality in the three countries, though these differentials are considerably larger at lower level facilities (clinics, health centers, dispensaries) than at hospitals. Family planning client satisfaction, however, appears considerably higher at private facilities - both hospitals and clinics - most likely attributable to both process and structural factors such as shorter waiting times and fewer stockouts of methods and supplies. Conclusions Because the public sector represents the major source of family planning services in developing countries, governments and Ministries of Health should continue to implement and to encourage incentives, perhaps performance-based, to improve quality at public sector health facilities, as well as to strengthen regulatory and monitoring structures to ensure quality at both public and private facilities. In the meantime, private providers appear to be fulfilling an important gap in the provision of FP services in these countries.
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                Author and article information

                Journal
                Glob Health Sci Pract
                Glob Health Sci Pract
                ghsp
                ghsp
                Global Health: Science and Practice
                Global Health: Science and Practice
                2169-575X
                06 June 2017
                27 June 2017
                27 June 2017
                : 5
                : 2
                : 274-285
                Affiliations
                [a ]Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa , Kinshasa, Democratic Republic of the Congo (DRC).
                [b ]Ministry of Public Health , Kinshasa, DRC.
                [c ]Lubumbashi School of Public Health, Faculty of Medicine, University of Lubumbashi , Lubumbashi, DRC.
                Author notes
                Correspondence to Dieudonné Mpunga ( mpungadieudonn@ 123456yahoo.fr ).
                Article
                GHSP-D-16-00205
                10.9745/GHSP-D-16-00205
                5487089
                28588047
                © Mpunga et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-16-00205

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