Geneva Health Forum Archive

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Causes, determinants, andtrends in maternal mortality among Palestine refugees during 2000-2010

Author(s) Ali Khader1, Majed Hababeh2, Wafaa Zeidan3, Irshad Shaikh 4, Yousef Shahin 5, Akihiro Seita6, 7, 8
Affiliation(s) 1Health, UNRWA, Amman, Jordan, 2Health, UNRWA, Amman, Jordan, 3Health, UNRWA, Amman, Jordan, 4Health, UNRWA, Amman, Jordan, 5Health, UNRWA, Amman, Jordan, 6health, UNRWA, Amman, Jordan, 7, , , , 8, , ,
Country - ies of focus Palestine
Relevant to the conference tracks Women and Children
Summary Despite the hardship socioeconomic status, the patern of Maternal mortality among palestine refugee population is similar to that among stable midle income countries, A shift was observed during the last decade from causes related to poor obstetric care such as hemorrage and infection to thromboemblic diseases.
Background The United Nations Relief and Works Agency for Palestine Refugees in the Near East has for over 60 yearsprovided comprehensive primary health care to 5.2 million Palestine refugees in five fields of operation: Gaza, Jordan, Lebanon, Syria and the West Bank. Despite the contextual challenges of chronic instability and poverty, the agency maintains high standards of antenatal care supported with subsidy of delivery in local hospitals, with comprehensive follow up of all registered pregnant women.
During the period 2000-2010 a total of 978,446 pregnant women were registered and followed up through UNRWA antenatal care services. A system to trace the outcome of each pregnancy was established. During the first year (2000) of implementation, 2145 (2.8%) pregnancies were with unknown outcome that was reduced to only 199 (0.2%) cases in 2010 and during this period a total of 230 maternal deaths were reported.
Objectives The aim of this analysis is identify the main causes and determinents of maternal mortality among Palestine refugees women served by UNRWA PHC system
Methodology UNRWA uses the Confidential Maternal Mortality Enquiry method for in-depth investigation of the direct and indirect causes of each maternal death. This retrospective study examines 230 confidential enquiry reports on maternal deaths of Palestine refugee women in five fields of operation during one decade. The confidential enquiry is completed immediately after a maternal mortality. A thorough investigation is conducted by a special committee established to investigate and reoprt on each maternal mortality
Results Analysis of the confidential enquiry reports revealed a maternal mortality ratio of 24/100000 with significant variations among fields (Lebanon and Syria the highest at 34, followed by Gaza and West Bank at 25 and Jordan at 19). 1.8% delivered at home while 14.8% of deaths occurred at home. 53% of them died in hospitals during the intra-post-partum period. 88% received 4 or more antenatal visits. Maternal deaths increased with higher parity. There was a shift in the leading documented causes of maternal deaths from pre-eclampsia and hemorrhage to pulmonary embolism. Thromboembolism was the first cause of death with 41% followed by toxemia and hypertensive disorders at 12, heart diseases at 11.8%, hemorrhage at 10.5% and infection and sepsis at 7.4%
Conclusion Maternal Mortality has plateaued over the last 10 years among Palestine Refugees. We have managed to reduce the deaths from infections, hemorrhage and pregnancy induced hypertension but the deaths from obstetric embolism and medical disorders in pregnancy have either stayed the same or have increased over the years. This can be partially attributed the lack of embolism prophylaxis in high risk cases as well as poor care of high risk women with medical disorders prior to pregnancy

The Impact of the Family Health Team (FHT) model on UNRWA PHC clinics: a success story in a resource-limited refugee setting.

Author(s) Ali khader1, Majed Hababeh2, Irshad Shaikh3, Yousef Shahin 4, Wafaa Zeidan 5, Akihiro Seita6.
Affiliation(s) 1Health Department- UNRWA, UNRWA, Amman, Jordan, 2health, UNRWA, Amman, Jordan, 3Health, UNRWA, Amman, Jordan, 4Health, UNRWA, Amman, Jordan, 5Health, UNRWA, Amman, Jordan, 6Health, UNRWA, Amman, Jordan.
Country - ies of focus Palestine
Relevant to the conference tracks Health Systems
Summary The Family Health Team (FHT) approach brought substantive changes to the PHC services provided by UNRWA to Palestine refugees. It improved staff satisfaction and positive working environments for staff as well as a fair distribution of workload. The relationship with the community and clients become stronger. The quality of care and the utilization of resources also improved.
Background UNRWA provides comprehensive primary health care to 5 million Palestine refugees through 137 clinics in Gaza, Jordan, Lebanon, Syria and the West Bank. UNRWA has, for over six decades, used a vertical, program-oriented model to achieve substantial gains in maternal and child health in particular.
In response to the changing health care needs of Palestine refugees, particularly in the context of an aging population facing a growing burden of non-communicable diseases, increasing client loads, rising costs and stagnating resources, UNRWA is reforming its primary health care services.
The framework for this new service delivery model is the Family Health Team (FHT) approach. This is a patient-centered model that provides comprehensive PHC services to the entire family through a multi-disciplinary team of service providers at every stage of life. Families are registered with a team consisting of a doctor and one or more nurses and the team is responsible for all the primary care needs of all the family members.
Currently the FHT model is implemented in 51 health centres serving 1.5 million. Plans are ongoing to expand this model to all health centres by the end of 2015.
Objectives To assess quality and efficiency gains brought by the Family Health Team model on UNRWA primary health care services.
Methodology Methodology.
We have used different instruments to assess the impact of the FHT approach after 6 months of implementation in Rashidieh health centre providing PHC services for Palestine refugees in Rashidieh camp in Lebanon including:
Client Flow Analysis (CFA): Conducted on 23rd June 2012 . CFA tracks a client’s movements from point of arrival to the clinic, measuring time spent between service delivery points and with each service provider.
Rational drug use survey: The methodology is based on a method described in the WHO manual “How to investigate drug use in health facilities” (WHO, 1993). The survey was conducted during two consecutive days, 23rd and 24th June 2012.
Client satisfaction Survey & staff satisfaction surveys: the Survey was conducted during June 2013 and the questionnaire was developed and tested in-house.
Work-load Assessment: The assessment was conducted during two consecutive days on 23rd and 24th June 2012 to measure the workload between teams and for each staff within the team. It was developed and tested in-house.
Results The CFA indicated that the implementation of the FHT Model appears to have resulted in significantly shorter waiting times to see the physician, which was reduced from 16.0 to 8.2 minutes, (P< 5%). The mean contact time with the physician increased by 1.51 minutes (from 3.19 minutes to 4.7 minutes). The team structure had resulted in a balanced distribution of workload between staff. For example, the number of consultations with physicians were similar for both teams: (team I: 52% vs team II: 48%). The number of medical consultations decreased by 33%, a more integrated and comprehensive care (NCD, General, MCH) is provided by both teams, a more equitable workload distribution among teams with relatively equal age and gender distribution of clients. The antibiotic prescription rate decreased from 26.2% to 20.8%.
83% of staff considered the FHT either very helpful or helpful, 76% of clients are more satisfied, 66% of clients perceived higher quality and longer consultation time after the FHT implementation.
Conclusion Conclusion.
The FHT model implemented by UNRWA is an innovative approach in a refugee context with limited resources. It improves the quality of care provided at primary health care facilities with more efficient use of limited resources in term of staff, time and premises by decreasing waiting time and increasing contact time with the physician and improving client’s inflow-outflow.