Institutional Support for a Program of Activities with the West Bank/Gaza

This 119-page report describes a 28-month-long pilot project that was developed to improve the health status of Palestinian women and their children in the West Bank and Gaza, where cultural norms favour early marriage and a preference for sons, in addition to large family size. Married women of reproductive age in Gaza have an average of 6.8 children, while those in the West Bank have 5.5; contraceptive use is very low among younger, low-parity women; and family planning is generally only acceptable after parity 4 for most families. Developed by the United States Agency for International Development (USAID) in collaboration with the FRONTIERS/Population Council, the Palestinian Ministry of Health and seven non-governmental organisations (NGOs), the goal of this Pilot Health Project (PHP) was to upgrade antenatal and postpartum services in 27 primary health care clinics in 3 areas of the West Bank and Gaza. In addition, PHP sought to collect data on the population and special topics which would assist in developing better health strategies and improve the evaluation of the PHP.

The building of research capacity - and the carrying out of research itself - were key strategies used: FRONTIERS provided institutional support to build the research capacity of the Health, Development, Information and Policy Institute (HDIPI), a nonprofit research organisation. This document contains detailed reports/findings of 3 of these activities:

1. Survey of clients and providers in the primary health care areas to measure key indicators for planning and evaluating the PHP, entitled "Pilot Health Project Baseline Survey Report, January 2001"
   
   
   • Key Findings: - In general, Palestinian women have a relatively high fertility level. On average, women made about 5 antenatal visits to the clinics during their pregnancies, but only 3.3% of women interviewed (n=792) reported returning to the clinic for postpartum care. 41% of those 3.3% accepted a family planning method during their visit. Very few women reported receiving a home visit by a health provider after their delivery. Despite almost universal knowledge about family planning (99%), only 58% of women interviewed ever used a family planning method. Information/counseling received by women regarding antenatal and postpartum care, including family planning, was partial or weak. Nearly all women reported that their husbands encouraged them to seek antenatal care services; however, only about one-fourth of their husbands accompanied them to the clinics. The results suggest that all categories of providers had inadequate technical knowledge and skills.
   • Recommended Strategies: Adoption of recently developed national standard protocols and guidelines for the above-mentioned services, competency-based training for all categories of health providers (with an emphasis on good communication and counseling skills), stronger public health education, and better outreach services and referral mechanisms.
2. A study entitled "Involving Men in their Wives' Postpartum Care in Palestine, December 2002"
   
   
   • Key Findings: - Men's participation tends to be limited to the period of pregnancy; men tend not to help with housework during their wives’ convalescence but make sure that other women in the family provide such support. The husband and wife make decisions regarding birth spacing jointly, but the use of family planning methods remains the responsibility of the woman. Men seldom accompany their wives to public clinics but may accompany them to a private clinic, especially when the doctor is male. The findings showed that social norms in Palestinian society do not encourage men's participation in what is considered to be women's health issues. The study identified several gaps in men's knowledge and/or behaviour. For example, many believe that sexually transmitted infections (STIs) only exist in Western societies and that they are mostly diseases of women. Further, men need to learn more about the emotional changes that women experience during pregnancy and after delivery, and to provide more emotional support. In addition, women in the study expressed a desire that their husbands better appreciate the advantages of birth spacing.
   • Recommended Strategies: Changes at the clinic level have been suggested by participants to enhance male involvement in the health of their spouses: (a) having an evening shift at the clinics so that husbands could join their wives; (b) hiring male health providers to make it easier for men to ask sensitive questions; and (c) allowing men to be present with their wives and if possible, arranging separate waiting areas for men. To increase men's knowledge about reproductive health matters, suggestions include: (a) distributing health brochures for couples to read together; (b) holding gender-specific seminars at the clinics or other public places; (c) incorporating reproductive health information into the school curricula of students at the intermediate and the secondary levels; (d) broadcasting reproductive health information on television so couples can watch together (preferred formats were soap operas, plays or panel discussions; participants, however, suggested that such programmes be aired late at night). "However, caution should be exercised in implementing policies to increase male involvement in matters related to the health of their spouses so as not to infringe on women's autonomy or privacy rights. Women should always have complete and voluntary choice as to when and how to involve their husbands."
3. A study on improving outreach between hospitals and postpartum women entitled, "Outreach Linkages with Public Hospitals to Promote Postpartum Care, October 2002"
   
   
   • Key Findings: - Almost all women in both public hospitals (Al-Shifaa and Jenin) and both groups (intervention and comparison) complained about the poor quality of care provided by the two hospitals. Also, they reported that they hadn't received any health education or counseling while at the hospitals. All women in the intervention group received a home visit from a community health worker (CHW) after delivery. Most of these visits (26 out of 30) took place 2 to 4 days after delivery. All women in the intervention group appreciated the home visit and recommended that it be systematically provided. Also, most of them appreciated the information, the counseling, and the information, education, and communication (IEC) materials received. Additionally, most of participants in the intervention group were able to recall the health information they had been given.
   • Recommended Strategies: - Give more attention to improving the infrastructure of maternity wards in public hospitals and employing more qualified nurses; ensure proper training of health providers on quality reproductive health care, especially counseling and client-provider interaction; establish a referral system to ensure proper and efficient communication and coordination between the hospitals and the local clinics; expand the intervention programme and widen its scope to include other key decision makers, like husbands and mother-in-laws, in diffusing relevant aspects of counseling; pay more than one home visit to recently delivered women during the first 60 days postpartum; and make available IEC programmes which educate women about their reproductive health needs and which emphasise the fact that breastfeeding alone may not be a reliable method of contraception.

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