The reliability of the situation analysis observation guide

The use of direct observation to assess the quality of family planning services is a central element of situation analysis studies. The interrater reliability of observational data from a study in Turkey was assessed using teams of multiple observers. Overall, the findings suggest a strong degree of reliability. Observers were more likely to agree when rating physical actions than verbal cues and when both observers were of similar backgrounds. The high degree of reliability in the situation analysis observation guide is considered to be due to a relatively low level of measurement and the use of crude indicators for several dimensions of quality. The guide's reliability makes this sort of study particularly valuable to family planning clinicians, program managers, and policymakers.

Survey questions for the measurement of induced abortion

Underreporting of induced abortion in survey research is a ubiquitous problem. The use of an indirect interview technique in which questions were asked about abortion in the context of unwanted pregnancy was described earlier as holding promise for increasing the response rate. This report reviews the mixed results from multicountry studies that used indirect technique. Exploratory qualitative studies are needed to identify a setting-specific context for discussing abortion. Because the subject of induced abortion is inherently sensitive, survey measurement of this practice is less precise than that of other, less controversial maternal health-care practices. This lack of precision should not deter the pursuit of the study of this critically important public-health-care concern.

The quality of abortion services in Turkey

The quality of abortion in Turkey's public sector hospitals is investigated using multiple research methods including observations of actual procedures, interviews with medical staff and clients, and an inventory of materials and equipment. The results suggest that women who obtain abortions in public sector hospitals have a higher abortion rate than the general population. They are likely to receive a vacuum aspiration with minimal pain control medication. Clinical infection control procedures are insufficient, as are interpersonal communication practices including counseling on reproductive health issues and providing factual information. Links with family planning services are strong and the majority of abortion patients who desire family planning receive a contraceptive method, either through direct provision of postabortion contraceptives or referral.

Improving the medical care and counseling of postabortion patients in Egypt

This report analyzes the results of an operations research project carried out at two sites in Egypt to improve the medical care and counseling of postabortion patients. Preintervention and postintervention surveys and observations were conducted. After the introduction of vacuum aspiration under local anesthesia, the number of cases treated with dilatation and curettage under general anesthesia dropped from an average of 169 per month to 16. The majority of the remaining cases (an average of 119 per month) were treated with vacuum aspiration. Both providers' and women's knowledge about postabortion complications improved. Family planning information provided to postabortion patients increased as a result of the project's training program. The proportion of patients intending to use a contraceptive method increased by 30 percentage points due to the improved counseling. Future programs linking family planning and postabortion medical services should be prepared to improve the medical care of existing emergency health services and to add counseling services.

The integration of family planning and childhood immunization services in Togo

Improvements in the constellation of services in the African context are largely addressed through attaining better measures of service integration, which can be achieved through improved referral across categories of health programs. The use of an unobtrusive referral message that linked family planning and the Expanded Program of Immunizations (EPI) services was tested in an operations research study in Togo. The introduction of the referral message was accompanied by an 18-percent increase in awareness of available family planning services and an increase in the average monthly number of new family planning clients of 54 percent. These positive results indicate that the use of referral can have a significant and dramatic impact on family planning services in a relatively short time. In Togo, no evidence existed of a negative impact on EPI services, and a majority of the EPI providers reported satisfaction with the effect of the referral message at the close of the study.

The simulated client method: evaluating client-provider interactions in family planning clinics

The "simulated client" method was first detailed in the family planning literature in 1985, but it has not been extensively covered since. As used by the authors to study client-provider interactions in family planning programs, this method essentially consists of sending women to a family planning service provider to request information, and interviewing them after the encounter. The women do not reveal to service providers they are participating in the study. This report describes the method; reviews some of the theoretical, ethical, and methodological issues related to it; and underlines its usefulness as a tool for examining quality-of-care issues in family planning programs.

A new approach to eliciting information about induced abortion

Reliable quantitative data on abortion are sorely needed, particularly in developing countries. Past experience in large-scale survey research has demonstrated that direct questioning on this subject results in significant underreporting. This article presents results of an experiment to collect data on induced abortion in Côte d'Ivoire within the context of a family planning operations research study. First, questions were employed to broach the topic of unwanted pregnancy in a value-free manner, and then the potential for a variety of actions, including abortion, was acknowledged. The results indicate that approximately 25 percent of all women attending a family planning clinic on the day of the survey had had an induced abortion. The use of improved abortion-related questions shows promise for providing more complete measurement of a neglected dimension of women's reproductive health.

Improving the quality of service delivery in Nigeria

This study evaluates the effect of a nurse training program in family planning counseling skills on the quality of service delivery at the clinic level, as well as its impact on client compliance with prearranged appointments. The study used a quasi-experimental design to compare certified nurses who received six weeks of family planning technical training with certified nurses who, in addition to the technical training course, received a three-day course in counseling skills. Data were collected through client exit interviews, expert observation, and inspection of medical record abstracts. Trained nurses performed better than their untrained counterparts in the quality-of-care areas investigated--interpersonal relations, information giving, counseling, and mechanisms for encouraging continuity. The likelihood that clients will attend follow-up visits was also found to improve when they were attended by trained professionals. Short-term counseling training can significantly improve the quality of care provided by family planning workers, as well as client compliance with follow-up appointments.

Mass media family planning promotion in three Nigerian cities

Television promotion of family planning and clinic sites in three cities of Nigeria--Ilorin, Ibadan, and Enugu--played a significant role in 1985-88 in increasing the number of new acceptors at family planning clinics in each city. Family planning skits, prepared with advice and support from the local service providers, were included in existing popular entertainment shows. Questions asked in a recall survey among the exposed population in Enugu and Ibadan revealed that about half of those surveyed in both cities had seen the television episodes. Of those who had watched, 79 and 99 percent, respectively, recalled the family planning messages, and 69 and 88 percent, respectively, recalled specific clinic sites mentioned. Following the media promotion, the number of new clinic clients per quarter in Ilorin increased almost fivefold (in the original clinics evaluated); in Enugu, the number of new clients per month more than doubled; and in Ibadan, the number of new clients increased threefold. Use of entertainment through this "enter-educate approach" is a promising technique that can be replicated in different settings to encourage new clients to seek family planning services.

User's perspective of counseling training in Ghana: the "mystery client" trial

Evaluating counseling training programs from the client's perspective has posed a methodological challenge for family planning researchers. This report describes an evaluation method that combines clinic observation with an exit interview methodology. Eighteen women posing as clients were requested to visit three clinics with trained and three clinics with untrained family planning counselors. These clients (called "mystery clients" in Ghana) were later interviewed to uncover any perceived differences between the consultations. The effect of training was evident. Trained counselors consistently provided more complete information about all available contraceptives. However, both trained and untrained counselors often treated younger clients with disrespect or refused to give them the information they requested. This behavior indicated the need to strengthen the values clarification section of the counselors' training sessions, which has now been done.

Aggressive combination therapy in the successful management of life-threatening intracranial hemorrhage in a patient with idiopathic thrombocytopenic purpura

We describe acute therapy for a 13-year-old female from Panama with chronic idiopathic thrombocytopenia purpura (ITP) refractory to steroids, splenectomy, vinca alkaloids, and azathioprine. She presented with neurologic deterioration from a posterior fossa intracranial hemorrhage (ICH). This followed a 3-month history of severe dysfunctional uterine bleeding, progressive from menarche, which had required multiple red cell transfusions. Steroid and vinblastine therapy and transfusion of 40 U of platelets failed to increase the platelet count above 10,000/microliter. Development of a second larger ICH (frontal) produced morbid increase in intracranial pressure that necessitated neurosurgical decompression. Plasma exchange and colloid repletion with intravenous gamma globulin (1 g/kg) and an infusion of 20 U of platelets resulted in a transient rise in platelet count to 160,000/microliter, permitting surgery without bleeding. Danazol (800 mg/day) and conjugated estrogen (Premarin 25 mg/day) were begun to control the uterine bleeding. Intensive plasma exchange and i.v. IgG infusions were continued daily for 24 days, then twice weekly for several weeks. Platelet-bound IgG decreased almost 500% over the first 10 days of therapy, and platelets increased dramatically to 600,000/microliter after 3 weeks of therapy. The patient has remained amenorrheic with a normal platelet count for more than 24 months on daily danazol therapy and monthly infusions of i.v. IgG (0.4 g/kg/dose).