Preceding Birth Technique

Abstract

• Name: Preceding Birth Technique (PBT)
• Purpose: Preceding Birth Technique (PBT) is a simple and inexpensive method for obtaining regular information on childhood mortality and monitoring changes in mortality over time.
• Type of Design: Longitudinal cohort study
• Sample Size: N/A
• Where Used: The tool has been implemented by BASICS in Senegal and Mali, Papua New Guinea, Benin (now on-going by CDC, which implemented it in a number of African countries during the 1980s), Tanzania (national health information system) and a field trial of HIV interventions in Mwanza, Tanzania. It has also been used in Latin America, and the UNECLAC and Latin American Demographic Centre (CELADE) have produced a computer program and users manual "PREVIO: v. 1.0 Preceding Birth Technique", LC/DEM/G.123, Series A., Nr. 274, August 1992.

To survey tool

Basic Information

Name: Preceding Birth Technique (PBT)

Source: BASICS

Basic Description: All child health programs aim to prevent the deaths of young children. Despite this, accurate and reliable measures of childhood deaths in developing countries are rarely available. The preceding birth technique (PBT) is a simple and inexpensive method for obtaining regular information on childhood mortality and monitoring changes in mortality over time.

The PBT asks mothers about the survival of their preceding born child at the time of a visit to a health facility for a subsequent delivery, or following a subsequent delivery. Mothers are asked three key questions: 1) Have you ever been pregnant before this last pregnancy or delivery?; 2) If yes, what was the outcome of this pregnancy? (live birth, still birth, miscarriage, or abortion); 3) If a live birth, is the child alive today?

An early childhood mortality index is then calculated by counting all the preceding born live births which have died before the enquiry (the numerator), and dividing by the total number of live births, dead and alive (the denominator). The early childhood mortality index has been demonstrated to be an accurate and reliable measure of under-two mortality in most developing country populations. The major limitation of the method is that it is facility-based and may not be a measure of true overall mortality in the surrounding population due to selection bias. For this reason, it is used to follow mortality trends over time, rather than estimate absolute levels of mortality.

Languages Available: English and French.

Type of Methods: Quantitative

Design: Longitudinal cohort survey of mothers to investigate trends in early child mortality.

Frequency of Administration: Three key questions are collected routinely from mothers at maternity clinics, antenatal care visits and vaccination of their recently born child.

Key Users of Information

This tool should help health planners, policy makers and health providers to monitor trends in early childhood mortality in their country or catchment area. Some uses of the PBT data are:

1. to identify problem areas for special focus.
2. to monitor the impact of primary health care programs in the catchment areas of health facilities
3. to improve understanding of the distribution of risk or differential risks among the population in the catchment area.
4. to conduct family risk assessment to improve/set targeting strategies to reach high risk groups.
5. individual patient management and follow-up of high risk mothers.
6. case investigation of adverse outcomes.
7. some cause of death inquiries may be possible, especially when data are obtained by health clinic staff.
8. evaluation of services by clinic staff.
9. to increase local awareness and involve district health committees and organizations in setting priorities for community health services.

Objectives and Scope of Tool

One obstacle to more effective program implementation is a lack of relevant and up-to-date information on past achievements. When vital registration data are incomplete, inaccurate or entirely lacking, program managers are forced to resort to a variety of different strategies including guess work. Very often, information on child survival is derived from the analysis of census data or from information contained in major household surveys such as the Demographic and Health Surveys (DHS). Program managers may have to conduct special surveys in between DHS, to monitor progress toward mortality reduction.

PBT is a tool for assessing child survival trends in developing countries using a continuous monitoring approach. It allows managers and health providers to generate running estimates of childhood mortality trends for districts and sub-populations. The results are easy to interpret even to those with only modest training in statistics and demography. The data collection process itself can fit into regular patient management since the indicator in question (the survival status of the preceding born child) has meaning both to the health professionals examining the individual mother, and to planners interested in the level and trend in early childhood mortality in the wider community.

Key Monitoring Needs and Evaluation Questions Tool Seeks to Address

The tool is meant to provide information on trends of child mortality, especially in programs where reliable data on childhood mortality is not available.

Key Indicators

PBT includes three simple questions for women included in the survey:

• Have you ever been pregnant before this last pregnancy or delivery?
• If yes, what was the outcome of this pregnancy? (live birth, still birth, miscarriage, or abortion)
• If a live birth, is the child alive today?

Based on these data, an "Index of Early Childhood Mortality" or IECM can be calculated as follows:

IECM = Deaths to previous births / all previous births

Mothers are surveyed at the following contact points:

• delivery at maternity clinics
• antenatal visits
• first vaccination contact (BCG) for her recently born child

Research Design

PBT can be administered in the following settings:

• Maternity Clinic Records: In many places data on the survival of the preceding child is already being collected in delivery room books or on cards held by mothers. The only additional work required for using the PBT involves systematizing the format of the questions put to mothers; making plans for collection of the raw data; and training health workers to use data effectively.
• Where the majority of pregnant women visit ante-natal clinics, a simple tally can be done from mothers' history of the numbers of preceding children who have died.
• Collect data when mothers bring their most recently born child for immunization. The health intervention which reaches the largest portion of mothers in developing countries is childhood immunization. The rate for immunizing children by BCG (the first immunization) is universally high. The question is how best to add additional questions related to child survival to an information system established principally to deliver vaccines to young children.

The routine collection of PBT data for management begins at the first level of patient contact with the health service. This information can be passed to higher levels to meet reporting requirements. The information can also be used at the point of collection to monitor, evaluate and reform services delivered at the district, regional or national levels.

Sample size: This tool is meant to be part of the routine health information system. Data should be collected from every woman coming for delivery, antenatal care or BCG vaccination (for her child).

Training: Training guidelines have not been completed. They exist in a draft form with the BASICS Project.

Lessons from experience:
BASICS tested the PBT in two African countries: Senegal and Mali. In both countries, the method was tested in six month prospective studies between April and September 1996. Health workers were trained to use the PBT at three possible contacts with the health facility: 1) at the time of antenatal visits; 2) at the time of delivery; 3) at the time of the first immunization visit (for BCG).

In Senegal, the method was implemented at six health facilities in four districts (Fatick, Dioffior, Kaolack and Kébémer). The early childhood mortality index was estimated to be 11 per 1000 live births for the population attending these health facilities. No significant differences were noted between the rates calculated using each of the three health facility contacts.

In Mali, the PBT was implemented in 58 health facilities in the districts of Kadiolo, Koulikouro and Koutiala. The early childhood mortality index was estimated to be between 126 and 151 per 1000 live births for the population attending these facilities. Again, no significant differences were noted in the rates calculated using each of the three facility contacts.

The major findings of these short implementation trials were:

• Health personnel in all three clinic settings (antenatal, delivery and immunization) were able to collect PBT data from women at the time of clinic visits.
• Existing data registers can be modified to allow PBT data to be recorded.
• The early childhood mortality indices did not differ significantly by type of clinic visit.
• The quality of the data collected suffered because of inadequate health worker training and supervision. This was particularly true of the immunization clinic workers who were not as experienced in collecting data. Because BCG coverage is often relatively high in these populations, the immunization contact may be the best opportunity for collecting PBT data. For this reason, methods for improving the practices of immunization workers may deserve further attention.
• Additional work is required in the area of compiling and analyzing mortality data and using these data for making local program decisions. Mortality data could be used locally to identify high risk groups within a population, to monitor changes in mortality over time, and to target high risk groups or individuals for better outreach, or other services.

These early trials suggest that the PBT can be used in developing country settings by local health workers. Widespread testing of the approach is recommended, possibly through integrating it with routine training and supervision for other primary health care activities. Further trials should investigate approaches for using PBT data for decision making.

Limitations: The tool is in the pilot testing stage. The feasibility of adding questions regarding preceding birth at child vaccination sites requires further testing. In addition, the tool is facility-based and therefore misses the mortality experience of those most at risk It also assumes a high total fertility rate. The type of data produced by the tool may not be of great value for routine program planning, yet it is useful for monitoring general trends over time.

References

Halstead, S.B. and Walsh (1990), Good health at low cost. Conference Report, Rockefeller Foundation, New York

Cham, K, (1987), Social Organization and political factionalism: PHC in the Gambia. Health Policy and Planning 2 (3): 214-26.

Rifkin, S. (1986), Lessons from community participation in health programs. Health Policy and Planning 1 (3): 240-9.

BASICS Trip reports:

Hill, A., Sur la mise en place de technique de l'accouchement Precedent, Senegal. 1996.

Hill, A., Rapport sur la mise en place de la technique do l'accouchement Precedent, Bamako, 1997.

Contact Person
Beth Plowman
BASICS Project
1600 Wilson Blvd.
Arlington, VA 22209
703-312-6800