Each year, nearly 600,000 women in the developing world die from pregnancy-related complications--and nearly 40% are from Sub-Saharan Africa. An additional 15 million women incur pregnancy-related injuries and illnesses, some of which will be lifelong.

Although lack of access to information and services is the central cause of this tragedy, in some cases the services that exist are themselves a part of the problem. Services may be of poor quality or unfriendly; clients may be subjected to unsafe conditions or long waiting times.

To help address concerns about the quality of services in programs we support, AVSC has recently adapted COPE--our widely used quality-improvement process--for maternity care use.

Testing the Guidelines

In the late 1980s, AVSC first developed COPE, a self-assessment technique used to identify and solve problems, as a means of improving family planning services. AVSC is now testing its new COPE guidelines for maternity services.

This past February, COPE facilitators from AVSC's Nairobi office and the Family Planning Private Sector (FPPS) tested the experimental module for maternity services at the Alice Nursing Home in Kariobangi, Kenya, a very poor section of Nairobi.

The small clinic, which has a 30-bed maternity ward, offers comprehensive health care services. The clinic's staff have used COPE family planning exercises in the past.

Problems and Solutions

First, the staff discussed, defined, and committed themselves to "quality services." The discussion was sparked by the question: "What kind of maternity services would you or your wife or sister like to receive?" Then they discussed their conceptions of clients' rights and providers' needs.

Next, the staff used the new self-assessment guidelines to identify impediments to delivering quality maternity services. Some of the issues addressed in the maternity module are: linkages to family planning information and services, such as whether such information is given during prenatal visits; the site's ability to handle obstetric emergencies; and whether the site has the equipment needed for maternal and neonatal emergencies.

Some of the problem areas were similar to those identified in COPE family planning exercises--needs for supplies, orientations, and improved interpersonal skills. But the content was specific to maternity services.

For example, the staff outlined needs for breastfeeding counseling training, a neonatal suction machine, and updates on how to improve their infection prevention measures. Other problems included the need for postpartum IUD services and informational pamphlets on pregnancy and family planning.

Success and Staff Satisfaction

The trial COPE maternity module worked very well at the clinic. As in previous COPE exercises, the staff pulled together, formed teams, and solved several of their problems on the spot.

The staff enjoyed the exercise, especially the teamwork. One nurse-aide, who was enthusiastic about the results, said, "This will make our work so much easier."

The testing of the COPE maternity module confirms that the technique is easily transferable to general reproductive health services. Plans to test the maternity module in larger hospitals and clinics are under way.