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My research: A PhD explains

Sabine Margarete Damerow

The project assessed real-life effects of a health system strengthening initiative for maternal and child health in rural Guinea-Bissau

What is the title of your thesis?

Health systems strengthening for maternal and child health: Real-life effects in rural Guinea-Bissau.

From which institute and/or research unit did you make your PhD thesis?

Bandim Health Project, Research Unit OPEN.

Who was your main supervisor?

Professor Ane Bærent Fisker. 


What question did you wish to answer with your thesis?

The project assessed real-life effects of a health system strengthening initiative aiming at reducing maternal and child mortality in Guinea-Bissau. 


What did you find out?

First, we found impressive increases in the coverage of essential maternal and child health services during the health system strengthening initiative – which aimed at improving service accessibility and quality of care. However, coverage remained suboptimal, and homebirths remained common in rural Guinea-Bissau: Despite the initiative’s implementation, around half of all births continued to occur at home without skilled birth attendance.

This stands in contrast to our findings revealing that most health workers and women regarded health facilities as the ideal place of birth. In addition, we found that the coverage developments were not associated with the initiative’s implementation. Instead, the coverage increases may have been linked to general socioeconomic trends such as increases in maternal education and household wealth over time.

Meanwhile, perinatal mortality (stillbirths and child deaths during the first week of life) remained unchanged at an alarming level of approximately 80 deaths per 1,000 births despite the initiative’s implementation. We found several likely explanations for these findings: First, geographical and financial access barriers persisted during the initiative’s implementation and made maternal and child health services hard to attain, especially for poor women in rural areas.

Second, the same access barriers led to crucial delays to emergency care, which likely contributed to persisting high perinatal mortality. Third, quality of care was severely compromised due to material and human-resource constraints at health facilities, which likely further contributed to persisting high perinatal mortality.


How did you do it (your methods)?

We used several complementary methods nested in the Bandim Health Project’s health and demographic surveillance system (HDSS), which continuously monitors pregnancies, service uptake, and survival in a nationally representative cohort of >50,000 women and children in rural Guinea-Bissau. We implemented three studies: First, an impact evaluation of the health system strengthening initiative’s effects on service coverage and perinatal mortality, in which we analysed data from 23,828 HDSS-registered births. 
Second, a mixed-methods study exploring women’s perspectives on facilitators and persisting barriers to timely and quality peripartum care during the initiative’s implementation. For this study, we conducted 258 structured interviews and 12 in-depth interviews with women who had recently given birth in 19 randomly selected HDSS villages.
Thirdly, a qualitative study exploring timeliness and quality of peripartum care at health facilities. For this study, we conducted 8 in-depth interviews and 192 hours participant observations at the target health facilities of the previously in-depth-interviewed women. We analysed quantitative data using generalised estimating equations and descriptive statistics; qualitative data using thematic network analysis.


How can your research be used (in the clinic/society etc.)?

First, our findings strengthen the call for real-life evaluations of health systems strengthening interventions: Despite health systems strengthening gaining increasing popularity as an approach to reduce maternal and child mortality in high-burden settings, such initiatives are frequently implemented on the grounds of “assumed effectiveness” – without much prioritisation of rigorous monitoring and evaluation.

However, health systems strengthening initiatives are often complex interventions which are implemented into typically equally complex contexts. This makes their effects hard to predict. In the case of the initiative we evaluated, effectiveness assumptions did not turn into real-life effects.

Instead, the findings from our assessments fall considerably short from the expectations of implementers and funders. Therefore, we show that rigorous monitoring and evaluation of health systems strengthening initiatives is “a must” to ensure the early detection of adverse developments, a purposive deployment of scarce global health resources, and learning from successes and failures.

Moreover, our findings reveal specific action points that need to be addressed to promote the accessibility of quality and potentially life-saving health services in rural Guinea-Bissau: the reduction of persisting geographical and financial barriers to care.

Do you want to know more?

Read more about the research from the Research Unit OPEN.

Read more

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When will / did you defend your thesis?

The 13th of October 2023.

Kommende ph.d.-forsvar

Redaktionen afsluttet: 26.09.2023