A Cross-Sectional Analytic Study of Postpartum Health Care Service Utilization in the Philippines

Background

The maternal mortality ratio in the Philippines remains high; thus, it will be difficult to achieve the Millennium Development Goals 5 by 2015. Approximately two-thirds of all maternal deaths occur during the postpartum period. Therefore, we conducted the present study to examine the current state of postpartum health care service utilization in the Philippines, and identify challenges to accessing postpartum care.

Methods

A questionnaire and knowledge test were distributed to postpartum women in the Philippines. The questionnaire collected demographical characteristics and information about their utilization of health care services during pregnancy and the postpartum period. The knowledge test consisted of 11 questions regarding 6 topics related to possible physical and mental symptoms after delivery. Sixty-four questionnaires and knowledge tests were analyzed.

Results

The mean time of first postpartum health care visit was 5.1±5.2 days after delivery. Postpartum utilization of health care services was significantly correlated with delivery location (P<0.01). Women who delivered at home had a lower rate of postpartum health care service utilization than women who delivered at medical facilities. The majority of participants scored low on the knowledge test.

Conclusion

We found inadequate postpartum health care service utilization, especially for women who delivered at home. Our results also suggest that postpartum women lack knowledge about postpartum health concerns. In the Philippines, Barangay health workers may play a role in educating postpartum women regarding health care service utilization to improve their knowledge of possible concerns and their overall utilization of health care services.     

Paternal Factors and Inequity Associated with Access to Maternal Health Care Service Utilization in Nepal: A Community Based Cross-Sectional Study

Background

The threat of maternal mortality can be reduced by increasing use of maternal health services. Maternal death and access to maternal health care services are inequitable in low and middle income countries.The aim of this study is to assess associated paternal factors and degree of inequity in access to maternal health care service utilization.

Methods

Analysis illustrates on a cross-sectional household survey that followed multistage-cluster sampling. Concentration curve and indices were calculated. Binary logistic regression analysis was executed to account paternal factors associated with the utilization of maternal health services. Path model with structural equation modeling (SEM) examined the predictors of antenatal care (ANC) and institutional delivery.

Results

The finding of this study revealed that 39.9% and 45.5% of the respondents’ wives made ANC visits and utilized institutional delivery services respectively. Men with graduate and higher level of education were more likely (AOR: 5.91, 95% CI; 4.02, 8.70) to have ANC of their wives than men with no education or primary level of education. Men with higher household income (Q5) were more likely (1.99, 95% CI; 1.39, 2.86) to have ANC for their wives. Similarly, higher household income (Q5) also determined (2.74, 95% CI; 1.81, 4.15) for institutional delivery of their wives. Concentration curve and indices also favored rich than the poor. SEM revealed that ANC visit was directly associated to institutional delivery.

Conclusions

Paternal factors like age, household wealth, number of children, ethnicity, education, knowledge of danger sign during pregnancy, and husband’s decision making for seeking maternal and child health care are crucial factors associated to maternal health service utilization. Higher ANC coverage predicts higher utilization of the institutional delivery. Wealthier population is more concentrated to maternal health services. The inequities between the poor and the rich are necessary to be addressed through effective policy and programs.     

General internal medicine reappears in the teaching hospital: the experience of the Royal Victoria Hospital.

The internal medicine unit of the Royal Victoria Hospital in Montreal was created in 1979 to improve the training of residents and the care of patients. The practices of four internists were brought together in one part of the institution, and within 2 years there were 10 attending staff and 6 residents. The unit now provides continuing care for 2500 patients, many of whom have multisystem or potentially lethal problems. Residents and attending staff share the responsibility of providing 24-hour coverage. The group handles 5000 outpatient visits per year (20% of them being consultations) and provides a general medical consulting service for other hospital departments, with about 300 consultations per year. The creation of the unit, with highly visible role models, appears to have given new prestige to general internists in the hospital. The unit has served as a model for the reorganization of the other medical clinics and provides a base for research in health care delivery.     

Are Husbands Involving in Their Spouses’ Utilization of Maternal Care Services?: A Cross-Sectional Study in Yangon,Myanmar

IntroductionHusbands can play a crucial role in pregnancy and childbirth, especially in patriarchal societies of developing countries. In Myanmar, despite the critical influence of husbands on the health of mothers and newborns, their roles in maternal health have not been well explored. Therefore, the aim of this study was to identify the factors associated with husbands’ involvement in maternal health in Myanmar. This study also examined the associations between husbands’ involvement and their spouses’ utilization of maternal care services during antenatal, delivery and postnatal periods.MethodsA community-based, cross sectional study was conducted with 426 husbands in Thingangyun Township, Yangon, Myanmar. Participants were husbands aged 18 years or older who had at least one child within two years at the time of interview. Face to face interviews were conducted using a pretested structured questionnaire. Factors associated with the characteristics of husband’s involvement as well as their spouses’ utilization of maternal care services were analyzed by multivariable logistic regression models.ResultsOf 426 husbands, 64.8% accompanied their spouses for an antenatal visit more than once while 51.6% accompanied them for a postnatal visit. Husbands were major financial supporters for both antenatal (95.8%) and postnatal care (68.5%). Overall, 69.7% were involved in decision making about the place of delivery. Regarding birth preparedness, the majority of husbands prepared for skilled birth attendance (91.1%), delivery place (83.6%), and money saving (81.7%) before their spouses gave birth. In contrast, fewer planned for a potential blood donor (15.5%) and a safe delivery kit (21.1%). In the context of maternal health, predictors of husband’s involvement were parity, educational level, type of marriage, decision making level in family, exposure to maternal health education and perception of risk during pregnancy and childbirth. Increased utilization of maternal health services was found among spouses of husbands who accompanied them to antenatal visits (AOR 5.82, 95% CI, 3.34–10.15) and those who had a well birth plan (AOR 2.42, 95% CI, 1.34–4.39 for antenatal visit and AOR 2.88, 95% CI, 1.52–5.47 for postnatal visit).ConclusionThe majority of husbands supported their spouses’ maternal care services use financially; however, they were less involved in birth preparedness and postnatal care. Exposure to maternal health education and their maternal health knowledge were main predictors of their involvement. Women were more likely to use maternal care services when their husbands company them for ANC visits and had a well-birth plan in advance.     

Reasons for Unmet Need for Child and Family Health Services among Children with Special Health Care Needs with and without Medical Homes

Objectives

Medical homes, an important component of U.S. health reform, were first developed to help families of children with special health care needs (CSHCN) find and coordinate services, and reduce their children’s unmet need for health services. We hypothesize that CSHCN lacking medical homes are more likely than those with medical homes to report health system delivery or coverage problems as the specific reasons for unmet need.

Methods

Data are from the 2005-2006 National Survey of Children with Special Health Care Needs (NS-CSHCN), a national, population-based survey of 40,723 CSHCN. We studied whether lacking a medical home was associated with 9 specific reasons for unmet need for 11 types of medical services, controlling for health insurance, child’s health, and sociodemographic characteristics.

Results

Weighted to the national population, 17% of CSHCN reported at least one unmet health service need in the previous year. CSHCN without medical homes were 2 to 3 times as likely to report unmet need for child or family health services, and more likely to report no referral (OR= 3.3), dissatisfaction with provider (OR=2.5), service not available in area (OR= 2.1), can’t find provider who accepts insurance (OR=1.8), and health plan problems (OR=1.4) as reasons for unmet need (all p<0.05).

Conclusions

CSHCN without medical homes were more likely than those with medical homes to report health system delivery or coverage reasons for unmet child health service needs. Attributable risk estimates suggest that if the 50% of CSHCN who lacked medical homes had one, overall unmet need for child health services could be reduced by as much as 35% and unmet need for family health services by 40%.     

Understanding users' perspectives of barriers to maternal health care use in Maharashtra, India.

This paper uses data collected using in-depth, semi-structured interviews to examine utilization of maternal health care services among two rural and urban populations of Pune and Mumbai in Maharashtra, India. The study aims to identify key social, economic and cultural factors influencing women's decisions to use maternal health care and the places used for child delivery, whilst considering the accessibility of facilities available in the local area. Socioeconomic status was not found to be a barrier to service use when women perceived the benefits of the service to outweigh the cost, and when the service was within reasonable distance of the respondent's place of residence. A large number of women perceived private services to be superior to those provided by the government, although cost often meant they were unable to use them. The provision of services did not ensure that women used them; they had to first perceive them to be beneficial to their health and that of their unborn child. Respondents identified the poor quality of services offered at government institutions to be a motivating factor for delivering at home. Thus further investigation is needed into the quality of services provided by government facilities in the area. A number of respondents who had received antenatal care went on to deliver in the home environment without a trained birth attendant. Further research is needed to establish the types of care provided during an antenatal consultation to establish the feasibility of using these visits to encourage women, particularly those with high-risk pregnancies, to be linked to a trained attendant for delivery.     

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Factors associated with home visiting in an inner London general practice.

We decided to examine the services provided by doctors in an inner London practice for domiciliary care. It was expected that the study would highlight the most relevant questions and variables related to access and uptake of this service; it would thus contribute to the design of an accurate procedure for auditing the pattern of delivery of home care to be conducted in the practice in the future. During the study period, 1976-81, there were 90 500 doctor-patient contacts. For patients up to the age of 10 years the proportion of home visits was 9.2%, falling to 2.2% in the age group 20 to 29; then there is a quasi plateau till the age of 60. After 60 the proportion of home visits doubles in each of the following 10 year age groups, reaching 54% in the over 80s. The proportion of home visits (standardised by age) rises from social class II (8.0%) to social class V (10.0%), but is higher in social class I (11.7%). The proportion of home visits according to distance from the practice rises from 8.2% near the health centre to 9.6% at a distance of 0.25 to 0.50 mile, and drops to 8.8% beyond 0.75 mile. The distance effect is not consistent when the social class dimension is added: social classes I and II have higher proportions of home visits in certain age and distance groups. Single people have the lowest proportion of home visits (6.8%); there are large differences between men and women among widowed (14.1% and 8.6% respectively) and divorced or separated (7.0% and 10.7% respectively) patients. There are important variations in the proportions of home visits made by the doctors in the practice, the trainees carrying out proportionally many more home visits. Data collected in the practice can be used to define specific issues for future audit exercises. Furthermore, sociodemographic characteristics of patients have been shown to be associated with use and access to medical services.     

Computers a cornerstone of evidence-based care,conference told.

Computers are poised to become key players in the delivery of health care, but are physicians ready for them? A recent conference on medical communication in the electronic era examined the potential of computers to assist in diagnosis, provide continuing medical education, disseminate evidence and research findings, and simplify practice management. However, delegates were told that even though many medical practices are computerized, it is often staff members and not physicians who use the technology. For computers to gain wider acceptance for medical purposes, physicians need to be made comfortable with their use at an early stage of training.     

Institutional Delivery Service Utilization among Women from Rural Districts of Wolaita and Dawro Zones,Southern Ethiopia; a Community Based Cross-Sectional Study

Introduction

The highest number of maternal deaths occur during labour, delivery and the first day after delivery highlighting the critical need for good quality care during this period. Therefore, for the strategies of institutional delivery to be effective, it is essential to understand the factors that influence individual and household factors to utilize skilled birth attendance and institutions for delivery. This study was aimed to assess factors affecting the utilization of institutional delivery service of women in rural districts of Wolaita and Dawro Zones.

Methods

A community based cross-sectional study was done among mothers who gave birth within the past one year preceding the survey in Wolaita and Dawro Zones, from February 01 –April 30, 2015 by using a three stage sampling technique. Initially, 6 districts were selected randomly from the total of 17 eligible districts. Then, 2 kebele from each district was selected randomly cumulating a total of 12 clusters. Finally, study participants were selected from each cluster by using systematic sampling technique. Accordingly, 957 mothers were included in the survey. Data was collected by using a pretested interviewer administered structured questionnaire. The questionnaire was prepared by including socio-demographic variables and variables of maternal health service utilization factors. Data was entered using Epi-data version 1.4.4.0 and exported to SPSS version 20 for analysis. Bivariate and multiple logistic regressions were applied to identify candidate and predictor variables respectively.

Result

Only 38% of study participants delivered the index child at health facility. Husband’s educational status, wealth index, average distance from nearest health facility, wanted pregnancy, agreement to follow post-natal care, problem faced during delivery, birth order, preference of health professional for ante-natal care and maternity care were predictors of institutional delivery.

Conclusion

The use of institutional delivery service is low in the study community. Eventhough antenatal care service is high; nearly two in every three mothers delivered their index child out of health facility. Improving socio-economic status of mothers as well as availing modern health facilities to the nearest locality will have a good impact to improve institutional delivery service utilization. Similarly, education is also a tool to improve awareness of mothers and their husbands for the improvement of health care service utilization.     

Twelve months of deputising: 100 000 patient contacts with eighteen services.

An analysis of a 1-in-5 sample of nearly 500 000 patients contacts with 18 deputising services showed considerable variation in the way cells were handled. Telephonists, usually work on shifts including at least one operator who was a trained nurse handled, without sending a deputy, between 3% of new calls at one service and 19% at another. In one service, 19% of visits were made by deputies who were general practitioners; in another, 78%. At least 42% of patients visited by one service were apparently seen within one hour; 74% by another service. The proportions referred to hospital varied from 9% to 16%. The use of deputising services continues to grow; there is as yet no substantiated evidence of shortcomings in the care they provide. The possibility of reviewing the activity of the services, with the use of such indices as those described, might enable present limitations on their use to be lifted.     

Comprehensive Approach to Improving Maternal Health and Achieving MDG 5: Report from the Mountains of Lesotho

Background

Although it is now widely recognized that reductions in maternal mortality and improvements in women''s health cannot be achieved through simple, vertical strategies, few programs have provided successful models for how to integrate services into a comprehensive program for maternal health. We report our experience in rural Lesotho, where Partners In Health (PIH) in partnership with the Ministry of Health and Social Welfare implemented a program that provides comprehensive care of pregnant women from the community to the clinic level.

Methods

Between May and July 2009, PIH trained 100 women, many of whom were former traditional birth attendants, to serve as clinic-affiliated maternal health workers. They received performance-based incentives for accompanying pregnant women during antenatal care (ANC) visits and facility-based delivery. A nurse-midwife provided ANC and delivery care and supervised the maternal health workers. To overcome geographic barriers to delivering at the clinic, women who lived far from the clinic stayed at a maternal lying-in house prior to their expected delivery dates. We analyzed data routinely collected from delivery and ANC registers to compare service utilization before and after implementation of the program.

Results

After the establishment of the program, the average number first ANC visits increased from 20 to 31 per month. The clinic recorded 178 deliveries in the first year of the program and 216 in the second year, compared to 46 in the year preceding the program. During the first two years of the program, 49 women with complications were successfully transported to the district hospital, and no maternal deaths occurred among the women served by the program.

Conclusions

Our results demonstrate that it is possible to achieve dramatic improvements in the utilization of maternal health services and facility-based delivery by strengthening human resource capacity, implementing active follow-up in the community, and de-incentivizing home births.     

Technological developments and approaches to improving service quality

In summary, major paradigm shifts in the health care industry are altering the way technology is maintained and supported. Service organizations are now responsible for maintaining a broader base of technology within the health care delivery network and must to this on an extremely rapid, efficient, and productive basis. A number of new technologies are coming on-line, which can allow a health care technology service organization to experience significant improvements in profitability, efficiency, and productivity. To realize maximum benefit from these technologies, service organizations may find themselves re-engineering their service processes. The author believes that this is a requirement for many service organizations, regardless of whether new technology is implemented. The traditional approaches to service delivery are ineffective in managing the new structural realities and service requirements of today's health care environment. New strategies and tactics are required for ensuring that these requirements are met. These approaches will no doubt improve the overall quality, productivity, and efficiency of service and are based on best practices utilized by leading OEMs and ISOs in the medical electronics and other high technology service industry such as information technology and telecommunications, where the service organization is responsible for supporting a broad array of the technology over a large geography with a densely populated installed base, not unlike the typical health care delivery service environment. Once operational improvements are made, a service organization can take advantage of the productivity and efficiency gains brought on by new technology. Organizations interested in doing so are urged to thoroughly research the current state-of-the-art and best practices, because there are numerous systems currently available off-the-shelf. The author believes that new technology will be a basic requirement for competing in the health care technology service marketplace, because it can significantly affect the profitability of service organizations. This technology will help level the playing field between ISOs, OEMs, and biomedical personnel. As our research suggests, efficiently operating biomedical personnel can achieve a significantly higher utilization and profitability than efficiently operating OEMs, due to the advantages of lower overhead and operating cost structure. In general, the process to improve service productivity and efficiency involves a review of current service operations and understanding of the customer environment perceptions as well as understanding of key service factors parameters. From there, service organizations should identify the current state-of-the-art service and infrastructure systems and technology. Based on this assessment, a service organization can evaluate best practices and identify new strategies and tactics for improving service delivery. Through better service management control and education of users on the improvement in service, which the new processes and technologies provide, the service organization can realize real, quantifiable improvements in service quality, productivity, and profitability.     

Walk-in clinics: implications for family practice.

To understand better the reasons for the growth in popularity of walk-in clinics in Canada we surveyed 321 patients with a regular physician in Toronto who attended a walk-in clinic in the same city over a 16-day period in February 1988. They were asked their reason for attending the clinic, their perception of the urgency of their problem, their choices as alternatives to walk-in clinics and their satisfaction and concerns with the type of care received at the clinic. The three most common reasons for attending the clinic were convenient location (in 33% of the cases), inability to see their regular physician soon enough (in 16%) and no appointment needed (in 13%). Most (80%) of the patients felt that they needed medical attention within 24 hours after the onset of their problem. Most (83%) of the respondents would have sought medical attention at another walk-in clinic, from their regular physician or at an emergency department had the clinic been closed. Only 36% and 18% of the patients respectively responded that their regular physician worked evenings or weekends. Most of the visits to the clinic were outside regular weekday business hours. The level of satisfaction with the service received at the clinic was high. The extended hours and no-appointment philosophy of walk-in clinics, coupled with family physicians'' reluctance to work evenings and weekends, have made such clinics an attractive option for patients with primary care problems that they believe require prompt attention.     

Evaluation of a primary care adult mental health service: Year 2

Aims This study aimed to examine the effectiveness of a primary care adult mental health service operating within a stepped care model of service delivery.Methods Supervised by a principal psychologist manager, psychology graduate practitioners provided one-to-one brief cognitive behavioural therapy (CBT) to service users. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) was used to assess service user treatment outcomes. Satisfaction questionnaires were administered to service users and referring general practitioners (GPs).Results A total of 43 individuals attended for an initial appointment, of whom 19 (44.2%) completed brief CBT treatment. Of the 13 service users who were in the clinical range pre-treatment, 11 (84.6%) achieved clinical and reliably significant improvement. Of the six service users who were in the non-clinical range pre-treatment, three (50%) achieved reliably significant improvement. Both service users and GPs indicated high levels of satisfaction with the service, although service accessibility was highlighted as needing improvement.Conclusion The service was effective in treating mild to moderate mental health problems in primary care. Stricter adherence to a stepped care model through the provision of low-intensity, high-throughput interventions would be desirable for future service provision.     

Which physicians make home visits and why? A survey

BACKGROUND: Recent changes in the North American health care system and certain demographic factors have led to increases in home care services. Little information is available to identify the strategies that could facilitate this transformation in medical practice and ensure that such changes respond adequately to patients'' needs. As a first step, the authors attempted to identify the major factors influencing physicians'' home care practices in the Quebec City area. METHODS: A self-administered questionnaire was sent by mail to all 696 general practitioners working in the Quebec City area. The questionnaire was intended to gather information on physicians'' personal and professional characteristics, as well as their home care practice (practice volume, characteristics of both clients and home visits, and methods of patient assessment and follow-up). RESULTS: A total of 487 physicians (70.0%) responded to the questionnaire, 283 (58.1%) of whom reported making home visits. Of these, 119 (42.0%) made fewer than 5 home visits per week, and 88 (31.1%) dedicated 3 hours or less each week to this activity. Physicians in private practice made more home visits than their counterparts in family medicine units and CLSCs (centres locaux des services communautaires [community centres for social and health services]) (mean 11.5 v. 5.8 visits per week), although the 2 groups reported spending about the same amount of time on this type of work (mean 5.6 v. 5.0 hours per week). The proportion of visits to patients in residential facilities or other private residences was greater for private practitioners than for physicians from family medicine units and CLSCs (29.7% v. 18.9% of visits), as were the proportions of visits made at the patient''s request (28.0% v. 14.2% of visits) and resulting from an acute condition (21.4% v. 16.0% of visits). The proportion of physicians making home visits at the request of a CLSC was greater for those in family medicine units and CLSCs than for those in private practice (44.0% v. 11.3% of physicians), as was the proportion of physicians making home visits at the request of a colleague (18.0% v. 4.5%) or at the request of hospitals (30.0% v. 6.8%). Physicians in family medicine units and CLSCs did more follow-ups at a frequency of less than once per month than private practitioners (50.9% v. 37.1% of patients), and they treated a greater proportion of patients with cognitive disorders (17.2% v. 12.6% of patients) and palliative care needs (13.7% v. 8.6% of patients). Private practitioners made less use of CLSC resources to assess home patients or follow them. Male private practitioners made more home visits than their female counterparts (mean 12.8 v. 8.3 per week), although they spent an almost equal amount of time on this activity (mean 5.7 v. 5.2 hours per week). INTERPRETATION: These results suggest that practice patterns for home care vary according to the physician''s practice setting and sex. Because of foreseeable increases in the numbers of patients needing home care, further research is required to evaluate how physicians'' practices can be adapted to patients'' needs in this area.     

The Inability of the Consumer Price Index to Measure “Cost of Quality” of Medical Care,Report of the Bureau of Research and Planning

The Consumer Price Index (CPI) of the Bureau of Labor Statistics is an index which measures the price changes of 300 goods and services. Among these 300 items are several which reflect price changes for selected health care and medical care services. These comprise the medical care index and physician fee index, depending on what services are being measured.The Physician Fee Index is based upon charges for five procedures rendered by physicians: Appendectomy, tonsillectomy, obstetrical delivery, home visits and office visits.Although the CPI takes into account quality changes in the prices for various goods, it is unable to do so for services, particularly physicians'' services.The difficulty in measuring the “cost” of quality of medical care overstates price increases in the physician fee and medical care indexes.