June 2001, Vol. 7, No. 2

Field Report
Quality of Services Assessed at Palestinian Clinics

While a large percentage of women in the West Bank and Gaza receive some antenatal care, very few return to health clinics for postpartum follow-up visits for mothers and newborns. To address this situation, the Population Council’s Frontiers in Reproductive Health program is helping to conduct a pilot health project in 27 primary health care clinics in three areas of the West Bank and Gaza. “We aim to improve the health of Palestinian women and their children by testing ways to increase the quality of antenatal and postpartum services,” says Laila Nawar, Council regional advisor in West Asia and North Africa. The Council and CARE International are implementing this health project in partnership with the Health, Development, Information and Policy Institute (HDIP), the Center for Development in Primary Health Care (CDPHC), and three other Palestinian nongovernmental organizations, and in coordination with the Palestinian Ministry of Health and the USAID/West Bank and Gaza Mission.

In collaboration with Frontiers, HDIP conducted a survey to determine the baseline levels of such key indicators of the project’s effects as the percentage of women who received antenatal and postpartum care and knowledge and skill among health care providers. All antenatal, postpartum, and family planning clients who visited the clinics during the data collection period from 30 May to 15 August 2000 were eligible for exit interviews in the baseline survey; 792 female clients were interviewed. The investigators also interviewed physicians, nurses, and community health workers and gathered data from service statistics. The baseline survey report provides a comprehensive look at antenatal and postpartum care services in the West Bank and Gaza, reporting on the existing standards of services offered at the clinic level and clients’ perceptions of these services.

Health information system shortcomings
Ideally, baseline data on many indicators would be extracted from clinic medical records. However, “different primary care clinics use different recording systems,” says Council program associate Nancy Ali, “and not all of a client’s health information is kept in a single file.” Thus, the researchers relied mostly on information gathered in interviews. HDIP will lead the development of a unified management information system for clinics.

Although the majority of women receive some antenatal care—five visits on average—only 3.3 percent reported returning to primary health care clinics for follow-up after giving birth. Only one-third of the 3.3 percent of women who returned to clinics for follow-up reported receiving a home visit by a health provider after delivery. About 41 percent of the women who reported returning to clinics for postpartum follow-up accepted a family planning method at that time. Overall, 58 percent of the women interviewed had ever used a family planning method. “Not a single woman reported using a contraceptive to delay her first birth,” says Dale Huntington, Council senior program associate.

Clinic quality
The survey findings revealed room for improvement in the quality of services provided at the primary care clinics canvassed by the pilot health project. Although most women received information about some aspects of antenatal and postpartum care, many did not receive such important information as health warning signs that could arise during pregnancy or after childbirth and information on health problems among young infants. Only four of the nine physicians interviewed reported that they routinely counsel their patients on how to conduct breast self-examinations. Similarly, only about half of the physicians reported providing services for obtaining Pap smears for detecting cervical cancer.

The study results also suggest that technical knowledge and skills could be improved among all categories of service providers. The overall level of education and training of community health workers interviewed was not consistent or standard. And, while most physicians reported receiving training on women’s health, they also felt that they needed additional training on some aspects of the topic.

Recommendations
On the basis of these findings, the researchers recommend that service providers at all levels receive additional training in maternal and child health care. Referral mechanisms should be established between hospitals and primary health care clinics to ensure that women receive essential postpartum care. The Ministry of Health, nongovernmental organizations working in health care, and individual clinics need to increase the public’s awareness about the importance of antenatal and postpartum care, including family planning and breast and cervical cancer screening, and clinics need to systematically provide these services. Clinics need to improve outreach services to track and reach women who have either stopped going for antenatal visits or have no intention of seeking postpartum care. Finally, primary health care clinics should implement mechanisms to ensure high-quality services and management systems. Many interventions based on these recommendations will be launched and tested during the pilot health project.

Source
“Pilot health project baseline survey report: West Bank and Gaza.” 2001. Frontiers report. Cairo, Egypt: Population Council.

Outside funding
United States Agency for International Development

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