Sot. Sri. Med. Vol. 33,No.
0277-9536191 53.00+0.00
12.~~. 138S-1390.1991
Pergamon Press plc
Printed in Great Britain
THE APPLICATION OF OPERATIONAL RESEARCH (OR) PROCEDURES TO MATERNAL MORTALITY FROM PUERPERAL SEPSIS IN A RURAL COMMUNITY 0.0.
ADETORO’, K. S. ADEYEMI’,B. PARAKOYI’, A. ONI’, T. AKURE’ and 0. OGLJNBODE’ Faculties of ‘Health and *Social Sciences, University of Ilorin, PMB 1515, Ilorin, Nigeria
Abstract-An operation research (OR) procedure on maternal mortality from puerperal sepsis was carried out in Irepodun Local Government Area of Kwara State of Nigeria. The study involved ten focus groups discussion (FGD) in two districts of the Local Government Area. The findings were analysed from three broad perspectives, that is, consumers’ views, providers’ views and community decision takers’ views. In general, the analysis revealed that the community knowledge of puerperal sepsis is poor. In addition, limited access and prohibitive cost of orthodox health care services prevented the community from full utilization of the few available health care centres in the community. The study also revealed that there is urgent need to introduce three key interventions for an improved maternity care in the community. These interventions are community health education, health institutions development and community participation in provision of ancillary services such as transportation.
Key words--operations,
research, maternal, mortality, puerperal, sepsis, rural community
INTRODlJflION Although regional variations exist, infection is always one of the major causes of maternal death. Also, puerperal sepsis is common in the developing
countries, and from studies in Nigeria, it accounts for 8-10% of maternal mortality [I, 21. Unfortunately, most of the affected are unbooked patients from the remote areas of the community. It is on this basis that an operational research (OR) technique is considered appropriate to investigate factors associated with maternal mortality from puerperal sepsis in the rural communities of Kwara State, Nigeria. This presentation is the report of the application of the focus group discussion (FGD) technique on the assessment of the community perception of puerperal sepsis and maternal death. The report is divided into sections. The first section is the introduction. The second section is a brief discussion of the study area, while the third section highlights the focus group design, selection, composition and the operational research (OR) approach to the conduct of FGDs. The fourth part contains the discussion topics which concentrate on the community knowledge, attitude and practice as regards puerperal sepsis as a cause of maternal death. The fifth section is the discussion of the findings of focus group activities for the purpose of developing the strategies for intervention. The last section is a review of the implications of the overall observations of the focus group on puerperal sepsis as a cause of maternal death. CHOKE OF STUDY AREA
Irepodun Local Government was chosen as the study area because it is one of the two experimental
local governments chosen by the Federal Government for the Primary Health Care (PHC) strategy. The rationale for the choice of Irepodun is threefold: first, it is an experimental PHC local govemment, and therefore it was assumed that it would be easier to integrate our intervention strategies for puerperal sepsis into the PHC programmes of the area. Secondly, the two districts are being used by the Faculty of Health Sciences, University of Ilorin as one of the centres on Community Based Educational Services (COBES) programme for the training of its medical students. Such a long interaction ensures an opportunity for understanding and cooperation between the districts and the research team. Thirdly, Irepodun is the nearer of the two PHC Local Government Areas so that the resources available to the investigators will not be overstretched. This geographical advantage can be seen on Fig. 1, showing the location of the two PHC Local Government Areas. METHODOLOGY The research methodology for the study was a multistage procedure. The procedure involved the conduction of focus group discussion, followed by institutional survey and then the community survey. This procedure was adopted in order to make use of the output of the qualitative methodology (focus group discussion) as an input into the preparation of the questionnaires for the community survey. The findings in this paper were those emanating from the application of operational research methodology of investigating the problem of maternal mortality as perceived by our clients, i.e., the rural dwellers in Irepodun Local Government Area of Kwara State of Nigeria. This is the first part of the three-part report.
1385
1386
0. 0. ADETORO et al.
pre-test and study area belong to the same Yoruba ethnic group and because of the culture of respect for elders, we were informed by our pre-test experience that some stratification had to be done for FGD involving women of reproductive age. Thus, it was decided arising from the pre-test that mothers should be divided into two sets; those aged 14-29 years and those aged 30-49 years. During the FGD planning stage, it was decided that eight focus group discussions would be carried out. The plan was to conduct four FGDs in each of the two districts. The rationale for this number was based on the assumption that the population in these two districts is relatively homogeneous. So, it was thought that even if more FGDs were conducted, the additional information would not justify the marginal resources (human and financial) to be expended. The distribution of the eight focus groups were four from each of the two districts, i.e.: m
Location Designated for primary
of University
of llorin
local
government areas health care programme
Fig. 1. Map of Kwara State of Nigeria. The procedure of focus group discussion being a qualitative information gathering approach is a difficult one. It is difficult in the sense that major mistakes through questioning should be avoided. In fact, the methodology of probing through discussion was adopted. Thus, focus group discussion guides and question typology were generated by the research team. These guides and question types were thoroughly discussed with modification inputs from both the research team and the focus group facilitators and note takers. At this juncture, pre-test discussion guides and probing statements were compiled. After the training of the FGD facilitators and note takers, a pre-test was done in the semi-urban area of Okelele District in Ilorin Local Government Area. The pre-test was carried out so that facilitators and note takers could master the art of conducting FGD. Similarly, the pre-test was done in a local government area different from that of the actual study districts in order to avoid mastering of our experience with the focus group discussions by the real FGD participants of Oro and Esie districts in Irepodun Local Government Area. In this pre-test, we decided not to throw questions at the participants but rather to introduce the topic of maternal death in such a way that participants contributed freely to the issue. They were not constrained for as long as they continued to focus on maternal deaths and their causes. Furthermore, it was discovered in the course of the pre-test that the women had good knowledge about most of the major causes of maternal death. Because the pre-test area was different from the study area, we could not make any major assumption beyond keeping our minds open regarding the level of awareness of maternal problems in Oro and Esie districts. Moreover, the pre-test afforded the facilitators and the research team the lesson that the elderly women in the same focus group as younger mothers would tend to dominate the discussions. Because both the
-women aged 14-29 -women aged 30-49 -Traditional Birth Attendants (TBAs) aged 40 + -community leaders aged 30-65. Inasmuch as the stipulated eight FGDs took care of our pre-FGD perception, it was discovered during the execution that two very important population targets were missing, i.e.: (i) the women in purdah (ii) the nomadic Fulani mothers. In order to take care of them, two additional FGDs were held; one for women in purdah and one for the nomadic Fulani women, making a total of ten. The women in purdah were mainly found in Oro district whose population is about 50% moslem as against about 30% in Esie. The moslems in Esie district are more liberal hence, there are very few women in purdah. Coincidentally, the nomadic Fulanis are predominantly found in Esie district. Thus, five FGDs were held in each of the two districts. Figure 2 shows the clustering of the focus groups (FG) by district. The size of each FG was fixed at 8-12 participants. The rationale for this size was partly because it would ensure active participation and indepth discussion by each participant of the FGD. Moreover, this range of size is consistent with what is available in the literature [8]. OPERATIONAL RESEARCH (OR) IN FOCUS GROUP DISCUSSION ON MATERNAL IMORTALITY IN OR0 AND FSIE DISTRICTS
Operational Research (OR) as it was practised in the immediate post-war period up to the mid 70s was mainly quantitative. This approach is usually directed at isolating causes and effects in discrete forms in such a way that it will be possible to achieve a single-valued objective function [3]. Such objective could be minimising or maximising some criteria. From the mid 7Os, it became clear that such a single valued objective function did not meet the aspiration of
OR procedures to maternal mortality from puerperal sepsis
1387
consumers of OR studies. Thus, there was the need to involve the clients more in the problem identification and solving [4, 51. The FGD in two districts, i.e. Oro and Esie, was conducted using Ackoffs [4] current operational research approach to clients’ problems. This approach regards the organisation (Oro and Esie districts in this case) as embodying a culture that needs to be understood on its own terms rather than in terms of some preconceived model or rational framework [6,7]. The reasons for taking this approach are three-fold:
6) to allow us as OR team to follow where the problems lead us rather than lead the problems to where we want; (ii) to let the OR team, facilitators and note takers and the FGD participants discuss the nature of maternal ‘messes’ they face and the difficulties they have in facing them; (iii) we were also informed that the approach would make the team aware of the degree of congruence between our pre-conceived maternal problem and the community’s actual experience and perception (Ackoff R.L., op tit). This is further justified by the fact that the OR team is very careful not to enact some ‘expert problem identification’ role on the basis of our superior tertiary facility knowledge and evaluation about the world of the rural community of Oro and Esie districts. Therefore, what the team did was to train facilitators (occasionally, team members acted as facilitators when necessary) who delicately conducted the FGDs but without influencing or leading responses to particular maternal mortality problems. DISCUSSION TOPICS
In conducting FGDs, discussion guides had to be prepared in some fairly lucid but comprehensive manner. Thus, discussion topics were identified, although not restricted to the list, inasmuch as they relate to maternal mortality problems in the two districts. The topics which we identified were not structured in a forma1 way since it was possible to discuss any of the topics listed any time within the focus of group session. Thus, the order of topic in the list is not important. A lot depended on the skills and dexterity of the facilitators. However, such skills were assured through proper training of the facilitators. Below is a list of the discussion topics used during the focus group sessions: (i) Genera1 understanding and practices as regards child-bearing and its impact on the health of the mothers. (ii) The knowledge, attitudes and practices regarding maternal mortality and its effects on the community. (iii) Community perception of maternal mortality from puerperal sepsis and its impact on the community. (iv) Basic health values.
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ADET0R0 ef
(v) Pre-natal, post-natal and preventive care for maternity services. 64 Puerperal sepsis: is it a recognised problem? (vii) What are the kinds of steps taken when puerperal sepsis occur (especially within few weeks of delivery); for those that take steps? Do they visit health practitioners? What type of pratitioners? Do they give self treatment? (viii) Type of maternal service deliveries: Traditional herbalists or midwives Faith healers Patent medicine vendors Chemists and Pharmacists Professional health care providers (Doctors, Nurses and Midwives). (i) Private (ii) Government the type of (ix) Cost of health care-by practitioner. (x) Access to government or private or traditional health facilities and perception of general utilization to those services to prevent, or treat puerperal sepsis. (xi) Problems encountered with each health facilities and recommendations for action. FINDINGS
The focus group data consist of the statement recorded in the group sessions. These findings therefore, emerge from interpreting those statements from the FGD participants in the light of the subject under investigation. We present the findings from three broad perspectives: -Consumers’ -Providers’ tendants) -Community
views views (i.e. Traditional decision-takers’
Birth At-
views.
Consumers’ views
The consumers in this case are the women of reproductive age represented by six focus groups including the following: -women aged 14-29 (one FG in each of Oro and Esie districts); -women aged 30-45 (one FG in each of Oro and Esie districts); -women in purdah (in Oro district); -nomadic Fulani women (in Esie district). The views of these consumers are categorised into the following problem areas: (i) Puerperal sepsis. None of the participants had a formal knowledge about puerperal sepsis (PS), although majority have a good knowledge of symptoms of puerperal sepsis. They are not aware that it can cause maternal death. Some believe that mothers will develop puerperal sepsis if they failed to have hot baths and sizth baths after delivery. They recognise that maternal death from whatever cause is a tragedy
al.
and all agreed that there is a need for a comprehensively developed health care delivery system which includes prevention of puerperal sepsis. (ii) Limited access. Most of the participants stated that they were disadvantaged by concentrations of public health facilities mainly in urban and periurban areas. Such a distant-decay distribution of health facilities coupled with transportation problems, have seriously constrained the consumers’ accessibility to service delivery centres. In fact, some villages have to wait for twelve or more hours before the next available transport. (iii) Cosfs. The consumers were unanimous about the prohibitive cost of seeking health care services. The costs of maternity care in all government health institutions have become prohibitive because of the national economic depression. All the participants agreed that visiting the government health institutions for maternity services always entail four principal costs: (a) Travel expenses. (b) Opportunity costs due to time spent in waiting to register, waiting for consultation, waiting for laboratory tests, waiting to pay for prescriptions and waiting to collect the medicine. (4 Psychological costs of being hostile, snobbed, neglected or abused by health personnels. Another aspect of psychological cost is inavailability of drugs after waiting for a long time. W Actual expenses such as consultation fees, treatment fees, registration fees, etc. (iv) Lack of supplies and equipment. The participants reported that there is chronic shortage of drugs and items needed for maternity services in all government health institutions around. They recorded that they have to go out to buy prescribed drugs from enterpreneurial pharmacists and bring them back to be administered to patients. Also, reagents are frequently unavailable, making laboratory tests impossible to carry out. (v) Attitude of health personnel in the public sectors. Although health care services are regarded as humanitarian, the participants reported certain degree of the uncaring attitudes of health service personnels. They were seen as being harsh, rude and uncaring to maternity cases. These observations were the participants’ views for all categories of health workers. (vi) Unorthodox health workers. The participants recognise the traditional midwives as easily accessible, whose fees are moderate and can be paid in kind or cash. A lot of participants reported that most traditional midwives provide free maternity services and more importantly, the traditional midwives are very accommodating and understanding. To them, the TBAs provide a set of services that cover both mental, social and body welfare. (vii) Other maternal problems. The participating consumers easily recognised that there are many other maternal problems some of which could be very fatal. In fact, the participants constantly referred to haemorrhage as a collosal maternal problem which had caused many maternal deaths. They also talked extensively about anaemia as a rampant maternal problem. Other causes of maternal mortality which
OR procedures to maternal mortality from puerperal sepsis the participants revealed are prolonged obstructed Iabour, eclampsia, supernatural powers and fate. Providers’ view (traditional birth attendants-TBAs)
The only group of providers who participated in this focus group session were the traditional midwives. Many can not clearly define puerperal sepsis although they have a good working knowledge about the symptoms. After they had been educated on the features of puerperal sepsis, they agreed that it can cause maternal death, through secondary effect. However, they claimed to have treatment for it and believe that only mothers who do not receive this care suffer from the lethal effect of puerperal sepsis. They reported that their practices thrive owing to the fact that they charge low fees with instalment payment options, and often the services are rendered free. Moreover, their consultations are holistic, more embracing and empathising. They have their drugs in stock, and patients do not need to wait for too long before they are seen. They always reassure their patients and provide a kind and gentle manner of approach in terms of care. Although most claimed to have effective treatment for puerperal sepsis, a few agreed that they occasionally referred cases to nearby public health institutions for further management. Community decision takers’ view
The community decision takers are the community leaders. The community leaders are the decision takers regarding whatever problems the districts face. In this case, as far as maternal mortality problem is concerned, their importance can easily be identified when it comes to a decision to seek care whether from the TBAs or from the orthodox medicine. However, it was noted that such decisions needed not be jointly taken at a congress meeting, but that it could be taken single-handedly by any community leader closest to the particular pregnant woman. Usually, the experience gained from such decisions serve as a lesson for all the community leaders who then act quickly and/or direct maternity cases to the perceived more efficacious care provider. They often refer suspected cases of puerperal sepsis to the traditional midwives because of easy reach and embracing care. DISCUSSION
AND CONCLUSIONS
Puerperal sepsis as a cause of maternal death is regularly reported all over the world. Also, the loss of a mother in the community becomes glaring as many children are neglected and uncared for. Unfortunately, puerperal sepsis which is one of the major causes of maternal death is not well recognised by both the consumers of health services and the traditional health care providers. This exercise revealed that many mothers do not receive orthodox maternity services for many reasons. These can be broadly summarised as inaccessibility, prohibitive cost and ignorance. There is the observation that lack of facilities in government health institutions and high cost of health care delivery services are increasingly encouraging patients to go to traditional midwives. In addition, the traditional health care practitioners claim to be superior to many orthodox health care
1389
providers. Unfortunately, most of their claims remain unverified by orthodox medical science. Hence, traditional midwifery practices still carry an undetermined risks to the well-being of the mothers. From this study, it is essential to appreciate the level of knowledge and understanding of the community with regards to puerperal sepsis. The questions raised for discussion revealed in general, that puerperal sepsis is not well recognised and worse still that its lethal effect is poorly understood. There is a general consensus that there is need for care in pregnancy, labour and puerperium to prevent complications and most women obtain one form of care or the other. However, the majority provide self care till there is a problem, for which they seek traditional midwifery care. It was observed that both the consumers and the providers were generally ignorant of what puerperal sepsis is all about, and cannot precisely record its causes. The participants agreed that it can cause maternal death if mothers do not get care, and noted that its preventive measure is through regular care during pregnancy either from traditional midwives or from government health institutions. The TBAs insisted that their care is more efficacious than that of orthodox medicine although the target consumers believe that there are some aspects of maternity services that cannot be handled by the TBAs while they are better care providers in other areas. The community decision-takers were of the view that TBAs have been performing a wonderful job given the economic, social and health constraints of the districts. They were also of the opinion that women who suffer from puerperal sepsis and other maternal problems were usually those who did not seek maternal care during pregnancy. Such negligence to them would not only affect the women but also the unborn children. The community leaders were quick in recognising the superior cause-effect knowledge of the orthodox medicine but they were disturbed about the apparent lack of concern by the government on the health of mothers in the rural areas. Though they said women in their communities will use orthodox health facilities if brought nearer to them, but that under present distant-decay distribution, the communities have no option other than rely on the experience and practice of the TBAs. In conclusion therefore, the focus group discussions exercise have certain implications for health policy makers, health care providers and health care donor agencies: (i) The FGDs reveal the need to develop strategies which will involve the community in order to minimise puerperal sepsis. (ii) During the focus group sessions, the TBAs indicated their interest in being’ trained to modemise and improve their service delivery. This interest has great implications for the Primary Health Care (PHC) strategy of the Federal Government. (iii) It came out clearly during the FG sessions that the community was willing to utilize facilities at the health centres if available at affordable prices.
O.O.ADETORO
1390
(iv) The community also indicated their willing(4
ness to participate in the health package that will minimise maternal mortality. It was also clear during the sessions that the health education effects of the PHC facilities in the districts might have increased the level of awareness of the community on health problems generally.
Having identified these implications, it was obvious to the team that whatever intervention strategies would be introduced must include the following programmes: Programme of health education
This programme has its target audience as consisting of two major groups. The first major group consists of the consumers of maternal service. This group is important because it is the group that consumes the facilities directly. The second group consists of the providers of maternal care. These include both the TBAs and the orthodox health workers. Programme of health institutional development
This relates to the improvement of accessibility to health facilities, enhancing the quality of health care delivery services, re-examining health institutions fees, as well as cost-recovery fees. Programme of ancillary services
This programme relates to other services which are not necessarily being provided by the health care
et al.
providers. Examples of such is transportation facility. This type of programme will be heavily developed around community participation. Acknowledgement-The authors gratefully acknowledge the financial grant received from Carnegie Corporation of New York. We also thank the Faculty of Medicine of Columbia University, Division of Prevention of Maternal Mortality Unit for the technical assistance provided. Finally, our special acknowledgement and thanks are owed to the facilitators and note takers and to Mrs Olayemi for the secretarial assistance.
REFERENCES
I. Harrison K. A. and Rossiter C. E. Maternal mortality. Br. J. Obsrer. Gynoecol. Suppl. 5, 100-115, 1985. 2. Adetoro 0. 0. Maternal mortality-a twelve year survey at the University of Ilo& Teaching Hospital (U.I.T.H.). Ilorin. Niaeria. Inr. J. Gvnoecol.Obster. 25. 43-98, 1987. ’ 3. Eden er of. Subjectivity in problem identification. Infer/aces 11, 1, 1981. 4. Ackoff R. L. Resurrecting the future of operational research. J. OperationalRes. Sot. 30, 3, 1979. 5. Williams A. J. From planning board to welding hall: a case study in operational research/client involvement. J. OperationalRes. Sot. 30, (ll), 941-952, 1979. 6. Jones S. er al. Operational research in the community. J. OperotionolRes. Sot. 32, (S), 335-345, 1981. 7. Graham R. J. Arthropology and operational research: The place of observation in management process. J. OperationalRes. Sot. 35, (a), 527636, 1984. 8. Prolch-Lyon E. and Trost J. F. Conducting focus group sessions. Stud. Fem. Plan. 12, (12), 443-449, 1981.
0277-9536191 53.00+0.00
12.~~. 138S-1390.1991
Pergamon Press plc
Printed in Great Britain
THE APPLICATION OF OPERATIONAL RESEARCH (OR) PROCEDURES TO MATERNAL MORTALITY FROM PUERPERAL SEPSIS IN A RURAL COMMUNITY 0.0.
ADETORO’, K. S. ADEYEMI’,B. PARAKOYI’, A. ONI’, T. AKURE’ and 0. OGLJNBODE’ Faculties of ‘Health and *Social Sciences, University of Ilorin, PMB 1515, Ilorin, Nigeria
Abstract-An operation research (OR) procedure on maternal mortality from puerperal sepsis was carried out in Irepodun Local Government Area of Kwara State of Nigeria. The study involved ten focus groups discussion (FGD) in two districts of the Local Government Area. The findings were analysed from three broad perspectives, that is, consumers’ views, providers’ views and community decision takers’ views. In general, the analysis revealed that the community knowledge of puerperal sepsis is poor. In addition, limited access and prohibitive cost of orthodox health care services prevented the community from full utilization of the few available health care centres in the community. The study also revealed that there is urgent need to introduce three key interventions for an improved maternity care in the community. These interventions are community health education, health institutions development and community participation in provision of ancillary services such as transportation.
Key words--operations,
research, maternal, mortality, puerperal, sepsis, rural community
INTRODlJflION Although regional variations exist, infection is always one of the major causes of maternal death. Also, puerperal sepsis is common in the developing
countries, and from studies in Nigeria, it accounts for 8-10% of maternal mortality [I, 21. Unfortunately, most of the affected are unbooked patients from the remote areas of the community. It is on this basis that an operational research (OR) technique is considered appropriate to investigate factors associated with maternal mortality from puerperal sepsis in the rural communities of Kwara State, Nigeria. This presentation is the report of the application of the focus group discussion (FGD) technique on the assessment of the community perception of puerperal sepsis and maternal death. The report is divided into sections. The first section is the introduction. The second section is a brief discussion of the study area, while the third section highlights the focus group design, selection, composition and the operational research (OR) approach to the conduct of FGDs. The fourth part contains the discussion topics which concentrate on the community knowledge, attitude and practice as regards puerperal sepsis as a cause of maternal death. The fifth section is the discussion of the findings of focus group activities for the purpose of developing the strategies for intervention. The last section is a review of the implications of the overall observations of the focus group on puerperal sepsis as a cause of maternal death. CHOKE OF STUDY AREA
Irepodun Local Government was chosen as the study area because it is one of the two experimental
local governments chosen by the Federal Government for the Primary Health Care (PHC) strategy. The rationale for the choice of Irepodun is threefold: first, it is an experimental PHC local govemment, and therefore it was assumed that it would be easier to integrate our intervention strategies for puerperal sepsis into the PHC programmes of the area. Secondly, the two districts are being used by the Faculty of Health Sciences, University of Ilorin as one of the centres on Community Based Educational Services (COBES) programme for the training of its medical students. Such a long interaction ensures an opportunity for understanding and cooperation between the districts and the research team. Thirdly, Irepodun is the nearer of the two PHC Local Government Areas so that the resources available to the investigators will not be overstretched. This geographical advantage can be seen on Fig. 1, showing the location of the two PHC Local Government Areas. METHODOLOGY The research methodology for the study was a multistage procedure. The procedure involved the conduction of focus group discussion, followed by institutional survey and then the community survey. This procedure was adopted in order to make use of the output of the qualitative methodology (focus group discussion) as an input into the preparation of the questionnaires for the community survey. The findings in this paper were those emanating from the application of operational research methodology of investigating the problem of maternal mortality as perceived by our clients, i.e., the rural dwellers in Irepodun Local Government Area of Kwara State of Nigeria. This is the first part of the three-part report.
1385
1386
0. 0. ADETORO et al.
pre-test and study area belong to the same Yoruba ethnic group and because of the culture of respect for elders, we were informed by our pre-test experience that some stratification had to be done for FGD involving women of reproductive age. Thus, it was decided arising from the pre-test that mothers should be divided into two sets; those aged 14-29 years and those aged 30-49 years. During the FGD planning stage, it was decided that eight focus group discussions would be carried out. The plan was to conduct four FGDs in each of the two districts. The rationale for this number was based on the assumption that the population in these two districts is relatively homogeneous. So, it was thought that even if more FGDs were conducted, the additional information would not justify the marginal resources (human and financial) to be expended. The distribution of the eight focus groups were four from each of the two districts, i.e.: m
Location Designated for primary
of University
of llorin
local
government areas health care programme
Fig. 1. Map of Kwara State of Nigeria. The procedure of focus group discussion being a qualitative information gathering approach is a difficult one. It is difficult in the sense that major mistakes through questioning should be avoided. In fact, the methodology of probing through discussion was adopted. Thus, focus group discussion guides and question typology were generated by the research team. These guides and question types were thoroughly discussed with modification inputs from both the research team and the focus group facilitators and note takers. At this juncture, pre-test discussion guides and probing statements were compiled. After the training of the FGD facilitators and note takers, a pre-test was done in the semi-urban area of Okelele District in Ilorin Local Government Area. The pre-test was carried out so that facilitators and note takers could master the art of conducting FGD. Similarly, the pre-test was done in a local government area different from that of the actual study districts in order to avoid mastering of our experience with the focus group discussions by the real FGD participants of Oro and Esie districts in Irepodun Local Government Area. In this pre-test, we decided not to throw questions at the participants but rather to introduce the topic of maternal death in such a way that participants contributed freely to the issue. They were not constrained for as long as they continued to focus on maternal deaths and their causes. Furthermore, it was discovered in the course of the pre-test that the women had good knowledge about most of the major causes of maternal death. Because the pre-test area was different from the study area, we could not make any major assumption beyond keeping our minds open regarding the level of awareness of maternal problems in Oro and Esie districts. Moreover, the pre-test afforded the facilitators and the research team the lesson that the elderly women in the same focus group as younger mothers would tend to dominate the discussions. Because both the
-women aged 14-29 -women aged 30-49 -Traditional Birth Attendants (TBAs) aged 40 + -community leaders aged 30-65. Inasmuch as the stipulated eight FGDs took care of our pre-FGD perception, it was discovered during the execution that two very important population targets were missing, i.e.: (i) the women in purdah (ii) the nomadic Fulani mothers. In order to take care of them, two additional FGDs were held; one for women in purdah and one for the nomadic Fulani women, making a total of ten. The women in purdah were mainly found in Oro district whose population is about 50% moslem as against about 30% in Esie. The moslems in Esie district are more liberal hence, there are very few women in purdah. Coincidentally, the nomadic Fulanis are predominantly found in Esie district. Thus, five FGDs were held in each of the two districts. Figure 2 shows the clustering of the focus groups (FG) by district. The size of each FG was fixed at 8-12 participants. The rationale for this size was partly because it would ensure active participation and indepth discussion by each participant of the FGD. Moreover, this range of size is consistent with what is available in the literature [8]. OPERATIONAL RESEARCH (OR) IN FOCUS GROUP DISCUSSION ON MATERNAL IMORTALITY IN OR0 AND FSIE DISTRICTS
Operational Research (OR) as it was practised in the immediate post-war period up to the mid 70s was mainly quantitative. This approach is usually directed at isolating causes and effects in discrete forms in such a way that it will be possible to achieve a single-valued objective function [3]. Such objective could be minimising or maximising some criteria. From the mid 7Os, it became clear that such a single valued objective function did not meet the aspiration of
OR procedures to maternal mortality from puerperal sepsis
1387
consumers of OR studies. Thus, there was the need to involve the clients more in the problem identification and solving [4, 51. The FGD in two districts, i.e. Oro and Esie, was conducted using Ackoffs [4] current operational research approach to clients’ problems. This approach regards the organisation (Oro and Esie districts in this case) as embodying a culture that needs to be understood on its own terms rather than in terms of some preconceived model or rational framework [6,7]. The reasons for taking this approach are three-fold:
6) to allow us as OR team to follow where the problems lead us rather than lead the problems to where we want; (ii) to let the OR team, facilitators and note takers and the FGD participants discuss the nature of maternal ‘messes’ they face and the difficulties they have in facing them; (iii) we were also informed that the approach would make the team aware of the degree of congruence between our pre-conceived maternal problem and the community’s actual experience and perception (Ackoff R.L., op tit). This is further justified by the fact that the OR team is very careful not to enact some ‘expert problem identification’ role on the basis of our superior tertiary facility knowledge and evaluation about the world of the rural community of Oro and Esie districts. Therefore, what the team did was to train facilitators (occasionally, team members acted as facilitators when necessary) who delicately conducted the FGDs but without influencing or leading responses to particular maternal mortality problems. DISCUSSION TOPICS
In conducting FGDs, discussion guides had to be prepared in some fairly lucid but comprehensive manner. Thus, discussion topics were identified, although not restricted to the list, inasmuch as they relate to maternal mortality problems in the two districts. The topics which we identified were not structured in a forma1 way since it was possible to discuss any of the topics listed any time within the focus of group session. Thus, the order of topic in the list is not important. A lot depended on the skills and dexterity of the facilitators. However, such skills were assured through proper training of the facilitators. Below is a list of the discussion topics used during the focus group sessions: (i) Genera1 understanding and practices as regards child-bearing and its impact on the health of the mothers. (ii) The knowledge, attitudes and practices regarding maternal mortality and its effects on the community. (iii) Community perception of maternal mortality from puerperal sepsis and its impact on the community. (iv) Basic health values.
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(v) Pre-natal, post-natal and preventive care for maternity services. 64 Puerperal sepsis: is it a recognised problem? (vii) What are the kinds of steps taken when puerperal sepsis occur (especially within few weeks of delivery); for those that take steps? Do they visit health practitioners? What type of pratitioners? Do they give self treatment? (viii) Type of maternal service deliveries: Traditional herbalists or midwives Faith healers Patent medicine vendors Chemists and Pharmacists Professional health care providers (Doctors, Nurses and Midwives). (i) Private (ii) Government the type of (ix) Cost of health care-by practitioner. (x) Access to government or private or traditional health facilities and perception of general utilization to those services to prevent, or treat puerperal sepsis. (xi) Problems encountered with each health facilities and recommendations for action. FINDINGS
The focus group data consist of the statement recorded in the group sessions. These findings therefore, emerge from interpreting those statements from the FGD participants in the light of the subject under investigation. We present the findings from three broad perspectives: -Consumers’ -Providers’ tendants) -Community
views views (i.e. Traditional decision-takers’
Birth At-
views.
Consumers’ views
The consumers in this case are the women of reproductive age represented by six focus groups including the following: -women aged 14-29 (one FG in each of Oro and Esie districts); -women aged 30-45 (one FG in each of Oro and Esie districts); -women in purdah (in Oro district); -nomadic Fulani women (in Esie district). The views of these consumers are categorised into the following problem areas: (i) Puerperal sepsis. None of the participants had a formal knowledge about puerperal sepsis (PS), although majority have a good knowledge of symptoms of puerperal sepsis. They are not aware that it can cause maternal death. Some believe that mothers will develop puerperal sepsis if they failed to have hot baths and sizth baths after delivery. They recognise that maternal death from whatever cause is a tragedy
al.
and all agreed that there is a need for a comprehensively developed health care delivery system which includes prevention of puerperal sepsis. (ii) Limited access. Most of the participants stated that they were disadvantaged by concentrations of public health facilities mainly in urban and periurban areas. Such a distant-decay distribution of health facilities coupled with transportation problems, have seriously constrained the consumers’ accessibility to service delivery centres. In fact, some villages have to wait for twelve or more hours before the next available transport. (iii) Cosfs. The consumers were unanimous about the prohibitive cost of seeking health care services. The costs of maternity care in all government health institutions have become prohibitive because of the national economic depression. All the participants agreed that visiting the government health institutions for maternity services always entail four principal costs: (a) Travel expenses. (b) Opportunity costs due to time spent in waiting to register, waiting for consultation, waiting for laboratory tests, waiting to pay for prescriptions and waiting to collect the medicine. (4 Psychological costs of being hostile, snobbed, neglected or abused by health personnels. Another aspect of psychological cost is inavailability of drugs after waiting for a long time. W Actual expenses such as consultation fees, treatment fees, registration fees, etc. (iv) Lack of supplies and equipment. The participants reported that there is chronic shortage of drugs and items needed for maternity services in all government health institutions around. They recorded that they have to go out to buy prescribed drugs from enterpreneurial pharmacists and bring them back to be administered to patients. Also, reagents are frequently unavailable, making laboratory tests impossible to carry out. (v) Attitude of health personnel in the public sectors. Although health care services are regarded as humanitarian, the participants reported certain degree of the uncaring attitudes of health service personnels. They were seen as being harsh, rude and uncaring to maternity cases. These observations were the participants’ views for all categories of health workers. (vi) Unorthodox health workers. The participants recognise the traditional midwives as easily accessible, whose fees are moderate and can be paid in kind or cash. A lot of participants reported that most traditional midwives provide free maternity services and more importantly, the traditional midwives are very accommodating and understanding. To them, the TBAs provide a set of services that cover both mental, social and body welfare. (vii) Other maternal problems. The participating consumers easily recognised that there are many other maternal problems some of which could be very fatal. In fact, the participants constantly referred to haemorrhage as a collosal maternal problem which had caused many maternal deaths. They also talked extensively about anaemia as a rampant maternal problem. Other causes of maternal mortality which
OR procedures to maternal mortality from puerperal sepsis the participants revealed are prolonged obstructed Iabour, eclampsia, supernatural powers and fate. Providers’ view (traditional birth attendants-TBAs)
The only group of providers who participated in this focus group session were the traditional midwives. Many can not clearly define puerperal sepsis although they have a good working knowledge about the symptoms. After they had been educated on the features of puerperal sepsis, they agreed that it can cause maternal death, through secondary effect. However, they claimed to have treatment for it and believe that only mothers who do not receive this care suffer from the lethal effect of puerperal sepsis. They reported that their practices thrive owing to the fact that they charge low fees with instalment payment options, and often the services are rendered free. Moreover, their consultations are holistic, more embracing and empathising. They have their drugs in stock, and patients do not need to wait for too long before they are seen. They always reassure their patients and provide a kind and gentle manner of approach in terms of care. Although most claimed to have effective treatment for puerperal sepsis, a few agreed that they occasionally referred cases to nearby public health institutions for further management. Community decision takers’ view
The community decision takers are the community leaders. The community leaders are the decision takers regarding whatever problems the districts face. In this case, as far as maternal mortality problem is concerned, their importance can easily be identified when it comes to a decision to seek care whether from the TBAs or from the orthodox medicine. However, it was noted that such decisions needed not be jointly taken at a congress meeting, but that it could be taken single-handedly by any community leader closest to the particular pregnant woman. Usually, the experience gained from such decisions serve as a lesson for all the community leaders who then act quickly and/or direct maternity cases to the perceived more efficacious care provider. They often refer suspected cases of puerperal sepsis to the traditional midwives because of easy reach and embracing care. DISCUSSION
AND CONCLUSIONS
Puerperal sepsis as a cause of maternal death is regularly reported all over the world. Also, the loss of a mother in the community becomes glaring as many children are neglected and uncared for. Unfortunately, puerperal sepsis which is one of the major causes of maternal death is not well recognised by both the consumers of health services and the traditional health care providers. This exercise revealed that many mothers do not receive orthodox maternity services for many reasons. These can be broadly summarised as inaccessibility, prohibitive cost and ignorance. There is the observation that lack of facilities in government health institutions and high cost of health care delivery services are increasingly encouraging patients to go to traditional midwives. In addition, the traditional health care practitioners claim to be superior to many orthodox health care
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providers. Unfortunately, most of their claims remain unverified by orthodox medical science. Hence, traditional midwifery practices still carry an undetermined risks to the well-being of the mothers. From this study, it is essential to appreciate the level of knowledge and understanding of the community with regards to puerperal sepsis. The questions raised for discussion revealed in general, that puerperal sepsis is not well recognised and worse still that its lethal effect is poorly understood. There is a general consensus that there is need for care in pregnancy, labour and puerperium to prevent complications and most women obtain one form of care or the other. However, the majority provide self care till there is a problem, for which they seek traditional midwifery care. It was observed that both the consumers and the providers were generally ignorant of what puerperal sepsis is all about, and cannot precisely record its causes. The participants agreed that it can cause maternal death if mothers do not get care, and noted that its preventive measure is through regular care during pregnancy either from traditional midwives or from government health institutions. The TBAs insisted that their care is more efficacious than that of orthodox medicine although the target consumers believe that there are some aspects of maternity services that cannot be handled by the TBAs while they are better care providers in other areas. The community decision-takers were of the view that TBAs have been performing a wonderful job given the economic, social and health constraints of the districts. They were also of the opinion that women who suffer from puerperal sepsis and other maternal problems were usually those who did not seek maternal care during pregnancy. Such negligence to them would not only affect the women but also the unborn children. The community leaders were quick in recognising the superior cause-effect knowledge of the orthodox medicine but they were disturbed about the apparent lack of concern by the government on the health of mothers in the rural areas. Though they said women in their communities will use orthodox health facilities if brought nearer to them, but that under present distant-decay distribution, the communities have no option other than rely on the experience and practice of the TBAs. In conclusion therefore, the focus group discussions exercise have certain implications for health policy makers, health care providers and health care donor agencies: (i) The FGDs reveal the need to develop strategies which will involve the community in order to minimise puerperal sepsis. (ii) During the focus group sessions, the TBAs indicated their interest in being’ trained to modemise and improve their service delivery. This interest has great implications for the Primary Health Care (PHC) strategy of the Federal Government. (iii) It came out clearly during the FG sessions that the community was willing to utilize facilities at the health centres if available at affordable prices.
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(iv) The community also indicated their willing(4
ness to participate in the health package that will minimise maternal mortality. It was also clear during the sessions that the health education effects of the PHC facilities in the districts might have increased the level of awareness of the community on health problems generally.
Having identified these implications, it was obvious to the team that whatever intervention strategies would be introduced must include the following programmes: Programme of health education
This programme has its target audience as consisting of two major groups. The first major group consists of the consumers of maternal service. This group is important because it is the group that consumes the facilities directly. The second group consists of the providers of maternal care. These include both the TBAs and the orthodox health workers. Programme of health institutional development
This relates to the improvement of accessibility to health facilities, enhancing the quality of health care delivery services, re-examining health institutions fees, as well as cost-recovery fees. Programme of ancillary services
This programme relates to other services which are not necessarily being provided by the health care
et al.
providers. Examples of such is transportation facility. This type of programme will be heavily developed around community participation. Acknowledgement-The authors gratefully acknowledge the financial grant received from Carnegie Corporation of New York. We also thank the Faculty of Medicine of Columbia University, Division of Prevention of Maternal Mortality Unit for the technical assistance provided. Finally, our special acknowledgement and thanks are owed to the facilitators and note takers and to Mrs Olayemi for the secretarial assistance.
REFERENCES
I. Harrison K. A. and Rossiter C. E. Maternal mortality. Br. J. Obsrer. Gynoecol. Suppl. 5, 100-115, 1985. 2. Adetoro 0. 0. Maternal mortality-a twelve year survey at the University of Ilo& Teaching Hospital (U.I.T.H.). Ilorin. Niaeria. Inr. J. Gvnoecol.Obster. 25. 43-98, 1987. ’ 3. Eden er of. Subjectivity in problem identification. Infer/aces 11, 1, 1981. 4. Ackoff R. L. Resurrecting the future of operational research. J. OperationalRes. Sot. 30, 3, 1979. 5. Williams A. J. From planning board to welding hall: a case study in operational research/client involvement. J. OperationalRes. Sot. 30, (ll), 941-952, 1979. 6. Jones S. er al. Operational research in the community. J. OperotionolRes. Sot. 32, (S), 335-345, 1981. 7. Graham R. J. Arthropology and operational research: The place of observation in management process. J. OperationalRes. Sot. 35, (a), 527636, 1984. 8. Prolch-Lyon E. and Trost J. F. Conducting focus group sessions. Stud. Fem. Plan. 12, (12), 443-449, 1981.
