Improving the quality of obstetric, neonatal and child care in facilities has been identified as a neglected and essential approach to reducing maternal deaths and enabling developing countries to achieve Millennium Developments Goals 4 and 5 which are reduction in maternal and infant mortality, and also, Sustainable Development Goal 3 (SDG 3) which is good health and well- being especially for women.
This study employed a descriptive design to evaluate the quality of Maternal and Child Health care (MCH) services in selected health facilities in Ile-Ife utilizing Donabedian model for quality care. Sample size was determined using Leslie Kish formula. Data were collected in selected 45 Primary Health Care centres (PHCs) and 7 Secondary health facilities (SHFs) using an adapted checklist. Data were also collected from 330 selected nursing mothers using an adapted questionnaire on client’s satisfaction (outcome) with the maternal and child healthcare services. Four research questions were answered and three hypotheses were tested at 0.05 level of significance.
Findings of the study reveal that majority of the Heads of the Maternal and Child Health Care units surveyed are females (90.4%), all the SHFs are charged by professional Nurses and Midwives while only 13 out 45 PHCs are charged by professional Nurses/Midwives. Three hundred and thirty (330) nursing mothers participated in the study, 180 (54.5%) mothers were 19-28 years, and only 5 (1.5%) respondents were below 19 years. 232 (70.3%) of the mothers were from PHCs and 98 (29.7%) were from secondary health facilities. In terms of structure, 34 (75.6%) of PHCs and 5 (71.4%) of SHF have personnel with inadequate training in MCH services mean 2.67±2.50 and 3.29±2.36 respectively. Thirty six (80%) of PHCs and 3 (42.9%) of SHFs have physical facilities that were not in good working condition mean 57.29±11.48 and 44.4±12.23 respectively. In terms of process, finding shows that majority of MCH services rendered in both the PHCs and SHFs are sometimes (100%) done, mean 70.22±8.64 and 73.29±9.98 respectively. The clients’ satisfaction survey reveal that majority of clients were satisfied with the MCH services in both Primary and Secondary health facilities in Ile-Ife, mean were 115.1±15.86 and 110.37±14.71 respectively. Findings of the study also show that most staff rendering MCH services in PHCs are Community Health Extension Workers and Health attendants There is a significant difference between the structure of MCH services p = 0.04, no significant difference between the MCH services p = 0.46 and client satisfaction p = 0.10 in PHCs and SHFs, p = 0.10.
The quality of Maternal and Child health services in both Primary and Secondary health facilities in Ile –Ife was below the standard as reflected in the findings. Therefore, government efforts at all levels should be directed towards improving the structure of healthcare facilities, training and retraining of staff, supervision, and provision of supplies and transportation for prompt referrals in health facilities through a robust National Health Planning and collaboration between stake holders.
Keywords: Evaluation, Quality, Maternal and Child Health services, Structure, Process
Word Count: 498
TABLE OF CONTENTS
Title page i
Table of Contents vi
List of Tables viii
List of Figures ix
CHAPTER ONE: INTRODUCTION
- Background to the Study 1
- Statement of the Problem 3
- Objective of the Study 4
- Research Questions 5
- Hypotheses 5
- Scope of the Study 5
- Significance of the Study 5
- Operational Definition of Terms 6
CHAPTER TWO: REVIEW OF LITERATURE
2.0. Introduction 8
2.1. Maternal and Child Health Service 8
2.2. Incidence of Maternal and Child Mortality 10
2.3. Maternal Mortality in Nigeria 11
2.4. Availability of Skilled Personnel for MCH Services in Nigeria 12 2.5. Health Facilities Assessment 18
2.6. Quality of Maternal and Child Health Services 19
2.7. Client Satisfaction with Maternal and Child Health Services 23
2.8. Factor that Determine Client Satisfaction 27
2.9. Conceptual Model 29
CHAPTER THREE: METHODOLOGY
3.0 Introduction 33
3.1 Research Design 33
3.2 Population 33
3.3 Sample size and sampling Technique 33 3.4 Instrument for Data Collection 36
3.5ValidityandreliabilityoftheInstruments 36 3.6 Data Collection Procedure 37
3.7 Method of Data Analysis 37
3.8 Ethical Consideration
CHAPTER FOUR: DATA ANALYSIS, RESULTS AND DISCUSSION
4.0 Introduction 39
4.1 Result Presentation 39
4.2. Data Analysis 39
4.3. Discussion of Findings 56
CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Summary 62
5.2 Conclusion 63
5.4 Limitation of the Study 64
5.5 Suggestion for Further Studied 64
LIST OF TABLES
1: Demographic data of the Participants (Structure and Process) 39
2: Demographic data of Respondents on client satisfaction (Outcome) 41
3: Structure of MCH in Primary and Secondary health facilities 43
4: Process of MCH in Primary and Secondary health facilities 47
5 Client’s satisfaction with MCH services in Primary and Secondary health facilities 50
6: Categories and Number of personnel for MCH services in health facilities 53
7: T-Test for the structure of MCH in Primary and Secondary health facilities 54
8: T-Test for the process of MCH in Primary and Secondary health facilities. 54
9: T-Test for the client satisfaction of MCH in Primary and Secondary facilities 55
LIST OF FIGURES
1: Conceptual Framework for quality of MCH services 31
2: Bar chart showing the percentage of Personnel with Training in MCH services 44
- Bar Chart showing Physical facilities that are available and in good
working conditions in percentages 45
- Bar chart showing the percentage distribution of Maternal and
Child health care services (Process) rendered by selected heath facilities 48
- Bar charts showing clients satisfaction with MCH services in
Health facilities in percentages 51
1.1 Background to the Study
The quality of care received during pregnancy and the place of delivery are great determinants of maternal and child morbidity and mortality. Improving and sustaining the quality of care in healthcare institutions has been an area of concerns and recurrent issue over the year. The client’s expression of satisfaction with the quality of health care can provide insightful feedback for healthcare providers, managers and policy makers to direct quality improvement efforts in a right direction (Beattie, Lauder, Atherton, Murphy 2014). Quality assessment is an important aspect of quality assurance which focus on identification of barriers and challenges in a system and not just bad performers (Tobin-West and Anastasia 2016).
On yearly basis, an average of 289 000 women reportedly die as a result of complications associated with pregnancy and child delivery. Also, about 6.6 million under 5 year old children death resulted from complications in the neonatal period and early childhood illness (World Health Organization (WHO), 2013). These deaths are preventable with provision of quality and optimal maternal and child health care in health facilities.
Although remarkable achievement has been recorded in some areas of reproductive, women and children health interventions over the years, little progress has been recorded in efforts directed towards improvement of maternal and child health outcomes due to a wide gap between the scope and the quality of health care provided in facilities (WHO, UNICEF, 2014). Quality of care is considered very important in the international initiatives and Global Strategy for Every Woman and Child.
Yearly, about 500,000 women and girls die due to complications arising from pregnancy, labour and or the 6 weeks post- delivery. Majority of these mortality happen in less developed countries (United Nations Millennium Development Goals 2009), making the process of delivery one of the most dreaded journeys for women of child bearing age. This is worrying some as statistical findings showed that the extent of maternal mortality in low and middle income countries resulting from pregnancy and childbirth is on the increase (United Nations Children Fund (UNICEF) Nigeria, 2014).
Similarly, the risk of death from conception and child delivery in Nigeria is ratio 1 to 13. On daily basis, about 2,300 under-five year old children and 145 women in their reproductive years die in Nigeria. With these figures, Nigeria was rated the second largest country contributing to the under–five and maternal death in the world. Many of these deaths could be prevented but for Nigeria’s coverage and quality of health care services that continue to fall short of expectation for women and children. According to United Nations International Children Fund (UNICEF), Nigeria (2014) report, less than 20% of health facilities in the country provide emergency obstetric care (Eoc) and about 35% of deliveries are taken by health professionals.
A national health policy formulated for Nigerians in 1988 was targeted at achieving quality health for all. Emerging health issues and the realities to focus on new trends prompted the review of the policy over the years to improve quality in health care services across the nation (Nigeria Demographic Survey, 2013). A health delivery system targeting reduction in maternal morbidity and mortality must ensure quality reproductive care for this group of people (United States Agency for International Development (USAID), 2013).
Donabedian model was developed in 1966 for assessing healthcare services and to evaluate quality of health care. The model was revised in 1988 and provides information about quality of care using three categories which are structure, process, and outcomes. Structure describes the context in which care is delivered, including hospital buildings, staff, financing, and equipment. Process involves the transactions between patients and healthcare professionals throughout the delivery of healthcare. Outcomes refers to the effects of healthcare on the health status of client and client satisfaction. Since then other quality of care frameworks, including the World Health Organization (WHO) recommended Quality of Care Framework and the Bamako Initiative etc. have been developed but the Donabedian Model continues to be the dominant framework for assessing the quality of health care up till today (Lawson and Yazdany 2012). In 2013, World Health Organization and Partnership for Maternal, Newborn, and Child Health used Donabedian model to develop key indicators for quality in Maternal, Newborn, and Child Health care.
Maternal health care is the care a woman receives during conception, delivery, and post- delivery, it is crucial for the survival and well-being of mother and child. It comprises a broad range of services like family planning, prenatal, intrapartum, and postpartum care with the focus of minimizing maternal death and disability (Franny, 2013).
Improving the quality of obstetric care in facilities has recently been identified as a neglected and essential approach to reducing maternal deaths and enabling developing countries to achieve Sustainable Development Goal 3 (SDG 3) which is good health and well- being especially for women (Van den Broek and Graham 2009). Postpartum hemorrhage is the most frequent cause of maternal deaths globally and in developing countries, accounting for 25% of maternal deaths. Next are hypertensive disorders in pregnancy (PE/E) at 15%, sepsis (8%) and obstructed labor (7%).2 Effective interventions exist for screening, preventing and treating obstetric and newborn complications, and they can be readily provided by skilled providers in facilities. However, achieving both high quality and coverage of these interventions is essential in order to reduce maternal and newborn deaths globally. International evidence suggests that the most important factor in reducing maternal and early neonatal mortality is the attendance of a skilled birth provider and provision of quality care (USAID/MCHIP 2013).
According to Kana, Doctor, Peleteiro, Lunet and Barros (2015), poor maternal and child health indicators have been a recurrent issue in Nigeria since the 1990s, and many interventions have been instituted to reverse the trend and ensure that Nigeria provides quality maternal and child health care.
However, various intervention reports have documented mixed findings of the successes and challenges as well as threats to the attainment of quality maternal and child health care in Nigeria. It has been observed that Nigeria is lagging behind in meeting MDG 4 and according to the United Nations mortality estimates, Nigeria has only achieved an average of 1.2% annual reduction in under-five mortality since 1990. And in order to meet MDG 4, Nigeria needed to have achieved an annual reduction rate of 10% in the five years leading to 2015 (Rajaratnam , Marcus , Flaxman , Wang , Levin-Rector , Dwyer , et al 2010).
Therefore, improving and ensuring quality of health care services in health facilities, developing strategies for quality serve as an integral component of scaling up interventions to improve health outcomes of mothers, newborns and children is of utmost importance (WHO, 2013).
1.2 Statement of the Problem
The quality of care received during pregnancy and the place of delivery are great determinants of maternal and child morbidity and mortality (United States Agency for International Development (USAID), 2013).Worldwide significant number of women and girls yearly (almost half a million) die as a result of complications during conception, delivery or 6 weeks post childbirth. Majority of these deaths happen in underdeveloped nations (United Nations Millennium Development Goals, 2009). The risk of death from conception and delivery is in Nigeria is 1 in 13, many of these deaths could have been averted with good coverage and quality maternal and child health care (United Nations International Children Fund (UNICEF), 2014).
Increased mothers and newborn death and morbidity has been linked to poor quality of healthcare services (USAID, 2013), and has been evident by increased death rates that inadequate availability of reproductive health services is an important challenge in Nigeria (WHO Nigeria, 2014). Although progress has been made in increasing the coverage of several key reproductive, maternal, newborn and child health interventions over the past two decades, there has been limited progress in improving maternal and paediatric outcomes because of a major gap between coverage and the quality of care provided in health facilities (WHO, UNICEF, 2014).
Also, it has been observed from clinical practice that there are still many cases of preventable pregnancy and delivery complications reporting in the teaching hospital in Ile-Ife on daily bases in spite of many healthcare facilities in the area. Improving the quality of facility-based health care services and making quality an integral component of scaling up interventions to improve health outcomes of mothers, newborns and children is of utmost importance (WHO, 2013).
Hence, the need to evaluate the maternal and child healthcare services in healthcare facilities in Ile-Ife for quality care to achieve Sustainable Development Goal 3 (SDG 3) which is good health and well-being.
1.3 Objective of the Study
The main objective of this study is to evaluate the Quality of Maternal and Child Healthcare Services in selected Healthcare Facilities Ile-Ife utilizing Donabedian model for Quality care
The specific objectives are to:
- assess the structure of maternal and child healthcare services in Primary and Secondary health facilities in Ile-Ife based on Donabedian model;
- determine the process of maternal and child healthcare services in Primary and Secondary health facilities in Ile-Ife based on Donabedian model;
- assess the client’s satisfaction (outcome) with the maternal and child healthcare services in primary and secondary health facilities in Ile-Ife based on Donabedian model for quality care and
- determine the categories of staff rendering maternal and child healthcare services in primary and secondary health facilities in Ile-Ife.
1.4 Research Questions
The following research questions were answered by the study:
- What is the structure of maternal and child healthcare services in selected health facilities in Ile-Ife?
- What is the process of maternal and child healthcare services in selected health facilities in Ile-Ife?
- What is the level of client’s satisfaction (outcome) with maternal and child healthcare services rendered in Primary and secondary health facilities in Ile-Ife?
- What categories of staff are rendering maternal and child healthcare services in health facilities in Ile-Ife?
The following hypothesis were tested at 0.05 level of significance.
HO1: There is no significant difference between the structure of Maternal and Child
Healthcare services in Primary and secondary health facilities in Ile-Ife.
HO2: There is no significant difference between the process of Maternal and Child Healthcare
Services in Primary and secondary health facilities.
HO3: There is no significant difference between the client’s satisfactions (outcome) with
Maternal and Child healthcare services in Primary and Secondary health facilities in Ile-
1.6 Scope of the Study
The scope of this study was delimited to Primary and Secondary Healthcare Facilities in Ile-Ife and nursing mothers of children 0-1year attending infant welfare clinics in selected healthcare facilities in Ile-Ife. The study covers the four local governments in Ile-Ife, which are: Ife Central Local Government, Ife East Local Government, Ife south local government and Ife North local government respectfully.
- Significance of the Study
According to World Health Organization Report (WHO 2008), maternal and newborn morbidity and mortality continue to be a problem with a huge disparity between developed and developing countries. Therefore, findings from this study might help with recommendations to improve the quality of maternal and child healthcare services thereby reducing maternal and child mortality and achieve Sustainable Development Goal 3 (SDGs) which is Good health and well- being.
The findings may assist the Federal Ministry of Health in adopting strategies to improve the quality of maternal and child healthcare services through collaboration between stake holders.
The findings may be useful in National Health Planning and Budgeting to improve the structure of healthcare facilities, training and retraining of staff, supervision, and provision of supplies and transportation for prompt referrals in healthcare facilities.
Findings may provide useful information on areas of partnering with local and international agencies for complementary role in maternal and child healthcare services.
The outcome of the study may be used to further challenge health professionals to identify factors influencing quality of maternal and child health care services in Nigeria and need for improvement.
Findings may add to the existing body of knowledge and would assist in achieving the desired goal of quality maternal and child healthcare services in Nigeria.
1.8 Operational Definition of Terms
Quality of Care: Care rendered to women during pregnancy, childbirth, and post-delivery in healthcare facilities in Ile-Ife based on Donabedian Model of quality care, this include the structure, process and outcome of Maternal and Child Health Care services.
Maternal and Child Healthcare: This is the care rendered to a pregnant woman from the time of conception to the delivery of the baby and care of the baby from birth to 2year in healthcare facilities in Ile-Ife .
Health Professionals: These are Midwives, Nurses, Community Health officers and Community Health Extension workers that provides Maternal and Child Healthcare services in healthcare facilities in Ile-Ife by the virtue of their training or qualifications.
Nursing Mothers: Women with babies 0-1year old who have received care during conception, delivery of the baby, after delivery, family planning, immunizations, care of the baby and attends immunization clinic at the time of the study in selected health facilities in Ile-Ife.
Healthcare Facilities: These are Primary Healthcare Centers (PHCs) and Secondary health facilities (General Hospitals and Comprehensive Health Centers) in Ile-Ife.
Donabedian Model: This is the conceptual model of quality care developed by Avedis Donabedian in 1966, reviewed in 1980 and 1988. The model was developed to assess quality of care in clinical practice; it has three categories in which information could be gathered for evaluating quality of healthcare services which are structure, process and outcome.
Structure: This is the physical facilities, human and material resources available in primary and secondary healthcare facilities for maternal and child healthcare services in Ile-Ife.
Process: This is the care and all actions rendered in Maternal and Child health services by the healthcare professionals. It contains all acts of maternal and child healthcare delivery (i.e. antenatal, intra-natal, postnatal care, neonatal and children care etc.) in healthcare facilities in Ile-Ife and interactions between health personnel and clients including relationships and respectful maternity care in the course of interactions.
Outcome: This is the effects of maternal and child healthcare services measured by mother’s satisfaction of the care received in Primary and secondary Healthcare facilities in Ile-Ife.