1 QUALITY ASSESSMENT AND COMPARISON OF ANTENATAL CARE SERVICES IN RURAL AND URBAN AREA PRIMARY HEALTH CARE FACILITIES IN RIVERS STATE By DR. PAULINE ARUOTURE GREEN M.B; B.S Benin (1998) A dissertation submitted to the National Postgraduate Medical College of Nigeria in part fulfilment of the requirements for the award of the final fellowship of the Medical College in Public Health. November 2010 DECLARATION
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QUALITY ASSESSMENT AND COMPARISON OF ANTENATAL CARE
SERVICES IN RURAL AND URBAN AREA PRIMARY HEALTH CARE
FACILITIES IN RIVERS STATE
By
DR. PAULINE ARUOTURE GREEN
M.B; B.S Benin (1998)
A dissertation submitted to the National Postgraduate Medical College of Nigeria in
part fulfilment of the requirements for the award of the final fellowship of the
Medical College in Public Health.
November 2010
DECLARATION
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I hereby declare that this work was done by me under supervision and that it has not been
submitted in part or full for any other examination.
------------------------------------------------
Dr Pauline A. GREEN
DEDICATION
This work is dedicated to my father, Late Chief Lawson E.O Tariuwa who taught me that I
can achieve any thing in life through hard work and dedication.
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ACKNOWLEDGEMENT
My deepest gratitude goes to my first supervisor Eze Dr P.N.C Abuwa, who has been more
than a supervisor in his fatherly disposition throughout the period of writing this book. His
concern and phone calls (which made my heart miss a beat knowing that I was lagging
behind schedule in completing the programme) never ceased to inspire me to work harder. I
am immensely grateful sir.
My thanks also go to Dr A.O Adebiyi who despite his busy schedules and distance did not
hesitate to accept being my co-supervisor. I am grateful sir for your guidance, wisdom and
useful materials you recommended and made available for my use. My head of department
Dr Meg Mezie-Okoye, your advice, encouragement and understanding during the writing
of this book is appreciated.
I must thank the consultant staff of the department of community medicine, University of
Port Harcourt teaching hospital for their contributions towards this work. I appreciate my
immediate past head of department, Dr Best Ordinoha for his support throughout my
training, Dr Seye Babatunde for his constructive criticisms and contributions to this book
and Dr Risen Agiobu for making relevant materials available to me. I am most grateful to
my teacher Prof. Mrs. Alice Nte of the department of pediatrics UPTH for her constructive
criticisms of my proposal.
My appreciation goes to the consultant staffs of the department of community medicine
University College Hospital Ibadan where I had my foundational training as a
supernumerary resident in public health notably Prof. M.C Asuzu, Dr. A.O Olumide, Dr
F.O Omokhodion, Prof. M. Onadeko, Dr K.O Osungbade and Dr E.T Owoaje. I remain
very grateful for your tutelage and privilege of having to learn under you all.
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I am indebted to my friends, Dr O.C. Uchendu, Dr A. Adebayo, Dr Femi Popoola and Dr
Simbo Ige; residents of the University college hospital Ibadan and Dr V.N Shaahu for your
valuable contributions and suggestions. I appreciate and value your friendships. Thank you
all so much for your time and assistance in the course of this study.
I appreciate all my research assistants - Baridi, Rebecca, Victoria, Belema, Florence and
Kemi God bless you all. My appreciation also goes to the PHC coordinators and heads of
the various facilities for their co-operation and assistance. I am immensely grateful to all
the respondents who participated in this study. This study would not have been possible
without them.
My gratitude goes to my mother and my sister, Mrs. Elizabeth A. Tariuwa and Mrs.
Gloria Ogunbor for their prayers, support and encouragement throughout the period of
writing this book.
To my husband, thank you so much for always being there- your patience, prayers and
understanding throughout this trying period and for the months/ year I had to be away from
home, I am deeply grateful.
Finally, to my father, the Almighty God who is faithful when we are not, who makes all
things possible and beautiful in his time, Lord I am indeed grateful.
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ABSTRACT
Introduction: High quality antenatal care is fundamental right of women to safe guard
their health. The present quality of care as depicted by the magnitude of high maternal
morbidity and mortality in Nigeria makes the realization of the Millennium Development
Goal for maternal health uncertain.
Objectives: The objectives of this study were to assess and compare the quality of
antenatal care services in urban (Port Harcourt city) and rural (Gokana) local government
area PHC facilities in Rivers State using indicators such as the infrastructure, human and
material resources necessary for quality antenatal care as well as investigate the process of
care.
Methodology: A cross sectional comparative study involving structured observation using
check lists and interviews using semi-structured questionnaires was carried out from May
to October 2009. A multi stage sampling technique was used to select an urban and a rural
LGA. A sampling frame of PHCs in each selected L.G.A was drawn and facilities meeting
the predetermined requirements of at least ten ANC clients per day were selected by simple
random sampling. Data collection was by an audit of facility equipment, personnel, drugs,
supplies and infrastructure and by observation of health care providers’ management of
client; interviews with health care providers and exit interviews with clients. A sample size
of 260 and 254 antenatal clients in urban and rural LGAs respectively was used for the exit
interviews. Total sampling was done following proportional sample allocation to the health
facilities based on their average monthly turnover of antenatal clients. Data was analyzed
using SPSS version 16. Frequencies were generated using tables and charts and
comparisons were made using Chi square and Fishers’ exact tests. Level of significance
was set at p < 0.05.
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Results: The urban health facilities ranked well in the quality of care assessed in all the
structural and outcome indicators assessed. These are general infrastructure 68.7%,
equipment 78.3%, drugs and supplies 87.5%, personnel 66.6%; client satisfaction and
health education were 97% and 61.5% respectively. However the rural health facilities
showed deficiencies in available equipment (53.3%) and available personnel (33.3%). The
quality assignment scores for process attributes however revealed that similar results (49%
versus 49% - average rating- respectively) were obtained for interpersonal care in both
settings. The rural health care providers however, performed marginally better (62%) than
the urban healthcare providers (59.7%) in the technical aspect of care observed. Quality of
care for outcome measures in the rural health facilities rated well with assignment scores of
94% and 72.5% for client satisfaction and health education respectively. On the barriers to
providing quality antenatal care by HCPs, results showed that there were deficits of staff in
both settings; most (28%) of the professional staff worked in the urban facilities compared
to 4.5% in the rural health facilities. Similarly, 64% of urban HCPs had received recent in-
service training compared to 45% of HCPs in rural facilities.
Conclusion: It is apparent from the foregoing that none of the urban or rural health
facilities met all of the minimum criteria (structural, process and outcome attributes)
required by national standards for quality ANC services in this study. Quality antenatal
care is meant to promote the health of antenatal clients, therefore periodic quality
assessments of the facilities to ensure that standards are maintained should be carried out
by relevant authorities as well as ensure equitable distribution of human and material
resources in both urban and rural settings. In addition supportive supervision as well as
staff development should be regular and ongoing.
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TABLE OF CONTENTS
Title page i
Declaration ii
Dedication iii
Certification iv
Acknowledgement v
Abstract vii
Table of contents ix
List of tables xii
List of figures xiv
List of appendices xv
Abbreviations xvi
Chapter One
Introduction 1
Problem statement 2
Rationale for the study 4
Objectives 6
Chapter Two
Literature review
2.1. Overview of quality of health care 7
2.2. Assessment of quality of health care 8
2.3. Dimensions of quality of health care 9
2.4 Perspectives of quality of health care 10
2.5 The concept of quality antenatal care 11
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2.6 Quality of infrastructure, equipment, drugs and supplies 12
2.7 Quality of process of antenatal care 15
2.8 Client satisfaction with antenatal care 19
Chapter Three
Materials and methods
3.1 Study area 22
3.2 Study design 23
3.3 Study population 23
3.4 Sample size estimation 23
3.5 Sampling technique 24
3.6 Research instruments 26
3.7 Data collection 27
3.8 Eligibility criteria 30
3.9. Validity 30
3.10 Data analysis 30
3.11 Ethical consideration 32
3.12 Study limitations 33
Chapter Four
Results 34
Chapter Five
Discussion 61
Conclusion 71
Recommendations 73
References 74
Appendices 86
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12
LIST OF TABLES
Table Title
Pages
Table 1 Infrastructural attributes of health facilities by location
34
Table 2 Available and functional equipment at health facilities by location
36
Table 3 Availability of recommended drugs and supplies
37
Table 4 Staff disposition by location
38
Table 5 Observed technical aspect of care by location of health facility
41
Table 6 Socio-demographic characteristics of clients by location of health
facilities
43
Table 7 Obstetric characteristics of clients by health facility
45
Table 8 Client satisfaction with selected aspects of care by location
47
Table 9 Clients’ overall satisfaction by location
48
Table 10 Socio-demographic characteristics of clients and their association
with client satisfaction
49
13
Table 11 Association between selected variables and client satisfaction
50
Table 12 Proportion of clients who received health information in clinic
by location of facility
51
Table 13 Summary of scores of attributes denoting quality antenatal care
53
Table 14 Quality assessment score for the attributes of care by location
of facilities
54
Table 15 Quality assignment of elements denoting quality antenatal care
55
Table 16 Proportion of clients who desired improvement in the quality of
ANC 56
Table 17 Demographic and work characteristics of health care providers by
location of facilities 57
Table 18 Proportion of health care providers who received supervisory visit
by location of facilities 58
Table 19 Distribution of health care providers who received training by
location of Facilities 59
Table 20 Perceived barriers to providing quality ANC by HCP 60
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LIST OF FIGURES
Figure Title
Page
Figure 1 Bar charts showing interpersonal aspect of care
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LIST OF APPENDICES
1. Checklist
2. Questionnaire
3. Ethical clearance
4. Letter of introduction
5. Maps of study area
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ABBREVIATIONS
ANC - Antenatal Care
CHO - Community Health Officer
DISH - Delivery of Improved Services for Health
FMOH - Federal Ministry of Health
FSP -Family Support Program
GA -Gestational Age
GOLGA - Gokana Local Government Area
HCP - Health Care Provider
HFA - Health for All
HIV - Human Immunodeficiency virus
IPT - Intermittent Preventive Treatment
ITN - Insecticide Treated Net
JCHEW - Junior Community Health Extension Worker
KSPA - Kenya Service Provision Assessment
KDHS - Kenya Demographic and Health Survey
LGA - Local Government Area
MCH - Maternal and Child Health
MDHFA - Minimum District Health For All
NDHS - Nigeria Demographic and Health Survey
NPHCDA - National Primary Health Care Development Agency
PHALGA - Port Harcourt City Local Government Area
PHC - Primary Health Care
PNC - Postnatal Care
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SCHEW - Senior Community Health Extension Worker
STI -Sexually Transmitted Infection
TT -Tetanus Toxoid
UNICEF -United Nations Children’s Fund
UNFPA -United Nations Population Fund
UTI - Urinary Tract Infection
VDRL - Venereal Disease Research Laboratory
WMHCP - Ward Minimum Health Care Package
WHO - World Health Organization
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CHAPTER 1
INTRODUCTION
The state of maternal and child health is an important indicator of a society’s level of
development, as well as an indicator of the performance of the health care delivery system.1
Globally, there is growing interest in the quality of reproductive health services. In spite of
the global efforts to improve maternal health in the developing countries, the present
quality as depicted by the magnitude of severe maternal morbidity and mortality makes the
realization of the Millennium Development goal for maternal health uncertain.2-5
In Nigeria, approximately 1100/100,000 women die yearly from pregnancy related
complications occurring throughout pregnancy, labour, child birth and in the postpartum
period6. Major causes of maternal deaths are haemorrhage 25%, infection 15%, eclampsia
12%, obstructed labour 8%, unsafe abortion 13%, and other direct causes 8%, indirect
causes 20%.7 The tragedy of maternal death lies in the fact that almost all the causes of
maternal deaths are preventable. These maternal and neonatal deaths can be prevented
through interventions that are cheap and effective.
Quality maternal health is attainable through antenatal care, the care a woman receives
during pregnancy that ensures healthy outcomes for both women and new born.8 ANC is a
key entry point for a pregnant woman to receive a range of health promotive and preventive
services which include prevention and treatment of anaemia, malaria, STI’s including
HIV/AIDS, pregnancy related complications and nutritional support and tetanus toxoid
vaccine for mothers.
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Primary health care is the permanent approach to Health for All (HFA) and is the key to
the effective functioning of the health care delivery system. In 1978, the Alma-Ata
Declaration on Primary Health Care identified maternal and child health, including family
planning as one of its eight essential components.9 Among the various pillars of safe
motherhood, antenatal care remains one of the interventions that has the potential to
significantly reduce maternal morbidity and mortality when properly conducted.10 The
enhanced pillars of safe motherhood in Nigeria rest on the solid foundation of primary
health care which is the entry point into the health care delivery system of the country. It
thus provides an ideal setting for prevention and identification of pregnancy complications
and provision of linkage to specialized care.
“Making Pregnancy Safer” is a WHO global initiative for accelerated reduction of
maternal and new born morbidity and mortality. It is a health sector response to improve
conditions in the health facility to ensure quality of care and capacity for emergency
obstetric care at primary health care level. The initiative focuses on the strengthening of the
health systems while the just introduced “Women and Children Friendly Initiative” focuses
on issues related to quality of care in terms of client oriented services which are culturally
sensitive and appropriate for their needs.7 Besides access and utilization of maternal
services, poor quality care also contributes significantly to the high maternal and perinatal
mortality figures.10The concept of quality of care is therefore becoming increasingly
recognized as a key element in the provision of health care; it links outcome of care with
the effectiveness, compliance and continuity of care.11
Problem statement
In high and middle income countries today, use of antenatal care by pregnant women is
almost universal with exceptions among marginalized groups such as migrants, ethnic
minorities, unmarried adolescents, the very poor and those living in isolated rural
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communities.8 Also, almost all women in the developed world have a skilled attendant at
birth. In the developing world (low income settings) coverage for antenatal care for at least
one visit is high. However there is a high contrast to use of a skilled health professional
during child birth1.
Despite improvement in ANC coverage, it is generally recognised that the antenatal care
services currently provided in many parts of the world fail to meet the recommended
standards8. Less than half of the women in developing countries get adequate health care
during and soon after child birth, despite the fact that most maternal deaths take place
during these periods.
In Nigeria, the health services have been shown to be unsatisfactory and inadequate in
meeting the needs and demand of the public.12 1These are exemplified by the unacceptably
high maternal and infant mortality rates and low health services coverage of rural and
urban poor.13 Majority of the Nigerian populace live in suburban and rural communities
with access to orthodox medical care mainly through the primary health care centres.
Nigeria’s maternal mortality rate is one of the highest in the world and has continued at an
unacceptably high level. The state of the health services in Nigeria also shows widely
recognized deficiencies in coverage with an estimated 54% of the populace having access
to modern health services leaving the rural communities and urban poor with sub optimal
services.12 Nigeria Demographic Health Survey (NDHS) shows that 58% of women
received antenatal care from a skilled provider while 36% did not receive any antenatal
care.1 The proportion who obtained ANC services from a skilled health worker is higher
among women residing in urban areas (84 percent) than among women who reside in rural
areas (46 percent)1. Similarly women in the rural areas were less likely than their urban
counterparts to receive specific components of ANC. Such services include the provision of
iron and intestinal parasites tablets, weight and blood pressure measurements, urine and
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blood samples for investigations as well as information on signs of pregnancy
complications1. Women in urban settings have options regarding where they could seek
care - a significant proportion of these women may also receive concurrent care from
multiple care providers14
A national research in safe motherhood revealed that less than half of mothers in Nigeria
are likely to make up to four (4) antenatal care visits recommended.7 In the NDHS only
41.7% urban and 23.5% rural dwellers made four to five ANC visits1.
The national budgetary allocation to the health sector is less than 5% of total expenditure
and there is inappropriate orientation with high expenditure that focuses on curative rather
than promotive and preventive health services.12 Community participation is also minimal
at critical points in the decision making process and communities consequently are not well
informed on issues of maternal health.
The basic infrastructure and logistics supports are also often defective owing to inadequate
maintenance and unreliable supplies of potable water and electricity and the poor
management of drugs and vaccines supplies12. This lack of basic infrastructure constitutes a
barrier to quality health care especially in the rural areas.
In Rivers State, data show that the physical infrastructures of some primary health care
facilities are dilapidated and lacking in basic amenities15. Also, equipment and skilled
health care providers are deficient and reports have also shown that though antenatal care
may be sought in health care facilities, most delivery do not occur in the facilities where
ANC was given15.
Rationale for the study
Thirty- two years after the Alma Ata conference of 1978 and the Riga conference of 1988,
health services especially PHC in Nigeria still remains unsatisfactory and inadequate in
meeting the health needs of the public.1These are exemplified by the unacceptably high
22
maternal and infant mortality rates and low health services coverage of rural and urban
poor.13 Literature indicates high quality ANC as one of the service interventions that has a
potential to impact on the high maternal mortality.17-20
In spite of the increasing importance of quality of antenatal care worldwide, detailed
information about the quality or effectiveness of antenatal care practices is less often
available or investigated in many of the populations where they are most needed. For
instance in Nigeria where healthcare service delivery is largely based on the primary health
care system, few studies that have addressed the issue of the quality of antenatal care have
focused on private and referral or tertiary health institutions.14,16 Since the majority of the
Nigerian populace live in suburban and rural communities with access to orthodox medical
care mainly through the primary health care centers, information derived from such
investigations are unlikely to achieve the desired impact on a large scale.
Although studies on quality of ANC have been carried out elsewhere in the country, there
is paucity of data on the quality of ANC in Rivers State. More rigorous assessment of the
quality of antenatal care is needed in order to identify specific problems and develop
strategies to improve and reduce maternal mortality.
Findings from this study could be fed into reproductive health programmes and guide the
development of policies for improving quality in ANC. Academically, findings of this
study will provide knowledge in the area of quality ANC. The results will also form
baseline data for improving quality of ANC in urban and rural areas and subsequently
contribute to reduction of maternal mortality in the State.
The rationale for investigating quality of antenatal care in the urban and rural health
facilities is therefore to identify deficiencies and differences in the study sites in order to
provide scientific evidence based information for the improvement of the quality of
antenatal care services.
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OBJECTIVES
General Objective:
To assess and compare the quality of antenatal care services provided to pregnant women
in selected urban and rural primary health care facilities in Rivers State.
Specific Objectives:
1. To assess the infrastructure of facilities that provides ANC services in study sites.
2. To determine the proportion of facilities with basic diagnostic equipment and drugs that
is available to provide antenatal care services.
3. To investigate the process of care (the interpersonal and technical aspects) of ANC
services in the rural and urban PHC facilities.
4. To determine and compare the proportion of clients that are satisfied with antenatal care
service in urban and rural PHC facilities.
5. To determine factors that influences the quality of care by the health care providers.
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CHAPTER 2
LITERATURE REVIEW
2.1 Overview of quality of health care
Quality means different things to different people. The definition of quality takes into
account the perceptions (i.e. views and feelings) of the client and it is only in this context
that the notion “quality” becomes meaningful 21, 22. High quality antenatal care is a
fundamental right for women to safeguard their health. Awareness of quality health service
has been on the increase in recent years on the part of the public, providers and
government23. In recent years the World Bank and other donors have been advising
developing countries to ensure that limited resources not only have an optimal impact on
the population’s health at affordable cost but also that health services are client-oriented24–
27. This has led to many developing countries actively seeking to improve the outputs and
outcomes of their health care delivery system by engaging in a process of reform.
The quality of technical care consists the application of medical science and technology in
a way that maximizes its benefits to health without correspondingly increasing its risks.28
The degree of quality is, therefore, the extent to which the care provided is expected to
achieve the most favourable balance of risks and benefits.28 Thus needs may be implied and
met through certain standards which the consumer may not comprehend28. Quality is not
simply connected with sophisticated technologies and procedures 21, 32. It has more to do
with the reliability and effectiveness of the service and its provision in ways that promote
accessibility and continuity; hence quality is also seen in the light of consumer
satisfaction.21, 29
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2.2 Assessment of quality of health care
Quality assessment is the measurement of the quality of health care services109. A quality
assessment measures the difference between expected and actual performance to identify
opportunities for improvement.109Quality can be assessed from the point of view of the
users (perceived quality) or by using technical standards. Donabedian offered a frame work
for its definition based on three major attributes – structure, process and outcome30, 32.
“Structure” refers to the attributes of the settings where health care occurs (material, human
and financial resources and organizational structure32. It typically measures the ratio of
provider of health care to patients, accreditation of facilities and types of equipment. It
therefore determines whether available resources are adequate in quality and quantity to
provide the potential for good care but cannot alone determine if the care is in-fact of high
quality32, 105.
“Process” denotes what is actually done in giving and receiving care and examines the way
available resources are used32. It looks at the total interaction between the facility and the
client and includes history taking, examination, diagnostic tests, treatment, follow up and
health education.31
“Outcome” indicates the effects of care on the health status of patients and populations
(morbidity and mortality).30, 32, 33 Outcomes have received special emphasis as a measure of
quality and is clearly the primary indicator of quality22. Quality assessment studies usually
measure one of three types of outcomes: Medical outcomes, costs and client satisfaction34,
35 and 106. Clients are asked to assess not only their own health status after receiving care but
their satisfaction with the services delivered because clients perspective is an essential
factor to consider when analyzing the quality of care by health facilities34,35 and 105.
Satisfaction of needs is therefore, one of the instruments used in quality assessment and
assurance of care105. It is an important outcome measure and may be a predictor of whether
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patients follow their recommended treatments i.e. their satisfaction is an important and
strong influencing factor in determining whether a person seeks medical advice, complies
with treatment and maintains a relationship with the provider / health facility36, 37.
2.3 Dimensions of quality of health care
There are eight dimensions of quality. These are technical competence, access to service,
effectiveness, interpersonal relations, efficiency, continuity, safety and amenities. 32, 38
Technical competences refer to the skills, capability and actual performance of health
providers, managers and support staff 28. It refers to how well providers execute practice
guidelines and standards in terms of dependability, accuracy, reliability and consistency105.
Access means that health care services are unrestricted by geographical, economic, social,
cultural, organisational or linguistic barriers 9, 28.
Effectiveness is an important dimension of quality at the central level, where norms and
specifications are defined and also at the local level where managers decide how norms are
to be carried out and how they are to be adapted to local conditions38.
Interpersonal relations refer to interactions between providers and clients, managers and
health care providers and the health team and the community. Good interpersonal relations
contribute to effective health counselling and to a positive rapport with patients 38, 53.
Inadequate interpersonal relationship can reduce the effectiveness of a technically
competent health service27. Patients who are poorly treated may be less likely to heed the
health care providers’ recommendations or may avoid seeking care. This will affect
utilization and coverage of a particular health care service in the long run106.
Efficiency ensures that optimal care rather than maximum care is provided in other words
the greatest benefits are achieved within the resources that are available31, 38.
Continuity of care ensures that clients have access to a complete range of health services
without interruptions in delivery28. This may require that the same health care provider
28
who knows the clients medical history is available or adequate medical records is kept 107,
108. Continuity of care also means that timely referrals for specialized services are provided
and follow up care is completed 38. The absence of continuity of care can compromise
other dimensions of quality of care such as efficiency and inter personal relations30, 31 and 38.
Safety- clients and providers are involved and need to be assured of minimal risks to
injections, injuries as well as side effects or adverse effects of drugs and other risk related
to health service delivery 30, 31.
Amenities refer to those features of health services that do not directly relate to clinical
effectiveness but may enhance the client’s satisfaction and willingness to return to the
facility for subsequent health care needs 27, 38. Amenities are also important because they
may affect the client’s expectations and confidence about other aspects of the service or
product106. Where recovery of cost is a consideration amenities may enhance the client’s
willingness to pay for services and it relates to the physical appearance of the facilities,
personnel, and materials; as well as to comfort, cleanliness, and privacy27, 38. Some
amenities such as clean and accessible rest rooms; and privacy curtains in examination
rooms may be luxuries in less developed countries but are important for attracting and
retaining clients and for ensuring continuity and coverage 32, 38 and 106.
2.4 Perspectives of quality of health care
For the clients and communities, quality health care meets their perceived needs and is
delivered courteously and on time 30, 38 and 105. The client’s perspective is very important
because satisfied clients often are more likely to comply with treatment and to continue to
use primary health services106. Thus the dimensions of quality that relate to client
satisfaction affect the health and well being of the community 38, 106. Patients and
communities often focus on accessibility, inter- personal relations, continuity, and
amenities as the most important dimensions of quality38. However from the provider’s
29
perspective, quality care implies that he or she has the skills, resources and conditions
necessary to improve the health status of the patient and the community according to
current technical standards and available resources28, 32. The provider’s commitment and
motivation depend on the ability to carry out his or her duties in an ideal or optimal way 29.
Providers focus on technical competence, effectiveness and safety29. As the health care
system responds to patients’ perspectives and demands, it also must respond to the needs
and requirements of the health care provider30.
He needs and expects effective and efficient technical, administrative, and support services
in providing high quality care30. Health care managers on the other hand are focused on the
various dimensions of quality in order to provide for the needs and demands of client and
providers28, 32. They are principally involved in supervision, financial and logistic
management.38
2.5 The concept of quality antenatal care
Antenatal care is an opportunity to promote the benefits of skilled attendance at birth and to
encourage women to seek post partum care for themselves and their new born 8, 39 and104. It
is an ideal time to counsel women about the benefits of child spacing and is an essential
link in the household-to-hospital continuum of care i.e. it is an intervention that can be
provided at both the household and peripheral facility levels and helps assure the link to
higher levels of care when needed.39 Among the various pillars of Safe Motherhood,
antenatal care remains one of the interventions that has the potential to significantly reduce
maternal morbidity and mortality when properly conducted.10,101,102 Available data from
developing countries including Nigeria found lack of antenatal care to be an important risk
factor for poor pregnancy outcomes.40-43 However, while poor access to basic antenatal
care is recognised as a major obstacle to improvement in pregnancy outcomes, there is a
growing consensus that access to antenatal care alone is insufficient to alter the present
30
maternal health profile and that the quality of antenatal services may be a key determinant
of maternal and perinatal outcomes.44 During the ante partum period, women are prone to
some physiological and psychological changes that may adversely affect pregnancy
outcomes.45 Thus the need for high quality antenatal care cannot be over emphasized.
Recently the emphasis is on ‘Focused Antenatal Care’ which emphasizes evidence- based,
goal-directed actions; family centred care and quality rather than quantity of visits and care
by skilled providers39. The goals of focused antenatal care are to promote maternal and new
born health and survival through early detection and treatment of problems and
complications, prevention of complications and disease, birth preparedness and
complication readiness as well as health promotion8, 39. Previously, care was based on risk
assessment with frequent visits that were not evidenced based or goal directed 11. This type
of care did not emphasize individual client needs and resulted in overburdening of the
health care delivery system 11. All women require high quality client-oriented antenatal care
services that address personal needs throughout the pregnancy to ensure their health and
that of their infants, irrespective of their socio-economic status and potential for pregnancy
complications8.
2.6 Quality of infrastructure, equipment, drugs and Supplies
In 1994, the WHO Regional programme meeting held in Yaoundé Cameroon discussed the
need for the implementation of the Minimum District Health for All (MDHFA) package by
African countries65. This package was implemented in Nigeria in the same year but was
however reviewed with a change of nomenclature to the Ward Minimum Health Care
Package (WMHCP) in 2001.In order to ensure synergy in the efforts of government to meet
the health needs of Nigerians this package was harmonized with the integrated Maternal
Neonatal and Child Health (IMNCH) strategy65.
31
The WMHCP is a set of health interventions and services that address health and health
related issues and the minimum package of resources required for the implementation of
these interventions, one of which is maternal and new born care. Thus, the WMHCP in its
minimum requirement recommends a total of twenty- eight essential equipment for primary
health care centre for antenatal/ interview room65. These items include furniture such as
plastic chairs and fans as well as equipment necessary for clinical examinations such as
thermometers, sphygmomanometer, and stethoscope e.t.c. The minimum staffing
requirement established by the NPHCDA for antenatal care in primary health care centre is
one community health officer, one public health nurse, three community health extension
workers, six junior community health extension workers, four nurse/ midwives and one
medical assistant which is optional 65.
Another document that was developed in 2007 by the FMOH as a result of the poor
maternal indices as well as low ANC attendance in the country is the Performance
Standards for Emergency Obstetric care in Nigerian hospitals 66. This document also
stipulates minimum standards to be met in infrastructure and process of care66. It is a
document that aids the health manager to assess every aspect of maternal care. These are
performance standards for process of care with verification criteria for each item/ attribute
being assessed. In the evaluation of performance standards for process of care, the HCP is
expected to receive and treat the pregnant woman cordially and respectfully, takes
personal, social, medical, and obstetric history as well as examines and provide health
information to the client. The document also stipulates the minimum requirement for
human, material and physical resources and this includes drugs and supplies as well as
furniture and equipment. Given this back ground the issue of quality in health facilities is
being revisited by the Nigerian government.
32
A cross sectional study by Pindiyapathirage and colleagues in the Gampaha District in Sri
Lanka assessed the quality of care provided at antenatal field clinics using checklists to
assess the structure and process attributes of quality48. The findings indicated that several
resource components needed upgrading in the district. The majority of clinics did not have
adequate seating arrangements, lacked a footstool, a height measuring instrument and
Vitamin C48. Similarly, in another study of four rural underserved districts in Burkina Faso,
Kenya and Tanzania, basic equipments such as working blood pressure gauges,
stethoscopes, and adult weighing scales were missing at many health facilities or were not
available in the maternal and child health (MCH) clinic or unit where antenatal checkups
are performed.49 The lack of these equipment and supplies was particularly severe at mid-
and lower-level facilities where the majority of antenatal clients are seen. These equipment
gaps made it difficult for providers to monitor pregnancy and detect problems, such as
pregnancy-induced hypertension.49 A functioning blood pressure apparatus and a foetal
stethoscope are essential equipment that should be available in the ANC service delivery
area; while essential ANC supplies that should be available in the facility are iron tablets,
folic acid tablets, and tetanus toxoid vaccines.50 Health care providers frequently face
shortages of basic medical supplies such as contraceptives, infection control equipment,
and gloves, even when they receive other types of support from the health care system. In
Bangladesh, Huezo noted that only about one-third of the providers, community-based
service agents and managers surveyed felt they had the necessary materials to do their work
adequately.46 Similar results (one third of providers) were reported by Khan in India.47 In
the Kenya Service Provision Assessment survey (KSPA) in 2004, all the essential
equipment and supplies were available in only 6 in 10 facilities. However, each individual
item was available in over 80% of the facilities. Eighty three percent of the facilities had
blood pressure apparatuses while 98% percent had fetoscopes. Iron tablets, folic acid
33
tablets and tetanus toxoid vaccines were available in 87%, 96%, and 82% of the facilities,
respectively50. In the same study, 99% of the facilities had either a bed or an examination
table, but only 2 in 10 facilities had an examination light. Government-managed facilities
were less likely than other facilities to have all three items for quality client examination
(5%). The item most often missing in all facilities was an examination light.50
In a study of first- tier health facilities by Boller and colleagues in Dares Salaam, Tanzania,
a sample of seven public- service and nine private- sector providers were randomly selected
and structural attributes of quality were assessed through a checklist51. Quality was
measured against national standards and an overall score calculated to permit comparison.
Basic diagnostic tools and equipment were clearly adequate in this urban area although it
was better in the private sector when compared to the public sector. Also, assessment of the
physical infrastructure of the first-tier public and private facilities was adjudged to be
reasonably good. However maintenance was generally better in private facilities. The
median overall score for structural attributes of quality, of a maximum of 72, was 51 (range
35-54) for the public and 64 (range 56- 72) for the private sector (p< 0.001)51.
2.7 Quality of process of antenatal care
Studies have shown that the most powerful predictor for client satisfaction with
government services is provider behaviour especially respect and politeness 22, 52. In the
study by Boller and colleagues process dimension of care was assessed through observation
of the patient- provider interaction and judgement of interpersonal aspect was based on the
accommodation provided for the women, privacy during consultation and the interaction
between the client and provider51. Results showed that in both public and private facilities
there were seats available and were offered to 89% of women attending public facilities
and to 93% in private ones. Privacy of consultation (i.e. the door of the examination room
being closed during the consultation) was observed in 81% of consultations in the public
34
sector and in 99% in the private sector. Overall, median summary score for interpersonal
aspects was higher for the private sector, where it was 13(range 4-16) whereas for the
public sector it was 11(range 5-16), of a maximum of 16(p< 0.001).51 Differing results
were obtained by Oladapo and colleagues in Sagamu, a semi urban LGA in Ogun State
southwest Nigeria. In their cross sectional survey of 452 pregnant women accessing care at
first level public health facilities, the perspectives of these clients were sought on the
quality of care received53. Most (93.8%) respondents opined they were treated with
respect while 96.5% felt the HCPs protected their privacy.53
The content of antenatal care is important in judging its quality1. However, considerable
variation exists in the content of ANC worldwide 54, 55. In Nigeria ANC includes history of
previous and current pregnancies, routine measurement of weight and blood pressure,
abdominal palpation, nutritional advice, distribution of iron and folic acid supplements,
malaria prophylaxis, and blood testing for haemoglobin, urine testing for protein and
tetanus toxoid vaccination1, 57. Others are blood group and genotype, screening for HIV and
VDRL for syphilis1.
Technical competence is defined as correctly following standard clinical guidelines56.
Boller and colleagues in their study assessed technical care by observing client- provider
interactions51. The general history of the pregnant women was taken in 35% of all
consultations in the public sector and 49% in the private sector and questions about recent
malaria episodes, urinary tract infections, or signs of anaemia were hardly ever asked. This
contrasts Bessinger and Katende’s findings in Uganda56. The authors observed that
providers asked 91% antenatal clients in DISH districts and 79% of clients in comparison
districts whether they were experiencing problems with their current pregnancy56. Boller
and colleagues however, noted that health personnel in the first tier facilities in Tanzania
carried out specific physical examinations such as weighing, palpation of fundus and
35
auscultation of foetal heart very frequently51. Findings in other parts of Africa do not
suggest substantial differences. In four rural underserved districts in Burkina Faso, Kenya
and Tanzania, tetanus toxoid vaccines were available at the majority of facilities in Kenya
and Tanzania and about half of those in Burkina Faso but essential consumable supplies
such as urine dipsticks, reagents for syphilis testing, malaria prophylaxis, and client
education materials on birth preparedness and obstetrics complications were not available
at many facilities, in the three countries49. Without these supplies, antenatal care providers
reportedly focused on taking clients pregnancy history, conducting the pallor test to detect
anaemia, and performing abdominal examinations - suggesting that important opportunities
to promote maternal health and to detect complications early were being missed. The
assessment demonstrated that no facility in Burkina Faso and only two in Tanzania had
HIV test kits while in Kenya 17% of facilities had HIV kits49.
In the Kenya Service Provision Assessment Survey, 79% of facilities offered ANC
services; one-third offered PNC, and 84% provided tetanus toxoid (TT) vaccines; while
one-third of facilities provided all three services50. Also, approximately three-fourths of
facilities offered ANC services five or more days per week, and 26% offered those services
one or two days per week. Similarly, tetanus toxoid services were usually offered five or
more days a week and almost all facilities offered tetanus toxoid on every ANC day50.
Among the facilities providing ANC/PNC services, only 36% had the capacity to test for
anaemia, 38% for urine protein and 39% for urine glucose. Hospitals and maternities,
private for-profit facilities and facilities in Nairobi were more likely than others to have the
capacity to conduct these tests.50 Blood pressure was measured during 90% of consultations
for both first-visit and follow-up clients, while three-fourths of first-visit clients received a
blood test for anaemia. Providers were more likely to measure blood pressure, conduct
urinalysis, and provide blood tests than they were to counsel clients about vaginal bleeding.
36
All the facilities offering ANC had anti-malarial available, and of those, 84% routinely
provided preventive anti-malarial as a component of ANC services.50
Minimum standards for ANC recommend at least four antenatal visits during pregnancy to
ensure proper care1, 60. In the Nigerian demographic health survey more than eight in ten
women had their weight measured and blood pressures taken, and almost two-thirds had
urine and blood samples taken while 45% respondents had received tetanus toxoid
vaccination1. However, for each of the specified components of ANC, women in urban
areas were more likely to receive the component than women in rural areas and older
women were likelier than younger women to report that they had received services.
Osungbade and colleagues in their cross sectional study of the content of ANC services of
six public secondary and six comprehensive health facilities in Osun State showed that the
number of services provided to pregnant women ranged from 3 to 12, with a mean of
8.7±1.6 services61. Pregnant women who booked in their third trimester had a significant
higher mean number of services, 9.1±1.4 than those who booked in the first trimester, 8.5±
1 and those who booked in the second trimester, 8.6±1.658. In both categories of facilities,
blood pressure measurement, abdominal palpation and detection of fetal heart rate services
were provided to all the respondents. History of previous and current pregnancies was more
likely to be taken in comprehensive health centers (92.5%) than in hospitals (87.3%) 58. A
cross-sectional study was carried out in Gnagna province (North-East Burkina Faso) in
200380. The operational capacities of health facilities were assessed, and a non-participating
observation of the antenatal care (ANC) procedure was undertaken to evaluate their quality.
Scores were established to summarize the information gathered and a total of 17 health
facilities were visited, and 81 antenatal consultations were observed80. Insufficiencies were
observed at all steps of ANC (mean total score for the quality of ANC was 10.3±3.0,
ranging from 6 to 16, out of a maximum of 20) and health facilities were poorly equipped,
37
and the availability of qualified staff remained low (mean total score for the provision of
care was 22.9±4.2, ranging from 14 to 33)80.
2.8 Client satisfaction with Antenatal care
Client satisfaction is a strong influencing factor in determining whether a person seeks
medical advice, complies with treatments and maintains a relationship with the provider
and health facility37.An essential factor that is considered in the analysis of quality of care
is the perception of clients as quality care is care that meets their perceived needs34, 35.
Fawole and colleagues in a cross sectional study of 395 previously booked pregnant
women randomly selected from private and public health facilities assessed the perceptions
of pregnant women on the quality of antenatal care in primary, secondary and tertiary
health facilities within Ibadan metropolis in southwestern Nigeria60. Satisfaction rate with
care received amongst the ante natal attendees was high (96.5%). However, in a study of
452 antenatal attendees, Oladapo and colleagues in Sagamu, southwestern Nigeria found a
lower level (81.4%) of client satisfaction with the care received at public primary health
care facilities53. Asekun-Olarinmoye and colleagues in a similar study of 289 randomly
selected pregnant women found an even lower satisfaction rating (77.5%) at a tertiary
health care facility in Ife Osun state 61. The major reason given by respondents (75.4%) for
non-satisfaction with the over-all perceived quality of care received in the clinic was time
wasting (mean total duration of time spent in the clinic was 2.53± 0.48 hours), whereas
43.3% women in the study by Oladapo and colleagues expected to be attended to within 30
minutes of arrival, their mean reported waiting time before consultation was 131.1
minutes53. Other reasons for non-satisfaction proffered by respondents in the study by
Asekun-olarinmoye were lack of privacy due to the presence of students (15.4%) and
boring health talks (13.8%) 61. Fifty-one respondents (17.6%) were not satisfied with the
quality of the health talk and their proffered reasons include the talk being too long (mean
38
duration of time spent on health talk was 25.50 minutes), boring or with inadequate content
in 85.4%, 53.6% and 25.5% of respondents respectively61.
Aldana and colleagues in their study of 1,913 persons chosen by systematic random
sampling of 55 fixed services and 42 outreach services in Bogra, a rural district in
Bangladesh found that a significant proportion of users (34.2%) were not satisfied with the
length of time that the facilities were open to the public while about a third (28.2%) of all
users were dissatisfied with the time they waited to receive care22. This is supported by
findings by Fawole and colleagues in Ibadan where 32.9% of clients rated the waiting time
to be inappropriate. The average waiting time for these users was 3.9± 1.4 hours while in
rural Bangladesh it was 57.1 ± 4.2 minutes. Furthermore, Aldana and colleagues found
that patients presenting for maternal care were significantly more dissatisfied (37.6%) than
clients presenting for other types of services22. The average waiting time clients would be
satisfied with was 10.6 ±0.3 minutes22. Half the clients considered 8 minutes the maximum
time they could wait in order to be satisfied, whereas only 25% would accept ≥12 minutes.
Waiting time expectations did not vary significantly among patients presenting for different
services or among fixed and outreach facilities22. In addition, individual variables such as
sex, marital status, level of education, number of children and occupation did not have
significant influence22. This however, contrasts findings by Fawole and colleagues and
Asekun- Olarinmoye and colleagues in Nigeria where associations were demonstrated
between waiting time and the level of education, socio-economic status, religion, parity and
occupation of the clients60, 61. Nisar and Amjad in their study of patterns of antenatal care at
a public sector hospital in Hyderabad Sindh Pakistan, (another developing country),
satisfaction with overall care was rated low (49.6%) and an even lower rating (36.6%) of
satisfaction with getting medicines was found59. Most (86.2%) of the clients in the same
study had waited for over two hours for checkups59. In contrast, Bessinger and Katende in
39
Uganda showed that almost all (97% and 100% respectively) antenatal clients reported
being satisfied with services and being treated well by both the provider and other clinic
staff56. Although the antenatal clients reported that they were treated well by the provider,
only about one-half of the clients said that they felt comfortable asking questions, and just
over one-quarter actually asked the provider any questions56. Many antenatal clients in this
study however, were not satisfied with the waiting time. Forty-three percent of DISH
clients and 35% of non-DISH clients reported that the waiting time was long or too long,
and almost a third of clients in both districts waited for over two hours to see the
provider56. This is comparable to findings by Fawole and colleagues where more than half
(58.0%) of the respondents spent between two-four hours, while 36.0% spent >4 hours at
each visit60. Bessinger and Katende established that the average time spent with the
provider was relatively short56. A first antenatal care visit lasted an average of 15 minutes,
whereas clients coming for a follow- up antenatal care visit spent 10 minutes with the
provider56. Other studies report similar short consultation time22, 61.
40
CHAPTER 3
MATERIALS AND METHODS
3.1 Study area
This study was carried out in Rivers State in south-south Nigeria. The State has twenty
three local government areas (LGAs), (four urban and nineteen rural). Administratively it is
made up of three senatorial districts which are Rivers South-East, Rivers East and Rivers
West senatorial districts. It is oil producing State with oil and gas exploration and servicing
industries. It has its capital as Port Harcourt, a cosmopolitan city that has sea ports, an
international airport and other large, medium and small scale industries. The main
occupational groups are professionals, artisans and small scale businesses such as trading,
in the urban and semi urban areas while the rural areas which are basically uplands and
riverine/creeks have farming and fishing as the predominant occupations.
The study sites were primary health care facilities that provide ANC and delivery services
in two local government areas of Rivers state- Port Harcourt city local government area and
Gokana local government area.
Port Harcourt city local government area is an urban LGA and headquarters of the Rivers
south-east senatorial district. It is located in the southern fringes of Rivers state about 41
kilometres from the Atlantic coast. Administratively it is made up of 20 wards and has a
total population of 598,206 and an estimated 131,605 women of reproductive age as well as
an estimated 29,910 pregnant women15. Port Harcourt city has 13 PHC facilities of which
eight offer maternal and child health services.
Gokana local government area is a rural LGA in the east senatorial district of Rivers State.
Administratively it is made up of 17 wards and has a total population of 252,971 and an
estimated 55,654 women of reproductive age as well as an estimated 12,649 pregnant
women15. Gokana LGA has 17 PHC facilities and seven of these offer MCH services. The
41
cadres of personnel at the primary health centres are medical officers (who are often
national youth service doctors), public health nurses, nurse midwives, community health
officers, community health extension workers, medical records officers and laboratory,
dental and pharmacy technicians and assistants. Supervision of activities at the primary
health facilities is headed by the PHC coordinator of the LGA.
3.2 Study design
This is a comparative, cross-sectional study of quality of care at antenatal clinics of
selected urban and rural PHC facilities.
3.3 Study population
The study population comprised ANC clients who received care from the selected primary
health care facilities during the study period. The clients were aged 15- 49 years and were
attending ANC clinic on their subsequent visits in the index pregnancy. Also included in
the study were health care workers who provide ANC to the clients in the PHC facilities in
both local government areas during the study period. The health care providers were
nurses, midwives, community health officers and community health extension workers.
The medical officers who were national youth service corps doctors were excluded as the
antenatal clinic days coincide with their community development activity day in the State.
3.4 Sample Size Estimation
The sample size for the assessment of client satisfaction was determined using the formula
for calculating sample size for the comparison of two proportions64.
n = Z1-α √ 2p (1-p) + Z1- β √ p1 (1-p1) + p2 (1-p2) 2
(p1-p2 )
Where
n = Minimum sample size for each group
Z1-α = Standard normal deviate corresponding to the probability of
making type I error (α) at 5% = 1.96
42
Z1- β = Standard normal deviate corresponding to the probability of
making type II error (β) of 10%. Power at 90% = 1.28
p1 = Proportions of clients who were satisfied in urban areas
p2 = Proportions of clients who were satisfied in rural population
assuming a satisfaction differential of 10% between urban and rural
dwellers
p = Mean of the two proportions- (p1+p2)/ 2
Results from a study done in Ibadan metropolis showed that 96.5% of clients were satisfied
with the services rendered60.
Therefore, P1 =96. 5% P2 = 86.5%
p = (p1+p2)/ 2= (96.50+86.5)/2 = 183/2 = 91.5%
n = 1.96 √ 2(91.5) (100-91.5) + 1.28 √ 96.5 (100-96.5) + 86.5 (100-86.5) 2
(96.5-86.5)
n = 161.2
Thus minimum sample size for each of the two groups was approximated to 162.
In order to compensate for non-response (a response rate of 90% was anticipated):
The minimum sample size per group ns100
= n ⁄0.90 = 162⁄ 0.90 = 180 per group. However,
a total of 514 antenatal attendees were interviewed: 260 respondents at the urban health
facilities and 254 at the rural health facilities.
3.5 Sampling technique
A multi stage sampling technique was used to select health facilities.
Stage I: There are 23 local government areas in Rivers State. One urban (Port Harcourt
city LGA) and one rural (Gokana LGA) were selected by balloting from a sampling frame
of the four urban and 19 rural LGAs respectively.
Stage II: A sampling frame of the PHC facilities in the selected urban and rural LGAs was
constructed with information obtained from the PHC coordinators of the selected LGAs.
The selected facilities were those who offer antenatal care services and attended to at least
10 antenatal clients per clinic day. Similar procedure was carried out in the assessment of
43
quality of care in Tanzania51. The selection of the health facilities were also made to fulfil
the requirement of covering at least 25% of the health care institutions in an area when
assessing quality of health care62, 63. In Port Harcourt city local government area
(PHALGA) a total of thirteen (13) PHCs were listed but only eight were providing ANC.
Using a table of random numbers four facilities were selected by simple random sampling
from the eight facilities that offered ANC. Similarly at Gokana LGA, a total of 17 PHCs
were listed out of which seven (7) offered ANC services. However, only four (4) met the
requirement of a minimum of 10 antenatal clients per visit per facility. Therefore in Gokana
LGA all four facilities that met the inclusion criterion were selected. A total of eight
facilities for both the urban and rural LGA’s were assessed. The urban health facilities were
Mini health centre Mile 3, FSP Orogbum, Churchill health centre and Potts Johnson health
centre while facilities selected at the rural level were B- Dere, K-Dere, Bomu and Kpor
health centres.
Selection of clients: Antenatal clients were selected using proportional to size sample
allocation based on the average turnover of clients over the preceding 12 months in
selected health centres. Eligible and consenting clients were consecutively recruited during
antenatal clinic days till the sample size was realized. Thus for each facility the number of
clients that were recruited for the study was calculated using the formula
N = Average monthly clinic attendance in the facility under study X Sample size
Total number of clients in all the selected health facilities
N was the number of clients that were recruited for each facility.
44
3.6 Research instruments
The study used a definition of quality of health care based on the framework by
Donabedian 20, 21. Structural inputs, process and outcomes were assessed in this study using
a triangulation of instruments. This was to ensure that wide ranges of quality issues were
captured and a fully rounded analysis of quality of antenatal care services is achieved. The
research instruments were observation checklists and semi structured questionnaires.
Health worker interview questionnaire (Appendix 1): This was a self administered
questionnaire that consists of 15 questions and in two parts; the first part explored the
socio- demographic data such as the age, sex, cadre and the duration of work experience of
the health care workers, while the second part dealt with supervision questions such as if
they had schedules for visits and last supervisory visit. Also questions on recent training
and their perceptions on the difficulties faced in carrying out their duties were asked. The
questions were a combination of open ended and closed ended where they were expected to
tick their response.
Client exit interview (Appendix 2): This was a four part interviewer administered
questionnaire that was a modification of MEASURE service provision assessment exit
interview for antenatal care client67. The questionnaire explored the socio- demographic
characteristics such as the age, marital status, religion; ethnicity, occupation and income of
the clients. Also the obstetric history such as parity, family planning awareness and practice
were explored. The clients’ experiences and perceptions of services received were also
explored and a fourth section on their level of satisfaction with the various aspects of the
services received. Responses to questions were varied; a few questions were open ended,
some responses were “yes or no and don’t know, undecided or can’t remember,” while in
some questions their responses were to be circled from a list of options.
45
The observation checklists were an adaptation of checklists as described by national
standards of personnel and essential equipment for PHC centres ANC/interview room and
performance standards for the assessment of process attribute of care 65, 66. The checklists
were used to audit the facility equipment (appendix 3) and physical infrastructure, drugs
and supplies and to observe provider-client interaction (appendix 4); personnel
(appendix5).
The observation checklist of essential equipment had a total of 15 items that were listed and
the minimum quantity required per facility as well as columns to indicate items that were
present or absent. The last column remark was to indicate if item was functional or not.
Appendix 4 is a checklist for assessment of general infrastructure, process attributes of
antenatal care and drugs/ supplies. The checklist had four columns. The first column
indicates attribute of quality being assessed, second column for description / item for
observation, third column for maximum score that was attainable per item observed and the
fourth column for score that was awarded to the facility being assessed.
The checklist of process of care was made up largely of lists of tasks that providers were
expected to carry out in their interaction with client (history and physical examination),
treatment and health information provided to client during consultation.
Appendix 5 is a checklist of proposed health manpower for PHC facility and comprised of
six cadres of manpower for PHC facility65. Each cadre had a minimum number of staff that
was required for each PHC facility stated against it.
3.7 Data collection
Data was collected between May and October 2009. Data was first collected at the urban
health facilities from the first week of May to the second week of June and data collection
days were on antenatal clinic days which were Tuesdays and Thursdays. At the rural health
facilities data was collected from the third week of June to the last week of October and
46
data collection days were Thursdays when clients presented for antenatal clinic follow up
visits. Data collection in the urban facilities lasted for about seven weeks due to larger
client load than the rural health facilities. On each interview day, the research team were
introduced to clients by the head of the facility at the patient waiting area where prayers
and health talks are held. After the introduction, the principal investigator explained the
purpose of the research and the eligibility criteria to the clients and answered questions that
arose. Eligible and consenting clients were recruited after they had been seen by health care
providers (i.e. at the end of consultation). Exit interviews were done in a quiet place away
from the consulting area to provide privacy and enable clients express themselves freely.
Informed consent was obtained verbally and data was collected using interviewer
administered questionnaire by four research assistants. The research assistants were one
national youth corps, an undergraduate of a tertiary institution and two secondary school
certificate holders. They had undergone two day training on how to collect accurate data
using the instrument. The research assistants were assessed for consistency and method of
validation of responses and where defects were observed necessary corrections were made.
The questionnaire was designed in English; however, clients who did not understand
English had the questions translated to them in their native language. Each questionnaire
took about 15 minutes to complete. In order to avoid double entry of clients who had been
previously interviewed during earlier antenatal visits, the index numbers on the antenatal
cards of the clients were recorded on clients’ questionnaires and cross checked at the end of
each day with previously completed questionnaires. Where the same index numbers were
found, only one was used for analysis in the study. However, when a client requested to be
interviewed more than once, she was obliged by the interviewer but the questionnaire was
not included in the data for analysis.
47
A total sample of all consenting health care providers present on each antenatal clinic day
during the study period was done using a time cluster sampling technique i.e. self
administered questionnaires were distributed by the principal investigator only to those
present/ on duty during the ANC clinic hours. A total of 25 urban and 22 rural health care
workers were available for the interview of a total of 68 urban and 45 rural health care
workers on the nominal roll provided by the heads of facilities. However, explanations
provided by heads of facilities for the discrepancies in the number of those who were
available for interview and the total health workers in the nominal roll were that some were
working in other shifts (evening and night shifts), a few were on leave/ off duty and some
who were JCHEWS were working in the community, hence could not participate during
the antenatal clinic hours. Those providing antenatal services at the urban health facilities
were nurse midwives, public health nurses and CHOs while at the rural health facilities,
services were provided by community health officers and community health extension
workers. There was only one public health nurse in the rural health facilities and did not
participate actively in providing clinical care to clients during the study period.
Observations of client- provider interactions were done by the author in the sampled health
facilities. At each facility, observation of the first ten client-provider interactions (similar
procedure was carried out in other studies75, 80,) was done using a modification of checklist
for process attribute66 (appendix 4). The health workers were not told the purpose of the
observation so as not to bias the findings. The author sat in the consulting room to observe
as well as listen during the consultation by the health worker. The observer however
appeared to be doing something else such as checking records i.e. not making it obvious to
the providers that they were being observed.
48
In each health facility, equipment, personnel, infrastructure, drugs and supplies checklist
was also completed by the investigator who interviewed the head of the facility. The
responses were confirmed by physical inspection of all available equipment and supplies.
3.8 Eligibility criteria
For the purpose of this study, questionnaires were administered to clients who had attended
the health care facility for their second or subsequent antenatal visit in the index pregnancy
at the time the study was conducted because the clients needed to be sufficiently exposed to
the service in order to form their own opinion on the quality of care they had received. This
is similar to procedure described in studies of antenatal clients in developing countries 60, 68,
103. Also excluded were pregnant staffs of the facility who received ANC from the same
facility they work in since the study was a service assessment study.
3.9 Validity: Face and construct validity was done by presenting the instruments to two
methodology and content experts. The questionnaires were pre tested in a primary health
care facility that was not enlisted for the study but was similar to the PHC facilities at the
study sites in terms of services provided to antenatal clients. This facility was Obio health
centre in Obio-Akpor LGA .After the pre-test, appropriate amendments were made to the
questionnaire prior to commencement of the study.
3.10 Data analysis:
Data was cleaned, collated and analysed using Statistical Package for the Social Sciences
(SPSS) version 16.0. Frequencies were generated and presented using tables and chart. Chi
square and Fisher’s exact tests were used to compare proportions across the various aspects
of care that were studied. Level of significance was set at p < 0.05. Other quantitative data
were summarised using mean, standard deviation, median and range.
In order to facilitate comparison of the dimensions of client satisfaction without
compromising the precision of the Likert scale, the subscales were split into dichotomous
49
variables representing “satisfaction” versus “dissatisfaction”69. Dichotomous variables
were created such that the two Likert points at the favourable end of the satisfaction scale
were recoded as “satisfied” while the three Likert points at the unfavourable end of the
satisfaction scale were recoded as “dissatisfied”. The choice of this cut-off is similar to
procedures described in other studies70, 71, 72, and 73.
To determine overall satisfaction for each group, the maximum item score of five was
multiplied by the total of nine items in the subscales to yield a total of 45 and a composite
score of ≤ 27 was recoded as “dissatisfied” while a score of ≥ 28 was recoded as
“satisfied”.
Summary of scores of elements denoting quality antenatal care (structural, process
and outcome):
Structural attributes: In order to allow for comparison of quality of care in both locations,
the total number of items under study in each domain was multiplied by the number of
facilities in each location to yield the maximum obtainable score. In the case of general
infrastructure for example eight (8) items were assessed in four facilities in each location.
Therefore in order to derive maximum obtainable score for general infrastructure, 8 items
were multiplied by 4 to yield 32 which was the maximum obtainable score for general
infrastructure.
Process attributes: The quality of services was scored on the basis of percentage of
activities performed correctly using the checklist for each element of antenatal services.
Percentages for different activities were pooled and then divided by number of activities/
location of the facilities to obtain overall grading of the health facilities. This result was
then multiplied by the number of observations to obtain overall score for the item being
analyzed.
50
Outcome attributes: Percentages for different activities were also pooled and then divided
by number of activities. This result was then multiplied by the maximum obtainable score.
Grading of quality of antenatal care:
Total score for each attribute was obtained by adding all the item scores. Furthermore,
quality scores representing very good, good, average, poor and very poor were deduced
using percentage scores under each attribute as well as the total scores. Calculated class
boundaries were approximated to the nearest whole number. Thus, in each domain of
attribute assessed, grading of the quality of antenatal services for each location was done
using 5 points scale as shown below
Quality score (%) Rank Grade
80+ 5 Very good
61- 80 4 Good
41- 60 3 Average(fair)
21- 40 2 Poor
0- 20 1 Very poor
3.11 Ethical considerations
Permission to carry out the study was obtained from the Rivers State Ministry of
Health and the PHC coordinators of the selected LGAs.
Ethical clearance for the study was obtained from the research and ethics committee
of University of Port Harcourt Teaching Hospital.
Verbal informed consent was obtained from each participant after the study was
explicitly explained to them.
51
To ensure confidentiality, no name was recorded on the questionnaires, instead
serial numbers were used to identify respondents and data was kept secure
throughout and after the study.
Refusal to participate in the study or withdrawal did not attract any penalty for the
respondent as this pertains to clients being seen on time and not discriminated
against.
3.12 Study limitations:
The presence of the principal investigator in the consulting room during the
consultation may have improved the clinical practices of the health care providers
(Hawthorne bias).
52
CHAPTER 4
RESULTS
Section I: Structural Attributes
Table 1: Infrastructural attributes of health facilities by location
General infrastructure Facilities with recommended minimum
Urban health facilities Rural health facilities
N=4 N=4
n (%) n (%)
Waiting area 4 (100.0) 4 (100.0)
Privacy of examination 4 (100.0) 4 (100.0)
room
Toilet facility 2 (50.0) 1 (25.0)
Water for hand washing in 3 (75.0) 4 (100.0)
examination room
Laboratory 3 (75.0) 2 (50.0)
Strong floors and walls 3 (75.0) 4 (100.0)
Clean facility 2 (50.0) 3 (75.0)
Clean toilet 1 (25.0) 1 (25.0)
53
Table 1 presents the infrastructural attributes of health facilities by location. In both study
locations, all the health facilities surveyed had adequate waiting areas and adequate privacy
in the examination rooms. More health facilities in the rural areas had strong floors and
walls (100% versus 75%), water for hand washing (100% versus 75%) and clean facilities
(75% versus 50%) than the urban. However in the urban area more facilities had laboratory
than the rural area (75% versus 50%). Toilet facilities were inadequate in both locations
but this was more in the rural area where only one (25%) facility had toilet facility
compared to two(50%) facilities in the urban area.
54
Equipment
Table 2: Available functional equipment at health facilities by Location
Available and functional equipment
(recommended minimum*)
Facilities with recommended
minimum
Urban n (%) Rural n (%)
Examination couch (1) 4 (100) 4 (100)
Weighing scales (1) 4 (100) 4 (100)
Sphygmomanometer (1) 4 (100) 4 (100)
Stethoscope (1) 4 (100) 4 (100)
Stainless steel bowls (1) for washing hands 4 (100) 4 (100)
Covered stainless bowls (2) for cotton wool 4 (100) 3 (75.0)
Mackintosh sheet (2) 4 (100) 2 (50.0)
Foetal stethoscope (2) 4 (100) 1 (25.0)
Height measuring stick (1) 3 (75.0) 2 (50.0)
Angle poised lamp (1) 3 (75.0) 2 (50.0)
Thermometer (2) 3 (75.0) 1 (25.0)
Pen torch (1) 3 (75.0) 0 (0)
Tongue depressor (6) 1 (25.0) 1 (25.0)
Latex disposable gloves (20 packs of 100 units) 1 (25.0) 0 (0)
Urine dip sticks (20 packs of 100 units) 1 (25.0) 0 (0)
* Recommended minimum NPHCDA 65
The number of facilities which had the recommended minimum (as stipulated by the
NPHCDA65) number of equipments is shown in Table 2. Examination couches, weighing
55
scales, sphygmomanometer, stethoscopes and stainless steel bowls for hand washing were
up to the recommended minimum number in all facilities in both study sites. None of the
rural facilities had the recommended number of units for latex hand gloves, pen torch and
urine dipsticks. All other essential equipments were present in more urban facilities than
the rural facilities. Only one (25%) facility each in both the urban and the rural areas had
the required number of tongue depressors.
Drugs and Supplies
Table 3: Availability of recommended drugs and supplies
Drugs and supplies Proportion of facilities with available drugs and supplies
Urban Rural
Iron tablets
n (%)
4 (100)
n (%)
4 (100)
Folic acid 4 (100) 4 (100)
Paracetamol 4 (100) 4 (100)
Penicillin antibiotics 4 (100) 4 (100)
Anti malarial (IPT) 4 (100) 4 (100)
Tetanus toxoid vaccine 4 (100) 4 (100)
Insecticide treated net
(ITN)
1 (25.0) 4 (100)
Vitamin A capsules 3 (75.0) 1 (25.0)
Table 3 shows the availability of drugs and supplies in health facilities by location. Six
items were available in all facilities at both the urban and rural areas. These items were iron
tablet, folic acid, paracetamol, penicillin antibiotics, anti- malarias and tetanus toxoid
56
vaccine. However, insecticide treated net was available in only 1 (25%) urban facility
compared to 4(100%) facilities at the rural area. 75% of the urban facilities had Vitamin A
capsules compared to only 25% at the rural area.
Personnel
Table 4: Staff disposition by location
Cadre of staff (recommended minimum65) Proportion of facilities with
recommended minimum
Urban Rural
n (%) n (%)
CHEW(3) 4 (100) 3 (75.0)
CHO (1) 4 (100) 2 (50.0)
PHN (1) 4 (100) 1 (25.0)
Medical Assistant (1) 3 (75.0) 2 (50.0)
Nurse/Midwife (4) 1 (25.0) 0 (0)
JCHEW(6) 0 (0) 0 (0)
Key:
* CHO Community health officer
* PHN Public health nurse
* CHEW Community health extension worker
*JCHEW Junior community health extension worker
Table 4 shows the staff disposition for each study site; all cadres of staff were found more
in adequate numbers in the urban sites compared to the rural except for the JCHEWs which
neither the urban nor the rural health facilities had in recommended numbers. In addition
none of the rural health facilities had adequate numbers of nurse/ midwives while only one
of the urban health centres did. All the urban centres however had the required numbers of
CHOs, PHN and CHEWs.
57
Section II: Process of care
100
92.5
95
52.5
30
17.5
2.5
2.5
0 20 40 60 80 100 120
client offered seat
explains useof drugs
greets client
privacy
asks about concern
explains diagnosis
non-interruption of speech
explains examination
rural
urban
Figure 1: Interpersonal aspect of care - Percentage of clients receiving attribute of care
Figure 1 presents interpersonal aspect of care in the study locations. Observations of client-
provider interaction revealed that all the clients in both study sites were offered seats.
However more of the rural clients (95.0%) were greeted by the health care providers, had
their privacy ensured (52.5%) and were given explanations on the use of drugs (92.5%)
compared to clients at the urban health facilities (77.5%), (25%), and (87.5%) respectively.
None of the clients in the urban and almost all (97.5%) of the clients in the rural facilities
58
had no explanations before examinations were carried out. Explanations on diagnosis were
more often provided at the urban health facilities (42.5%) than in their rural counterparts
(17.5%). Interruption of clients’ speech by the health care provider during the consultation
process was common in both sites, but was more frequent in the rural as only 2.5% of
clients did not have their speech interrupted compared to 7.5% in the urban facilities.
59
Technical Aspects of Care
Table 5: Observed technical aspects of care by location of health facility
Some technical care characteristics
assessed
Client-provider interactions observed
Urban
N=40
Rural
N=40
n (%)
History taking n (%) n (%)
General history taking 3 (7.5) 9 (22.5)
History for malaria 9 (22.5) 7 (17.5)
History for UTI
0 (0.0) 2 (5.0)
Physical examination
Blood Pressure check 40(100.0) 40(100.0)
Examination for fundal height, foetal
heart/position
40(100.0) 40(100.0)
Checking eyes/ palms for pallor 7(17.5)
0(0)
Investigation
Haemoglobin check 40(100.0) 40(100.0)
Urine glucose and albumin 40(100.0)
30(75.0)
Health Education
Health Education for nutrition
30(75.0) 40(100.0)
Health education for prevention of
malaria
30(75.0) 40(100.0)
60
The technical aspects of care by location of health facilities are shown in table 5. General
history taking was done infrequently, 7.5% in the urban centres and 22.5% in the rural
centres. More clients in the urban centres were asked about a history of malaria 22.5%
versus 17.5% in the rural areas. History about symptoms of urinary tract infections was not
obtained from any client in the urban health facilities and only from 5% in the rural health
facilities. Most required examinations were carried out in both study locations with the
exception of examining the eyes or palms for pallor which none of the rural clients had
done and only 17.5% of those in the urban health facilities had checked. Health education
on nutrition and prevention of malaria were done more often in the rural centres.
61
Section III: Client exit interview
Table 6: Socio-demographic characteristics of clients by location of health facility
* Occupational class85, 87
Variables Urban
N = 260
Rural
N = 254
χ2
p-value
Age group(years)
15 – 24
25 – 34
35 – 44
Mean age ± SD
n(%)
75(28.8)
172(66.2)
13(5)
27 ± 4.4
n(%)
130(51.2)
108(42.5)
16(6.3)
25.2 ± 5.3
26.62
0.000
Educational level
No formal education
Primary completed
Secondary completed
Post secondary
6(2.3)
22(8.5)
154(59.2)
78(30.0)
18(7.1)
78(30.7)
143(56.3)
15(5.9)
Tribe
Indigenes
Non- indigenes
142(54.6)
118(45.4)
228(89.8)
26(10.2)
Religion
Christianity
Islam
Traditional
252(96.9)
7(2.7)
1(0.4)
248(97.6)
5(2.0)
1(0.4)
Marital status
Single/never married
Cohabiting
Married
Others(divorced,separated,widowed)
3(1.2)
8(3.0)
249(95.8)
0(0)
17(6.7)
31(12.2)
202(79.5)
4(1.6)
32.19
0.000
Occupation *
Professional
Skilled
Partly skilled
Unskilled
7(2.7)
57(21.9)
114(43.8)
82(31.5)
42(0.8)
47(18.5)
128(50.4)
77(30.3)
Monthly income
< N7,500
≥N7,500
117(45.0)
143(55.0)
181(71.3)
73(28.7)
36.37
0.000
62
Table 6 shows clients’ socio-demographic characteristics by location of health facility.
Clients at the urban health facilities were older with a mean age of 27 ± 4.4 years compared
to clients at the rural health facilities who had a mean age of 25.2 ± 5.3 years. The majority
172(66.2%) of the urban respondents were aged between 25-34 years whereas the majority
130(51.2%) of the rural respondents were aged 15-24 years (p<0.001). Likewise a
significantly higher proportion, 154(59.2%) respondents who had completed secondary
education were found at the urban health facilities compared with 143(53.3) respondents at
the rural health facilities (p = 0.001). The marital status of respondents also differed
significantly with a higher proportion 249(95.8%) respondents being married at the urban
health facilities compared with 202(79.5%) at the rural health facilities (p< 0.001). Similar
proportions of respondents in both areas were Christians and partly skilled workers.
However more, 143(55.0%) urban clients earned more than N7, 500 monthly when
compared with the rural clients 73(28.7%).
63
Table 7: Obstetric characteristics of clients by health facility
Obstetric
characteristic
Urban
N = 260
Rural
N = 254
Test statistics
χ2
p-value
Parity
Primi parous
Multiparous
n(%)
118(45.4)
142(54.6)
n(%)
68(26.8)
186(73.2)
19.27
0.000
G.A* at booking
in trimesters
1st Trimester
2nd Trimester
3rd Trimester
Mean G.A at
booking
35(13.5)
190(73.1)
35(13.5)
20.6 ± 5.8
21(8.3)
187(73.6)
46(18.1)
21.7 ± 5.7
4.948
0.084
History of
miscarriage
Yes
No
46(17.7)
214(82.3)
55(21.7)
199(78.3)
1.277
0.258
History of still
birth
Yes
No
23(8.8)
237(91.2)
24(9.4)
230(90.6)
0.56
0.813
Family planning
awareness
Yes
No
231(88.8)
29(11.2)
203(79.9)
51(20.1)
7.787
0.005
Family planning
practice
Yes
No
54(20.8)
206(79.2)
52(20.5)
202(79.5)
0.007
0.934
G A* – Gestational age
64
Table 7 shows respondents’ obstetric characteristics by health facility. There was a
significantly higher proportion of primiparous respondents, 118(45.4%) at the urban health
facilities compared with 68(26.8%) at the rural health facilities (p < 0.001). Conversely,
there were 186(73.2%) multiparous respondents at the rural health facilities compared with
142(54.6%) at the urban health facilities. Histories of miscarriage and still birth were not
significantly different between the urban and rural respondents. Most urban respondents
190(73.1) booked in the second trimester similar to 187(73.6%) respondents at the rural
health facilities (p = 0.084). There was a significantly higher(88.8%) proportion of clients
in the urban health facilities who were aware of family planning compared with 79.9% of
clients in the rural health facilities( p= 0.005). Family planning practice was low(21%) in
both settings.
Clients’ experiences and perceptions of aspects of services: With regards to waiting time
a higher proportion188 (55.5%) of clients at the rural health facilities had waited > 60
minutes compared with 151 (44.5%) of clients in the urban health facilities (p=0.001).
Similarly on their perception of waiting time, a higher proportion 145 (57.1%) of the
clients at the rural health facilities reported that the waiting time was too long compared to
127 (48.9%) of the clients in the urban health facilities (p= 0.06). Concerning the cost of
service; a higher proportion 143(55.0%) of clients in the urban health facilities perceived
the cost of service to be cheap compared with 96 (37.8%) of the clients in the rural
facilities (p=0.001). Furthermore, 219 (84.2%) of the clients in the urban facilities reported
that the clinic hours were all the time convenient compared to 171(67.3%) clients in the
rural facilities (p=0.001).
65
Table 8: Clients’ satisfaction with selected aspects of care by location of health facility
Variables
Urban
N=260
Rural
N=254
χ2
p-
value
Satisfied
n (%)
Dissatisfied
n (%)
Satisfied
n(%)
Dissatisfied
n (%)
Discussion of
concerns about
pregnancy
251(96.5) 9(3.5) 244(96.1) 10(3.9) 0.082 0.775
Explanation of
diagnosis/treatments
246(94.6) 14(5.4) 240(94.5) 14(5.5) 0.004 0.949
Availability of drugs 241(92.7) 19(7.3) 227(89.4) 27(10.6) 1.740 0.187
Examination of
client
234(90.0) 26(10.0) 233(91.7) 21(8.3) 0.464 0.496
Privacy during
examination
233(89.6) 27(10.4) 221(87.0) 33(13.0) 0.847 0.357
Privacy during
discussion
222(85.4) 38(14.6) 229(90.2) 25(9.8) 2.722 0.099
Convenience of
hours of service
208(80.0) 52(20.0) 197(77.6) 57(22.4) 0.458 0.498
Cleanliness of
facility
189(72.7) 71(27.3) 195(76.8) 59(23.2) 1.132 0.287
Waiting time 149(57.3) 111(42.7) 93(36.6) 161(63.4) 22.08 0.000
Table 8 shows clients’ satisfaction with various aspects of the health service. The highest
satisfaction 96.5% was reported for ability to discuss concern about pregnancy with
provider in the urban facilities similar to 96.1% of the rural clients. Waiting time was the
area of least satisfaction in study locations, 36.6% in the rural and 57.3% in the urban
health facilities (p < 0.001).
66
Satisfaction rates for other aspects of service were high with no statistically significant
differences between the urban and rural respondents.
Table 9: Clients’ overall satisfaction by location of health facility
Location Satisfied Dissatisfied Total
Urban 251(96.5) 9(3.5) 260(100)
Rural 238(93.7) 16(6.3) 254(100)
Total 489(95.1) 25(4.9) 514(100)
χ2 = 2.24; p = 0.135
Table 9 shows overall satisfaction by location of health facilities. More respondents
251(96.5%) from the urban health facilities reported they were satisfied with all aspects of
service compared to 238(93.7%) respondents in the rural area (p = 0.135).
67
Table 10: Socio- demographic characteristics of clients and their association with
client satisfaction
Socio-demographic
characteristics
Urban health facilities
N=260
Rural health facilities
N=254
Satisfied Dissatisfied
n (%)
Satisfied Dissatisfied
n (%)
Age
30 years and below
31 years and above
203(95.8) 9(4.2)
48(100) 0(0)
Fisher’s exact test p=0.218
207(94.1) 13(5.9)
31(91.2) 3(8.8)
Fisher’s exact test =0.364
Marital status
Currently married
Not currently married
240(96.4) 9(3.6)
11(100) 0(0)
Fisher’s exact test p=1.000
190(94.1) 12(5.9)
48(92.3) 4(7.7)
Fisher’s exact test p=0.748
Educational level
Primary & Below
Secondary & Above
28(100.0) 0(0)
223(96.1) 9(3.9)
Fisher’s exact test p=0.603
95(99.0) 1(1.0)
143(90.5) 15(9.5)
χ2=7.227, p= 0.006
Ethnicity
Non-indigenes
Indigenes
114(96.6) 4(3.4)
89(96.7) 3(3.3)
Fisher’s exact test p=1.000
25(96.2) 1(3.8)
184(95.3) 9(4.7)
Fisher’s exact test p=1.000
Monthly income
< N 7,500
≥ N 7,500
112(95.7) 5(4.3)
139(97.2) 4(2.8)
Fisher’s exact test p=0.735
173(95.6) 8(4.4)
65(89.0) 8(11.0)
Fisher’s exact test p=0.082
68
Table 10 shows socio- demographic factors associated with client satisfaction. None of the
socio-demographic characteristics were significantly associated with satisfaction with care
in both study sites except the level of education in the rural health facilities where more
(99.0%) respondents who had primary or less education were likely to be satisfied
compared with (90.5%) respondents who had secondary or more education (p = 0.006).
Table 11: Association between selected variables and client satisfaction
Variables Urban respondents N=260
Satisfied n (%)
Rural respondents N=254
Satisfied n (%)
Yes No Yes No
Number of visits
4 visits or less
5 visits or more
168(96.0) 7(4.0)
83(97.6) 2(2.4)
Fisher’s exact test p=0.722
186(94.4) 11(5.6)
52(91.2) 5(8.8)
Fisher’s exact test p=0.365
Waiting time
<1 hour
≥1 hour
107(98.2) 2(1.8)
144(95.4) 7(4.6)
χ2=1.486 p= 0.223
61(92.4) 5(7.6)
177(94.1) 11(5.9)
χ2=0.246 p= 0.620
Table 11 shows association between selected variables and client satisfaction. The selected
variables were not significantly associated with clients’ satisfaction with care.
69
Content of health talk
Table 12: Proportion of clients who received health information in clinic by location
of health facility
Variables Urban
N=260
Rural
N=254
Information on recognition of warning
symptoms/signs in pregnancy
n(%)
n (%)
Swollen face/hands/legs 177(68.1) 192(76.0)
Bleeding
165(63.5) 188(74.0)
Headache/blurred vision 178(68.5) 208(82.0)
Tiredness/breathlessness
169(65.0)
213(84.0)
Fever 166(64.0) 219(86.2)
Health talk topics received by ANC clients
HIV counselling and testing 221(85.0)
213(84.0)
Breast feeding 205(79.0)
213(84.0)
Prevention of malaria 192(74.0)
202(80.0)
Prevention of STIs 161(62.0) 191(75.2)
Breast self examination 143(55.0) 181(71.3)
Child spacing 137(53.1) 180(71.1)
Prevention of cervical cancer 10(0.04) 30(0.12)
Table 12 shows the proportion of clients who received information on recognition of
warning symptoms/signs in pregnancy and other health talks as reported by the clients. The
most frequently reported warning signs mentioned at ANC clinics in rural health facilities
were fever (86.2%), tiredness and breathlessness (84.0%), headache/ blurred vision
(82.0%) while at the urban health facilities headache/ blurred vision (68.5%), swollen
face/hands and legs (68.1%) and tiredness and breathlessness (65.0%) were reported.
70
Frequently reported health topics that were received in ANC clinics in both settings were
HIV counselling and testing, breast feeding and prevention of malaria. However, by eye
balling the proportion of respondents in the rural health facilities who had received the
various health information where more compared to their urban counterparts with the
exception of HIV counselling and testing where the urban respondents were slightly more
(85.0%) than their rural respondents (84.0%).
71
Section IV
Table 13: Summary of scores of attributes denoting quality antenatal care
Attribute
(maximum obtainable score)
Urban facilities
Total composite
score (%)
Rural facilities
Total composite
Score (%)
Structural attributes
General Infrastructure(32) 22(68.7) 23(71.8)
Equipment(60) 47(78.3) 32(53.3)
Drugs and supplies(32) 28(87.5) 29(90.6)
Personnel(24) 16(66.6) 8(33.3)
Process of care
Interpersonal aspect of care(40) 19.6(49.0) 19.6(49.0)
Technical aspect(40) 23.9(59.7) 24.8(62.0)
Outcome
Client satisfaction (10) 9.7(97.0) 9.4(94.0)
Health education(20) 12.3(61.5) 14.5(72.5)
Note:
Test of statistics not valid as N =4 therefore, S.D will be more than the mean.
72
The scores awarded to the urban and rural health facilities in each domain that was
evaluated are as shown in table 13. Rural facilities had slightly higher scores in the general
infrastructure, drugs and supplies while urban facilities had higher scores in adequacy of
personnel and equipments.
Table 14: Quality assessment score for the attributes of care by location of facilities
Indicator Maximum score
(100%)
Quality score
Urban health
facilities
Score (%)
Rural health
facilities
Score (%)
Structural attributes 148 113(76.4) 92(62.2)
Process attributes 80 43.5(54.4) 44.4(55.5)
Outcome 30 22(73.3) 23.9(80.0)
Table 14 shows the summary of quality assessment scores for the three attributes of care
assessed by location of the facilities. The results show that higher scores (76.4%) were
obtained for structural attributes in the urban health facilities compared to (62.2%) in the
rural health facilities. However, outcome attribute shows that rural health facilities scored
higher (80.0%) than the urban (73.3%) health facilities.
73
Table 15: Quality assignment of elements denoting quality antenatal care
Indicator Urban health facilities Rural health facilities
Structural attributes
General infrastructure
Equipment
Drugs and supplies
Personnel
Good
Good
Very good
Good
Good
Average(fair)
Very good
Poor
Process attributes
Interpersonal aspect of care
Technical aspect of care
Average(fair)
Average(fair)
Average(fair)
Good
Outcome
Client satisfaction
Health education
Very good
Good
Very good
Good
Note:
Quality assignment based on five scale ranking in methodology.
Table 15 shows quality of care for each domain evaluated. The urban health facilities
ranked well in the quality of care assessed in all the structural and outcome elements of
care assessed while the quality of care in the interpersonal aspect for process attribute of
care was ranked average in both locations. However, the rural health facilities ranked poor
in the available personnel and average (fair) in the quality of equipment available for
antenatal care.
74
Table 16: Proportion of clients who desired improvement in the quality of ANC
Areas of desired
improvement
Urban
N=260
Rural
N=254
Infrastructure
n(%)
97(37.3)
n(%)
38(14.9)
Ease of getting care 30(11.5) 58(23.0)
Decrease cost of
service
20(7.7) 14(5.5)
Adequate staffing 9(3.5) 11(4.3)
None 104(40.0) 133(52.3)
Table16 shows the areas of desired improvement, 97(37.3%) of the urban respondents’
would like an improvement in the infrastructure of the facility compared to 14.9% in the
rural facilities. Improving ease of getting care was more often stated 23.0% in the rural than
in the urban facilities11.5%. Decrease in the cost of service was desired by 7.7% of urban
clients against 5.5% of the rural clients. Having adequate staff at the health facilities was of
importance to 3.5% and 4.3% urban and rural clients respectively. In the rural health
facilities however, a higher proportion (52.3%) of clients compared to 40.0% of clients in
the urban health facilities did not offer suggestions on areas they would desire
improvement in the quality of antenatal care.
75
Section V: Health care provider interview
Socio-demographic characteristics of health care providers (HCPs)
Table 17: Demographic and work characteristics of health care providers by location
of health facilities
Characteristics Urban
N= 25
n (%)
Rural
N= 22
n (%)
χ2
p- value
Age(years)
<40
≥40
10(40.0)
15(60.0)
17(77.3)
5(22.7)
6.650
0.01
Sex
Male
Female
2(8.0)
23(92.0)
4(18.2)
18(81.8)
Fisher’s exact
p = 0.398
Cadre of staff
Professional*
Auxiliary**
7(28.0)
18(72.0)
1(4.5)
21(95.5)
Fisher’s exact
p = 0.052
Duration of work
experience
<10 yrs
≥10 yrs
≥ 20 yrs
5(20.0)
20(80.0)
19(86.4)
3(13.6)
20.62
0.000
* Doctors, Nurses/midwives
** CHOs, SCHEWS, and JCHEWS
A total of 25 health care providers in the urban health facilities were available for interview
of the expected 68. 22 of the 45 health care providers in the rural health facilities were
available for interview.
Table 17 shows the demographic characteristics of health care providers by health
facilities. Those health care providers (HCPs) aged 40 years and above were more in the
urban ( 60%) than in the rural health centres(22.7%)(p=0.01). Females were the majority at
both study sites. There were more professional staff in the urban centres 28% versus 4.5%
in the rural (p>0.05). Similarly more of the urban health workers had 10 or more years of
work experience when compared to the rural HCPs (87% versus 13%).
76
Supervision of health care providers:
In the urban health facilities 16(64.0%) health care providers had supervisory visit schedule
while 9(36.0%) HCP did not. In the rural health facilities 17(77.3%) HCP reported they had
a schedule for supervisory visit while 5(22.7%) did not have a schedule for supervisory
visit.
Table 18: Proportion of health care providers who received supervisory visit by
location of health facilities
Last supervisory visit Urban health facilities
N=16*
Rural health facilities
N=17*
≤ 6 months
n(%)
13(81.3)
n(%)
15(88.2)
> 6 months 3(18.7) 2(11.8)
*Assessed for HCP who had supervisory visit schedule
With respect to last supervisory visit 13(81.3%) of the HCP had received supervisory visit
in the last six months in the urban health facilities compared to 15(88.2%) in the rural
health facilities.
Furthermore concerning what the supervisor did during the last supervisory visit, in the
urban health facilities, all 16(100%) of the HCPs reported that their supervisor observed the
management of clients compared to15 (88.2%) in the rural health facilities. At the urban
health facilities 12(75.0%) of the HCPs stated that the supervisor updated them on current
management of antenatal clients while 9(53.0%) rural HCP reported same. Other activities
carried out by the supervisor were delivered supplies reported by 7(43.8%) HCPs in the
urban and 5(29.4%) in the rural health facilities as well as discussed problems with supplies
7(43.8%) versus 11(65.0%) urban and rural HCPs respectively.
77
Training of health care providers on antenatal care
Table 19: Distribution of health care providers who received training by location of
health facilities
Variable Urban health facilities
N=25
Rural health facilities
N=22
χ2 p-value
Recent training
(< 2 Years)
Yes
No
16(64.0)
9(36.0)
10(45.0)
12(55.0)
7.28
0.006
Table 19 shows that more than half of the urban HCPs (64%) had received a recent in-
service training while 45% of the rural HCPs had done so (p<0.05).
On whether the training received involved clinical practice, 8(50.0%) of the HCPs in the
urban health facilities compared to 3(30.0%) in the rural health facilities had received
training on clinical practice.
78
Barriers to providing quality ANC
Table 20: Perceived barriers to providing quality ANC by health care providers
Variables Urban HCP
N=25
Rural HCP
N=22
n (%)
14(56.0)
n (%)
Staff Shortage
14(56.0) 7(31.8)
Lack of Motivation 12(48.0) 14(63.6)
Lack of Supply and Stock 10(40.0) 12(54.5)
Poor work Environment 9(36.0) 16(72.7)
Lack of Feedback on Performance 8(32.0) 8(36.4)
Lack of training 7(28.0) 8(36.4)
Lack of Supervision
6(24.0) 4(18.2)
Table 20 presents barriers to provision of quality care by health care providers. At the rural
health facilities the most frequently reported barriers were poor work environment (72.7%),
lack of motivation (63.6%) and lack of supply and stock (54.5%) compared to 36%, 48%
and 54.5% in the urban health facilities respectively. Conversely at the urban health
facilities the most (56.0%) frequently reported barrier was staff shortage.
79
CHAPTER 5
DISCUSSION
This study was conducted to assess and compare the quality of antenatal care services in
primary health centres in selected urban and rural areas of Rivers State through checklists,
observation of process of care and interviews. In this study, quality of care was determined
based on the “Donabedian framework” which assesses quality using three attributes:
structural (infrastructure, equipment, drugs and supplies as well as personnel); process
(interpersonal and technical aspects); and outcome (health information received by clients
and client satisfaction). This framework for assessing quality of care was used for
evaluation of health services in developing countries in similar studies51, 74, and 75.
Assessment of the quality of infrastructure, equipment, drugs/ supplies and personnel
for antenatal care
Findings from this work revealed that most of the facilities in both the urban and the rural
health facilities met the minimum that was required for general infrastructure and physical
amenities such as waiting area, privacy of examination room, water for hand washing in
examination room and the state of the floors and walls of the facilities. This may have been
due to efforts by the State government to improve the state of the PHC facilities through
renovations and constructions of dilapidated facilities. Similar to this are findings by Boller
and colleagues in urban Dar es Salaam, Tanzania which showed that physical infrastructure
as well as maintenance of all first-tier facilities was reasonably good in the public
services51 The renovation activities however, were not reflected in the availability of toilet
amenities where only 50% and 25% of the urban and rural health facilities had toilets
respectively. Also, it is necessary to note that the facilities which had toilets, were not kept
in hygienic conditions thus may not have been in a state that clients would comfortably use.
80
The relevance of amenities cannot be over emphasized. It has been shown that amenities
though not directly related to clinical effectiveness, may enhance clients’ confidence in
other aspects of the service and willingness to return to the facility for future health
needs25. Further more in rural Burkina Faso, Kenya and Tanzania, studies revealed that
poorly maintained physical infrastructure as well as inadequate water and power supplies
constrained the quality and availability of care at all levels in the district health system.49
This study showed that neither the urban nor the rural health facilities had all (15) essential
equipments for quality antenatal care as defined by national standards. These equipment
deficits make it impossible for health care providers to utilise their skills as well as achieve
little in providing quality antenatal care. Some of this essential equipment such as
thermometer, foetal stethoscope, and angle poised lamp, latex disposable gloves and urine
dipsticks though affordable were not available in the rural health facilities. In support of
this finding was an evaluation of the quality of ANC in rural Burkina Faso which revealed
that insufficiencies were observed at all steps of antenatal care and health facilities were
poorly equipped.80 Similarly in rural Tanzania, inadequacies observed in the detection of
anaemia in mothers were attributed to inadequacy and non availability of screening
instruments75. The urban health facilities in this study were also lacking in tongue
depressors, latex examination gloves and urine dipsticks even though they were better
equipped than their rural counterpart [composite score 47(78.3%) versus 32(53.3%)
respectively]. These deficits of equipments in both locations may be due to poor
managerial and supervisory activities by the authorities (such as the State ministry of health
and the local government) responsible for procuring and maintaining regular and adequate
provision of these equipments.
The presence of essential drugs and supplies for ANC in all facilities in both study sites of
this study is comparable to the KSPA survey in 2004, where all essential supplies such as
81
iron tablets, folic acid tablets and tetanus toxoid vaccines were available in over 80% of the
facilities50. The provision of iron and folic acid supplement and malaria prophylaxis
routinely at antenatal visits in developing countries helps to maintain stores throughout
pregnancy and prevent severe anaemia which is a cause of intra uterine growth retardation
and anaemia in pregnancy 77, 78. However in the concurrent study, urban health facilities
mostly lacked ITNs while the stock of vitamin A capsules was inadequate in most of the
rural health facilities. As supplies are most often obtained from the State this may be an
indicator of inadequate and inconsistent supply from a higher level. This is in consonance
with findings from the DISH project which reported that reliable supply of drugs and
supplies was a critical but lacking factor in provision of service in their evaluation79.
Quality of care has been closely linked to the quality of the health services personnel51.
This study showed that there was inequitable distribution of personnel between the urban
and the rural health facilities. Urban health facilities were better staffed by national
standards having higher proportions of facilities with professional staff (community health
officers 100%, public health nurses100% and midwives 25% when compared to 50%, 25%
and 0% respectively at the rural facilities. This isn’t surprising and is probably due to rural-
urban drift phenomenon, as people have the tendency to move to urban areas in search of
jobs where there are better infrastructure and amenities such as roads, electricity, pipe
borne water and schools for the health care providers and their families. Thus care was
often provided by lower cadre staff such as the CHEWs in the rural health facilities. In
rural Burkina Faso an evaluation of the quality of ANC revealed that the availability of
qualified staff was low.80 In the concurrent study, none of the urban or rural facilities had
the required number of JCHEW that are needed for the important community linkage and
provision of essential services within the community. This finding might have been due to
other competing sources of livelihood in Rivers State such as working as lower cadre staff
82
in oil industries and other large scale industries or self employments in petty trading,
artisan and motor cycle riding whose income are thought to be higher than government
service.
Assessment of the quality of process of care of antenatal service
Observed interpersonal aspects of care revealed that a higher proportion of clients were
treated cordially (greeted and offered seats) at the rural health facilities compared to the
urban clients. HCPs at the rural health facilities were observed to be communicating in the
local dialects of the clients and this may have improved their cordiality with their clients.
This is an unexpected finding as the health care providers who were providing clinical
services were observed to be CHEWS and midwife assistants at the rural facilities whereas
at the urban facilities care was being provided by PHNs, CHOs and midwives. It is
expected that the higher the level of education of the HCP the better they are expected to
communicate with the clients. The finding however, differed from that obtained in a
tertiary institution in Osun State where the degree of negative attitudes of health personnel
increased from the cadre of the doctor to that of the medical records personnel 61. This
study also showed that privacy was not a priority especially at the urban centres where 75%
of the clients observed did not have privacy assured compared to 47.5% in the rural
facilities. This finding is not commendable in both settings as not assuring clients privacy
may infringe on the rights of the client in accessing quality care. Similar findings were
reported by a study of government health facilities in rural Bangladesh and some other
studies on quality in which less than half of the clients had their privacy maintained22, 74, and
82. In Iran, a study revealed that although providers treated the clients respectfully in more
than 80% of the consultations, their privacy was not assured in one-third of the cases81. The
value one- third or 33.3% obtained in the Iranian study is however lower (75% versus
47.5%; urban versus rural respectively) than observed in this study. This high rates of lack
83
of privacy observed may have been due to the assumption by the HCPs that most of the
clients were of the same sex and therefore, did not deem it necessary to provide each
individual with her own privacy, as consulting room doors were left open and in other
instances where examination screens were available they were not put to use. Furthermore,
in this study it was observed that both urban and rural health care providers rarely gave
explanations before examining their clients (0% versus 2.5%) nor offer explanations on
diagnosis (42.5% versus 17.5%) respectively. This however is not good practice as well
informed clients are likelier to comply with treatments and follow ups. Also, studies
document that satisfaction has been shown to be strongly related to patient-provider
communication83, 84. In the case of rural health care providers the issue may simply be
ignorance of the importance of providing information on this aspect of care as care was
provided by lower cadre staff. However, in the case of the urban health care providers the
higher client load may have made them overlook intimating their clients with information
on examination and diagnosis since they were better qualified and were expected to have
performed better. This compared well to the study in Iran where less than one-third of the
clients were encouraged to ask questions or raise concerns81. In rural Bangladesh however
the result varied; even though providers were willing to ask patients their reasons for
attending the clinic in 82.3% of cases they gave advice to only 53.5% and some sort of
explanation about the nature of their health problem in 48.9% of clients22.
A well taken history is the foundation stone of effective antenatal care104. In this study,
history taking practices were generally poor in both urban (7.5%) and rural (22.5%) health
facilities even though this is essential at any visit. Providers rarely asked antenatal clients if
they were experiencing problems with current pregnancy. This differed from findings in
Uganda where 91% of clients in DISH districts and 79% of clients in comparison districts
were asked whether they were experiencing problems with their current pregnancy and
84
when this was done, more than half of the clients reported experiencing complications with
their pregnancy56. Furthermore clients in the DISH districts experiencing a problem were
significantly more likely to be given suggestion for resolving the problem. In the
concurrent study histories for malaria and UTI were rarely obtained in both settings
reflecting that history of common illnesses in pregnancy weren’t sought for. These
important elements of care which were often omitted may have been due to hurried staff
and lack of commitment in history taking regarding the clients’ general health which would
have assisted in the rapid identification of complications. Similar findings were reported in
secondary health care facilities in Osun State by Osungbade and colleagues58. This may
seriously compromise the health of both the mother and the unborn child as malaria and
UTI are known to have adverse effects on pregnancy outcome such as intrauterine growth
retardation and intrauterine death. Examination of clients’ conjunctivae or palms for pallor
was also scarcely carried out. It was also observed that all clients were requested to have
their haemoglobin checked routinely at each or most of their follow up visits. Thus, simple
physical examination would have distinguished those that may need further laboratory
investigation there by reducing cost of care for the clients and the inconvenience of doing
haemoglobin checks for frequent visits and also reducing the burden on the health care
delivery system. This is pertinent since the traditional ANC was still being practiced at the
PHC centres.
All the pregnant women who were observed in this study had their blood pressure checked
in both locations of health facility which was in compliance with WHO recommendation8.
This component of care is used to screen for hypertension which acts as an early and
detectable sign of eclampsia86. Abdominal palpation and detection of fetal heart rate were
consistently conducted in the facilities in both study sites. This compared to findings by
Osungbade and colleagues where all the clients received such services as blood pressure
85
check, abdominal palpation and foetal heart detection58. Most clients in this study were
provided with basic and minimum investigations required to be carried out on blood. The
finding however, differed from earlier reports that local facilities often lacked the capacity
to measure anaemia55, 75, and 88. Three quarters of the clients had their urine checked for
glucose and proteins at the rural health facilities. Urine testing for glucose and proteins are
screening tests for diabetes mellitus and hypertensive disorders such as pregnancy induced
hypertension (pre-eclampsia) and eclampsia104. The test assists in the rapid identification of
problems and provides criteria for appropriate decisions that may prevent complications or
enable its early detection and management8, 104. Those clients who did not have the
investigations done may have been due to lack of equipment for urine estimation of protein
and glucose.
It has been shown that health workers with higher qualifications provided better quality
care89. This study however, has shown that although the urban facilities had more
professional staff providing ANC to clients than the rural, the quality of the process of care
(interpersonal and technical care) did not differ appreciably given the quality scores 54.4%
and 55.5% that were observed in the urban and rural health facilities respectively. Some
evidence exist in literature which shows that when lower cadre health workers receive
training the quality of patient–provider communication was equal to that offered by more
qualified staff89.
Assessment of clients’ outcome of care
In this study, clients in both study locations were satisfied with most aspects of their health
care. The satisfaction rates for urban and rural clients were 96.5% and 93.7% respectively.
Several other studies have also reported high client satisfaction with ANC and other
primary health services in Nigeria and other developing countries22, 53, 56, 60, 61. Similarly
studies from developed countries have reported high satisfaction levels with ANC. A study
86
in Netherlands showed that women, regardless of parity, were very positive about the
quality of the maternity care they received90. Some explanations for these expressed high
levels of satisfaction include courtesy bias, lack of knowledge of required care, low
expectations, and the uncritical attitude of the clients sometimes in the face of poor quality
health service 53, 60. This is an added indication for the use of multidimensional rather than
global overall measures of satisfaction with care as a means of capturing detailed
information about the health care experiences of clients70, 91, and 92. For instance, the
concurrent study revealed differences in the levels of satisfaction for the different areas of
service delivery with waiting time being the area of least satisfaction. This finding supports
other studies where shorter waiting time was significantly associated with satisfaction.83, 93
and 94. Rural clients expressed more dissatisfaction (63.4%) with the waiting time compared
to the urban (42.7%) clients. The clients who used the rural health services may have been
less satisfied as they had waited longer than their urban counterparts to access care. This
has also been reported by other studies revealing that waiting time is associated with client
satisfaction22, 60 and 61. Although the time spent with the provider during consultation was
not assessed in this study, it is rather unlikely that individual clients received equally long
attention.
In this study there was no significant difference observed with respect to satisfaction with
care and socio-demographic and obstetric factors. This is not an unexpected finding since
the satisfaction rate was high in both urban and rural setting. The exception was in the area
of education where those with lower level of education were more satisfied in the rural
facilities. Less educated people (those with primary and no formal education) are more
likely to be less informed and therefore have fewer expectations and felt needs and likelier
to make fewer demands from the health care service. This further confirms the importance
of knowledge in client satisfaction as reported by other studies95, 96.
87
One of the main goals of ANC is provision of adequate information that is essential for
maintaining and improving pregnancy outcomes 104. In most developing countries, the high
turn up for antenatal services, could be used as an entry point for providing essential
obstetric care and planning for deliveries 8,104. More of the rural clients reported being
informed about danger signs than did the urban clients. Similarly the content of other health
topics as reported by the clients was higher in the rural facilities than the urban except with
regards to HIV counselling and testing where the urban facilities had a slightly higher
proportion of the ANC attendees reporting having received some education. This is an
unexpected finding as the HCPs at the urban health facilities were of higher qualifications
and experience and therefore expected to have performed better in the dissemination of
vital information to clients. This finding does not support studies that demonstrated that the
quality of performance was linked to the training level of the personnel97, 98. In India
dietary advice was given to only 51.3% of antenatal attendees and a negligible percentage
2.3% received advice regarding family planning80. The findings are however in contrast to
other studies in Nigeria where women interviewed scored the provision of health
information highly 53, 60 and 61. However, studies where observations of information
procedures are combined with women’s exit interview showed that women received less
information than they often report18. Therefore, there are chances that information received
in this study may actually be less than expressed.
Areas of desired improvement in quality of ANC by clients
More clients in the urban health facilities desired improvement in the infrastructure of
health facilities compared to the rural respondents. Here infrastructure for the clients refers
to their perception of the physical health care facility such as building in good repair,
sanitation or clean facilities and toilets, available water and electricity and adequate seats
88
and privacy. This may have been due to the fact that some of the infrastructures were
dilapidated and clients having observed other health facilities in the urban area such as the
private clinics and hospitals where attention is paid to the aesthetics of the facility would
have therefore desired improvement in the current infrastructure of the PHC facilities. The
area of desired improvement for respondents who use the rural health facilities was in the
ease of getting care which was expressed as their ability to get to be seen (waiting time)
and convenience of the facilities location. This stands to reason as the rural clients waited
longer to access care than their urban counterparts. These findings suggest that respondents
in the rural facilities were less likely to access the care they need. This is supported by
findings that access to safe motherhood services in rural areas is more limited than in urban
areas13. It is interesting to note the high proportion of respondents in both study sites who
did not desire any improvement in the current state of services they had received. This may
further explain the high satisfaction rates expressed with the antenatal service.
Barriers to quality provision of quality ANC care by health care providers
In this study most of the older and more experienced health care providers were
inequitably distributed to the urban health facilities. This may be due to the fact that they
may have served their required time in the rural area at some point in the past as these
cadres of staff are recruited and deployed by the State government. Also, in the face of staff
shortage, preference of deployment of staff to the urban health facilities may have further
worsened the distribution. However, this practice may leave a dearth in the number of
qualified and experienced staff in the rural area as is observed in this study.
In both settings more than 80% of HCPs reported that they had received supervisory visit in
the last six months and still over 80% reported that the supervisor observed the
management of client. Even though HCPs reported they were being supervised, the non
participatory observation of client management in this study has brought to fore the fact
89
that supervisors may not be aware of the quality of client management being provided at
the facilities as HCPs may have improved on their practice in the presence of the
supervisor. On recent training of HCPs, only 45% of the rural health care providers had
received training while 64% of the urban health care providers had received training on
ANC. This may have been due to easier access and reduced cost to train the urban health
care providers since most training and training institutions are located in the urban area.
HCPs in the rural health facilities identified poor work environment, lack of motivation and
lack of supply and stock as barriers to providing quality antenatal care while the urban
health care providers reported staff shortage. This is similar to findings reported where
health care providers identified lack of reimbursement and practice environments that fail
to facilitate more consistent delivery of services 99.
Conclusion
It is apparent from the foregoing that based on predetermined criteria by national standards
quality assessment of the general infrastructure, equipment and personnel of the facilities
providing antenatal care in the urban health facilities rated good in quality while drugs and
supplies rated very good in quality assessed. Also, the general infrastructure and drugs/
supplies are rated good and very good in quality respectively in the rural facilities.
However, the study revealed deficits in the quality of equipment and personnel needed for
the achievement of quality antenatal care in the rural health facilities which rated average
(fair) and poor respectively.
The urban health care providers unexpectedly fared worse than the rural health care
providers in the quality of the process of care where their rating was average (fair) in
interpersonal and technical aspects of care while the rural health care providers rated
average and good in interpersonal and technical aspects of care respectively.
90
The clients in both the urban and rural health facilities expressed high satisfaction rates
(96.5% and 93.7% respectively) with the quality of care received in spite of their
displeasure with some important aspects such as infrastructure and ease of getting care. The
least satisfaction was expressed in the area of waiting time with the rural clients being
significantly less satisfied (36.6%) than the urban (57.3%) clients. However, observation of
the client – provider interactions indicated that the quality of process of care provided is not
commensurate to the high satisfaction expressed by clients. This demonstrates that clients’
expression of satisfaction may not be relied on in deciding on quality set by national or
international standards.
Important areas that deserve attention from the perspectives of the health care providers in
the rural health facilities are poor work environment, lack of motivation, inadequate
supplies and stock, lack of feedback on performance and in service training which majority
(55%) of the rural HCPs had not received. The prominent barriers to providing quality
antenatal care reported by HCPs in the urban health facilities were staff shortage and lack
of motivation as well.
Finally, this study has provided insight to important but often neglected aspects of quality
care (such as equitable distribution of human and material resources and the quality of
process of care) that is necessary to improve the current maternal health in this
environment. It has also provided valuable information on the areas to be focused on in
providing quality antenatal services in primary health centres in urban and especially
underserved rural areas in Rivers State.
91
Recommendations
In order to improve quality of antenatal care in the study settings, there is need to
commit political will and resources. The following recommendations are made:
1. Adequate supply and equitable distribution of the minimum recommended package
of supplies, equipment, personnel and infrastructure should be provided in all health
facilities by government.
2. Staff development should be regular and ongoing as competency of staff is
engendered by these exercises.
3. The state government should provide clear guidelines and work ethics encouraging
local governments to follow these guidelines, monitoring implementation and
appropriate sanctions applied as necessary.
4. Relevant authorities should undertake periodic quality assessment of the facilities to
ensure that they maintain required standards all of the time.
5. Heads of facilities should ensure that clients are attended to promptly to reduce the
delays clients experience in accessing care.
6. Clients should be educated on their rights and privileges because informed clienteles
are likely to insist on their right.
92
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APPENDIX 1
QUALITY ASSESSMENT AND COMPARISON OF ANTENATAL CARE SERVICE IN RURAL AND URBAN AREA PRIMARY HEALTH CARE FACILITIES IN RIVERS STATE. HEALTH WORKER INTERVIEW QUESTIONNAIRE LGA----------------- HEALTH FACILITY ------------- SERIAL NUMBER ------------ DATE---------
Dear Health worker, The purpose of this study is to assess the quality of ante natal care services. Your response will be confidential and will not be used against you. Please answer the questions as honestly as possible. Thank you for your anticipated co-operation. SECTION A: Personal Details 1. Age (last birthday in years) ----------------------------------------------- 2. Sex 1. Male 2. Female 3. Category of health worker: 1. Matron 2. Nurse/Midwife 3. CHO 4. SCHEW 5. JCHEW 6. Others (specify) 4. Duration of work experience as a health worker? ---------------------------------------- SECTION B: Supervision and Training of Health Worker 5. Do you have a schedule for supervisory visits?
1. Yes 2. No If Yes, go to Q 6. If No, go to Q. 8. 6. When was the last time you had a supervisory visit? -------------------------------------------- 7. How many times have you had a visit from a supervisor? 1. In the last 6 months -------------------------- (number of times) 2. In the last 12 months --------------------------- (number of times)
3. Supervisor works here and sees worker daily ----------------------
105
8. What did your supervisor do the last time he/she supervised you? (Please tick)
Yes No NA
1. Delivered supplies (medicine)
2. Observed management of client
3. Updated health provider on current information
4. Discussed problem with supplies and equipments
5. Others (specify): ……………………………………………………… …………………………………………………………………………......
9. What are the difficulties you face in doing your job?
Yes No NA
1. Lack of training
2. Lack of feedback on performance
3. Lack of motivation
4. Lack of time
5. Poor work environment
6. Staff shortage
7. Lack of supply and or/stock
8. Lack of supervision
9. Others (specify): …………………………………………………………... …………………………………………………………………………......
10. Have you discussed these problems with your supervisor?
1. Yes 2. No 3. Not Applicable 11. Have you attended any recent training (last 2 years) on ante natal care
1. Yes 2. No 12. If yes, state the dates and duration of training
1. Date:………………………… Duration (Days)……………………… 2. Date:………………………… Duration (Days)……………………… 3. Date:………………………… Duration (Days)……………………… 4. Date:………………………… Duration (Days)………………………
13. Where did you receive the training programme on ante natal care?
1. ……………………………………………………………………………. 2. ……………………………………………………………………………. 3. ……………………………………………………………………………. 4. …………………………………………………………………………….
14. Did your training involve clinical practice? 1. Yes 2. No
106
15. Please list the content of the training you received. ----------------------------------------------------------------- ----------------------------------------------------------------- ---------------------------------------------------------------- ---------------------------------------------------------------- ----------------------------------------------------------------
107
APPENDIX 2 CLIENTS EXIT INTERVIEW LGA----------------- HEALTH FACILITY ------------- SERIAL NUMBER ------------ DATE--------- QUALITY ASSESSMENT AND COMPARISON OF ANTENATAL CARE SERVICE IN RURAL AND URBAN AREA PRIMARY HEALTH CARE FACILITIES IN RIVERS STATE. INTRODUCTION: Dear Ma, My name is ………………………., and I am part of a research team from Department of Community Medicine, UPTH This questionnaire is to assess the quality of services that you have received in this health facility. It is meant for research purposes only. Your name is not required and confidentiality will be ensured. Please kindly answer the questions as honestly as possible. Thank you for your co- operation. Section A: Socio-Demographic Data 1. How old are you? (Last birthday in years) ---------------------------------------- 2. What is your ethnicity? 1. Ibo 2. Yoruba 3. Hausa 4. Ijaw 5. Ogoni 6. Ikwerre 8. Others (Specify) ………………………………………………… 3. What is your religion? 1. Christianity 2. Islam 3. Traditional 4. Others (specify) ………………………………………………… 4. What is your marital Status? 1. Single/Never Married 2. Cohabiting 3. Married 4. Separated 5. Divorced 6. Widowed 5. Educational Level 1. No Formal Education 2. Primary School Completed 3. Secondary School Completed 4. Post Secondary Education 5. University Education 6. Educational Level (Spouse) 1. No Formal Education 2. Primary School Completed 3. Secondary School Completed 4. Post Secondary Education 5. University Education 7. What is your Occupation? ……………………………… 8. What is the Occupation of your Spouse? ………………………………
108
9. Average monthly income ……………………… (Naira) Section B: Obstetric History 10. How many weeks pregnant are you? 1. Weeks -------------------------------------------- 2. Don’t know 11. How many weeks pregnant were you at your first visit to this facility? 1. Weeks -------------------------------------------- 2. Don’t know 12. How many visits have you made so far? ------------------------------ 13. Is this your first pregnancy? 1. Yes 2. No 14. How many living children of your own do you have? …………………… 15. Have you ever had an abortion (Miscarriage)? 1. Yes 2. No 16. Have you had still birth? 1. Yes 2. No 17. Have you had child death (less than 5years old)? 1. Yes 2. No 18. Are you aware of Family Planning? 1. Yes 2. No 19. If yes to the above, have you ever practiced Family Planning? 1. Yes 2. No Section C: Experiences with ante natal care 20. How long did you wait between the time you first arrived at the clinic and the time
you saw a clinic staff for ante natal appointment. …………………… (minutes/hours) 21. Is the waiting time acceptable? 1. Reasonable/short 2. Too long 3. Undecided
109
22. Are the clinic hours convenient? 1. All the times are suitable 2. Most of the times are suitable 3. None of the times are suitable 4. Don’t know 23. Were you treated in a friendly and respectful manner? 1. Yes 2. No 3. Don’t know 24. Did you find the clinic area to be clean? 1. Yes 2. No 3. Undecided 25. How much did you pay for the service offered? ……………………Naira 26. What is your perception of the cost for your service? 1. Expensive 2. Moderate 3. Cheap 27. Was it easy to get to the clinic? Distance? ------------- 1. Yes 2. No 3. Don’t know 28. How did you get information about this service? 1. Friends 2. Relatives 3. Nurses/Midwife 4. Social worker 5. Doctor 6. Mass Media 7. Others (Please specify) …………………………………………. 29. Did you register for ANC in another facility? 1. Yes 2. No 30. If yes to above, where did you register? --------------------------------------- 31. During this or previous visits did the provider discuss where you plan to deliver with you? 1. Yes, this visit 2. Yes, previous visit 3. No 4. Can’t remember 32. Have you decided where you will have your delivery? 1. Yes 2. No 33. If yes to above, where do you plan to deliver? 1. At this facility 2. At other health facility 3. At home 4. At a private maternity home 5. Others (Please specify) ----------------------------------------------------- 34. During this or previous visits has a provider talked with you about any signs that warn of
problems with the pregnancy?
110
1. Yes, this visit 2. Yes, previous visit 3. No 4. Can’t remember 35. What warning signs were mentioned? (Please tick those mentioned)
Yes No Cant Remember
1. Bleeding
2. Swollen face/Hands/Legs
3. Fever
4. Headache/Blurred vision
5. Tiredness/Breathlessness
6. Others (specify) ………………………………………………………………… …………………………………………………………………………………..
36. During this or previous visits did you receive health talks on the following?
Yes No Cant Remember
1. Breast self examination
2. Prevention of malaria during pregnancy
3. HIV counselling / Testing
4. Breast feeding
5. Child spacing
6. Prevention of sexually transmitted infections
7. Prevention of cervical cancer
37. What do you like best about this clinic? ………………………………………………. …………………………………………………………………………………….. 38. What do you dislike about this clinic? ………………………………………………. …………………………………………………………………………………….. 39. What suggestion(s) do you have to help improve services in this clinic? ………………………………………………………………………………………….. …………………………………………………………………………………….. 40. Would you recommend this facility to another pregnant woman? 1. Yes 2. No 3. Undecided 41. Would you use this facility in future pregnancies? 1. Yes 2. No 3. Undecided
42. If yes to Q.41, why would you use this facility in future pregnancies?
111
-----------------------------------------------------------------------------------
43. If no why would you not use this facility in subsequent visit?
--------------------------------------------------------------------------------
Section D
Client satisfaction with antenatal care services
How satisfied were you with the following aspects of the antenatal care services you
received today?
Dissatisfied Some what
Dissatisfied
Indifferent Some
what
satisfied
Very
Satisfied
1. Time you waited?
2. Ability to discuss
problem or concerns
about your pregnancy
with the provider?
3. Amount of
explanation about the
problem or treatment?
4. Examination and
treatment provided?
5. Privacy from others
seeing you being
examined?
6. Privacy from others
hearing discussion?
7. Availability of
medicines at the facility?
8. Convenience of the
hours of services?
9. Neatness of facility?
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APPENDIX 3
Name of LGA----------------- Serial No. ------------------
Name of Health Facility-----------------
Checklist of essential equipment for antenatal/ interview room for primary health care
centre
S/N Item Quantity
Required
*
Present Absent Remark
1. Stainless covered bowl for cotton wool 2
2. Examination couch 1
3. Foetal Stethoscope 2
4. Latex gloves, disposable pack, pack of 100 20
5. Height measuring stick 1
6. Mackintosh sheet 2
7. Pen torch 1
8. Sphygmomanometer, mercurial (Accosons,
table top)
1
9. Stethoscope 1
10. Thermometer 2
11. Tongue depressor 6
12. Weighing scale 1
13. Angle poised lamp 1
14. Bowls stainless steel with stand 1
15. Urine dipstick for sugar and albumin, pack of
100
20
* NPHCDA, August 2007; FMOH 2007
113
APPENDIX 4
Name of LGA----------------- Serial No. ------------------
Name of Health Facility-----------------
Checklist for assessment of quality of antenatal care (structural and process
attributes)
Attribute of quality
Description/ item Maximum
Score
Facility
Score
Structural Attributes 1. General Infrastructure
i Waiting area 2
ii Privacy of
examination Room
2
iii Toilet facility 2
iv Water to wash hands in
examination room
1
v Laboratory 1
2. Maintenances of facility
i Maintenance of floors and
walls
2
ii Cleanliness of facility 2
iii Cleanliness of toilet 2
Process attributes
Interpersonal Aspects
i. Politeness/ greets client
1
ii. Making woman
comfortable (offered a seat)
1
iii. Non interruption of
speech
1
114
Attribute of quality
Description/ item Maximum
Score
Facility
Score
Interpersonal Aspects contd. iv. Asking about woman’s
concerns
1
v Privacy (door closed
during consultation
1
Explaining procedures to
women
vi. Explaining before
examination
1
vii. Explaining of diagnosis 1
viii. Explaining the use of
prophylactic drugs
1
Technical Aspect of care
Assessing the history of
women
i. General history taking 1
ii. History for Malaria 1
iii. History for UTI 1
Investigations/tests
iv. Haemoglobin check 1
v. Urine for albumin and
glucose
1
Physical examination
vi Blood pressure check 1
vii. Checking eyes for pallor 1
viii. Abdominal
examination (foetal heart or
foetal position)
1
Providing health
education
ix. Health Education for
Nutrition
1
x. Health Education for
prevention of malaria.
1
115
Attribute of quality
Description/ item Maximum
Score
Facility
Score
Drugs and supplies i Ferrous Sulphate 1
ii Folic Acid 1
iii Paracetamol 1
iv Penicillin Antibiotics 1
v IPT (Antimalarials) 1
vi ITNS 1
vii Tetanus Toxoid 1
viii Vitamin A Capsules 1
116
APPENDIX 5
Name of LGA----------------- Serial No. ------------------
Name of Health Facility-----------------
Checklist of proposed health manpower for PHC facility
Cadre of staff Recommended
minimum*
Number available in
facility
Remarks
Community health
officer(CHO)
1
Public health nurse
(PHN)
1
Community health
extension worker
(CHEW)
3
Junior community
health extension
worker (JCHEW)
6
Nurse/ Midwife 4
Medical assistant 1
*- NPHCDA August 2007.
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119
120
121
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