Quality of service analysis towards development of a model for primary-level maternity care in Ibadan, Nigeria
The unacceptable high rate of maternal and neonatal deaths in Nigeria has been persistently unabated. Therefore, the present quality of maternal care evident by the magnitude of severe maternal/neonatal morbidity and mortality in this region makes designing of a model that will serve as a framework for provision of quality maternity care to women and their new-born a worthwhile study. The global report of deaths related to pregnancy and childbirth documented 600,000 maternal deaths annually. Developing countries, including Nigeria, have the highest burden of maternal and neonatal deaths resulting from complications related to pregnancy and childbirth. There has been no improvement in Nigeria as far as maternal and neonatal deaths are concerned. In Nigeria, the maternal mortality ratio in 2008 was recorded as 545/100,000 live births, and 576/100,000 live births in 2013. Women and children from low socioeconomic background are the vulnerable groups. The peculiarity of their vulnerability predisposes them to finding quicker and cheaper avenues to seek health care. The Primary Health Care (PHC) maternity facilities are to serve this large population of women and their babies at grassroots level. Few studies have been done to measure quality of antenatal and delivery care separately at higher level of care with resultant subjective findings and conclusions. Each of these aspects of maternity is a part of the whole and not the whole. Currently, there is gross dearth of literature regarding quality of maternity services at the disposal of the vulnerable women, who are likely to utilize the PHC facilities. The measurement of the quality of the existing maternity services at primary level is imperative for designing a more effective model capable of improving quality of services at this level. This study sought to develop a quality service improvement model for primary level-based maternity following rigorous analysis of the quality of its structure, the process and the outcome as proposed by Donabedian. The specific objectives of the study were to describe the status of infrastructures, equipment, instruments, medications; investigate the degree to which the services rendered are timely, appropriate, satisfactory and consistent with current professional knowledge; investigate the degree to which services rendered in the facilities are satisfactory to the women and uphold their basic reproductive rights; measure clients’ return rates for maternity-related services in the facilities; and to develop a validated model to guide provision of quality maternity care in PHC facilities. Using a theory-generating approach, the study was conducted in two distinct phases. The first phase focused on analysis of the existing maternity services at PHC level, while the second phase concentrate on model development. The first phase, which is an embedded mixed-methods approach, utilized validated clients’ questionnaire, health workers’ questionnaire, observation checklist, focused group discussions, and in-depth interviews for data collection. A multistage sampling method was used for sample size selection. Five local government areas (LGAs) in Ibadan were selected purposively. Similarly, all the facilities that offer maternity care in each LGA were purposively selected. Postnatal women, health workers in each facility, medical officers of health (MOHs) and heads of facilities were the participants in the study. A total of 755 postnatal women who participated in the surveys were recruited from the sample frames (attendance registers) using systematic random sampling. A validated structured questionnaire was utilized to elicit information on their experiences with their chosen places of antenatal and childbirth care from pregnancy to puerperium. Similarly, the 130 health workers who participated in the surveys were recruited from the sample frames (duty rosters) using systematic random sampling. A validated structured questionnaire was utilized to elicit information on their competences, attitudes and the midwifery practice in their respective facilities. In addition to the quantitative surveys, focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted for some postnatal women and four MOHs/heads of group of facilities. The participants for the FGDs and the IDIs were conveniently and purposively selected, respectively. FGD guide and IDI guide were used to guide the interviewers. The study was approved by the Faculty Board Research and Ethics Committees, the Senate Research Committee of University of the Western Cape and Oyo State Research Ethical Review Committee in Nigeria. Informed consent was obtained from each study participant. Autonomy, anonymity, and confidentiality of information provided by the participants were ensured. Nobody was coerced to participate in the study. The data collected with the aid of observation checklist and questionnaire from the selected PHC, health workers and client (postnatal women) were analyzed using descriptive statistics (frequency/percentage distributions); while association between variables of interest and difference in mean values were done using chi-square and t-test statistics, respectively. The second phase of the study focused on model development, and was done in line with a theory- generating research process in the literature supported by McKenna & Slevin, (2008) and Chinn& Kramer (2014). The developed model was tested for its appropriateness, adequacy, accuracy and whether it represents reality, for it to be assumed effective in achieving the goal if applied in midwifery practice at primary level.Client-participants were between 15 and 44 years; their mean age ± standard deviation was 28 ±5.3. The health workers were between 20 and 58 years; mean age ± standard deviation being 41 ±10. Out of the 730 client-participants, 92.1 % were married. None of the women had access to preconception counselling in any health facility. A total of 92.6 % of the women received prenatal care under the existing traditional model of antenatal care (ANC), out of which 22.6 %registered for ANC in two different facilities for various reasons. Although there was gross shortage of manpower in all the facilities, the percentage of nurses/midwives was fewer than that of the community health extension workers (CHEWs) and health assistants (HAs), while only one medical doctor was employed to cover all the different types of facilities in each local government area . There was a questionable staff level of competence reported in the study. Evidence of training in life-saving skill (LSS), post-abortion care (PAC) and safe motherhood was rare among the health worker participants. Among health workers who had witnessed vaginal laceration and those who claimed to have performed episiotomy on women, 30.2% and 32.6 % would depend on other health workers for repair of the vaginal traumas, respectively. Partograph was not in use for management of progress of labour by any health worker in any of the facilities. Both quantitative and qualitative data analysis showed evidences of abuse of women’s rights to timely, quality and respectful maternity care and risky practices by the health workers. The conditions of the buildings used for PHC centres and the beds were not satisfactory. There was gross inadequacy of essential and basic items needed to provide standard and quality care across all the facilities, while significant proportion of the available equipment/instruments were obsolete, dirty, rusty and faulty. The infection prevention and control practices were sub- standard. Inadequate funding by respective local government authorities was implicated for the poor conditions of infrastructures, equipment/instruments, staff recruitments and consequent shortage of manpower. Low level of patients’ satisfaction, evidenced by verbal expression, percentage difference between antenatal registration and childbirth record, immunization clinic visits and childbirth record in each facility, was reported. Therefore, fixing the deplorable and/or non-commodious building infrastructures to meet the required standard, provision of facilities and items needed for quality care and infection prevention, recruitment of skilled qualified health professionals, establishing a new Primary Health Board in the state to provide efficient funding and effective monitoring systems were recommended, based on the findings of the study. Lastly, the implementation of the newly developed model is strongly recommended in order to improve women’s and new-born’s health.