UTILIZATION OF DONABEDIAN MODEL IN EVALUATION OF MATERNAL AND CHILD HEALTHCARE QUALITY SERVICE
CHAPTER TWO
LITERATURE REVIEW
2.1 MATERNAL HEALTH CARE SERVICES
Maternal health care services comprise three elements: Community based services (Primary Health Care); Essential Obstetric Care at the first referral level to deal with complications and thirdly, effective communication and transport between the community-based services and the first referral centre. 20
In a wider context of women’s reproductive health care, the following components of maternal health care services are recognized: Pre-conceptual (Premarital or Adolescent care); antenatal care; intrapartum care (Delivery services) and postpartum (Postnatal) care.19 The elements as enumerated above should have a linkage to these components as well as to family planning and specialist obstetric care at the tertiary level.
The antenatal period clearly presents opportunities for reaching pregnant women with a number of interventions that may be vital to the health and wellbeing of mothers and that of their infants. The basic objectives of antenatal care are to detect and manage symptomatic and even symptomless but potentially serious complications of pregnancy, and to meet the pregnant woman’s need for information, advice and reassurance.14 The antenatal care policy in Nigeria follows the newest WHO approach to promote safe pregnancies. It recommends at least four ANC visits for women who do not have obvious complications. This updated approach, called Focused Antenatal Care (FANC) emphasizes quality of care
during each visit rather than focus on the number of visits. FANC hinges on the principle that every pregnancy is at risk of complications.14 Apart from receiving basic care, every pregnant woman should therefore be monitored for complications.14 This implies that for antenatal care to be effective, it should be goal directed, family centered, client oriented, evidence based, with reduced frequency of visits, however with emphasis on the quality of care by skilled providers.21
The content of FANC is an essential component of the quality of services. Activities and contents of a FANC include: Health education on proper nutrition, personal and environmental hygiene, danger signs of pregnancy and signs of labour; provision of preventive services, monitoring the progress of pregnancy; screening for early diagnosis; birth preparedness and complication readiness, and risk assessment to determine high risk pregnancy. Such medical examinations as measurement of blood pressure, urine testing for proteinuria, blood tests for anaemia and infections like syphilis and HIV/AIDS, have been proved to be beneficial. Cost effective interventions like the vaccination of women of reproductive age group with tetanus toxoid, prevention of mother to child transmission of HIV/AIDS (PMTCT), are affordable in most countries. However, some of these services are not accessible to most women who need them, probably because of reasons such as lack of awareness, cost, non-availability, rumours and fears of side effects, and the quality of services provided.6, 22.
Nonetheless, it has become clear that antenatal care interventions alone cannot be expected to have the much desired significant impact on morbidity and mortality. It has been documented that the higher the proportion of deliveries attended by skilled birth attendants in a country, the lower the country’s maternal mortality ratio.21 Thus the safe motherhood programmes, and recently the Millennium Declaration base their priorities on the need for skilled care, including emergency obstetric care, rather than ensuring that all pregnant women received antenatal care.16,23. In addition, conceptions are now changing from the once held belief that most life threatening obstetric complications are predictable and preventable. It has been revealed that large proportion of the so called “low risk” women develops complications. Therefore every pregnancy faces risks.24 The United Nations
Committee on Economic, Social and Cultural Rights (ESC Rights Committee) states that “health facilities, goods and services must be scientifically and medically appropriate and of good quality.” 25 The ESC Right Committee concluded that in the absence of service capable of providing appropriate and effective care, carrying out of risk assessment is unethical. It therefore implies that quality maternal health care service requires inter alia, scientifically approved and unexpired drugs, hospital equipment, safe water, adequate sanitation and skilled medical personnel, including emergency obstetric care. 25
While many factors contribute to maternal death, one of the most effective means of preventing maternal death is to improve health systems and primary health care to ensure availability of skilled attendance at all levels and access to 24-hour emergency obstetric care. Emergency Obstetric Care (EOC) is available only in 994 facilities out of the 17, 976 health facilities in Nigeria and are unevenly distributed too.26 This finding shows that the met need EOC is still low (19.8%).26 Under the United Nations Guideline, 100% of women are expected to have obstetric care, and should be treated in EOC facility.26 A study by Cooperative for Assistance and Relief Everywhere (CARE) and Ministerio de Salud (MINSA) PERU in 2000, showed that “30.4% of met need for EOC did not receive the care they needed.” It was also reported that after a sustained intervention through the provision and utilization of qualty maternal health care services, CARE was able to increase the met need for EOC in Peru to 75.9% by 2005.27 A 2003 study by Fatusi and Ijadunola in Nigeria revealed that about two-thirds of all Nigerian women deliver outside health facilities and without skilled attendants present.13 While only 42% of public health facilities met internationally accepted standards for EOC.13, 28-30. In Nigeria, the South East geopolitical zone has the highest proportion of institutional deliveries (74 percent), followed by the South West (70 percent), while the North West has the lowest proportion (8 percent).14
Postnatal Care (PNC) is necessary to monitor and ensure return to normal of some physiological changes that occured during pregnancy and delivery, and any abnormalities detected are treated. Postnatal Care is necessary for the early detection and treatment of
maternal health problems such as infection, puerperal fever, hemorrhage, psychosis. It also provides an opportunity for the provision of family planning counseling services and support to mothers on breast feeding and childcare. The NDHS of 2008 shows that,” more than half (56 percent) of Nigerian women, did not receive any postnatal care; however, 38 percent received a postnatal check-up within two days of delivery, and 3 percent of women had check- up 3 to 41 days after delivery.” 15 By zone, the South West zone had (68%) the highest percentage of women who received postnatal care within the first two days after delivery.14
Fort et al, 31 carried out a population- based multicountry comparative study to analyze the variables (occurrence, timing, and background characteristics) associated with receipt of postpartum care in thirty developing countries representing the major regions of the world. The findings of this study showed that maternal mortality continues to be high in many countries of the developing world. 31 They posited that better understanding of conditions such as postpartum haemorrhage—the largest killer—and its occurrence in the early postpartum period have shown the importance of early and universal postpartum care. Data from Demographic and Health Surveys carried out between 1999 and 2004 in these countries were also used in the study. Results show that about half of all births in these countries continue to occur outside health institutions, and in seven out of ten births mothers do not receive any postpartum care. 31 Of the noninstitutional births for which mothers receive postpartum care, the average timing of the first postpartum checkup is three days after birth. It was also reported that if all births are counted—assuming institutional births receive postpartum care 12 hours after delivery—the average timing of postpartum care is two days following delivery. 31
2.2 MATERNAL MORTALITY AND QUALITY OF MATERNAL HEALTH CARE SERVICES.
Maternal Death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to
or aggravated by the pregnancy or its management, but not from accidental or incidental causes.32 Indices for maternal mortality include: maternal mortality ratio and maternal mortality rate. Maternal Mortality Ratio (MMR) is the number of maternal deaths during a given time period per 100,000 live births during the same time-period, while Maternal Mortality Rate is the number of maternal deaths in a given period per 100,000 women of reproductive age during the same time-period. 32
Indices for maternal mortality remains a sensitive measure of the health status of women, access to care, adequacy and quality of health care.33 It is indicative of the performance of the health care system.33 Several international conferences, most recently the Millennium Summit in 2000 have included the goal of improving maternal health. Experience has also shown that improving maternal health depends critically on the provision and use of quality maternal health care for managing complications.34
Choudhry and Tauqeer, 35 in 2005 carried out a study on the relationship between quality of maternal health care and maternal mortality in Pakistan. The aim of the study was to find out different aspects, perspectives and necessities of a quality maternal health care department and then to analyze the interventions implemented in different countries to improve quality of maternal health care. Criterion-based clinical audit, quality of care, performance and quality improvement tool, facility based maternal death review, better management, multi-strategy approach, confidential enquiries into maternal deaths and near- miss case review were the approaches used in these studies for quality improvement. Then evidence was sought for a relationship between improved quality care and maternal mortality. It was evident from the results that improvement in quality of maternal health care happened to decrease maternal mortality in all of the cases reviewed. 35
Ibeh 36 carried out a cross sectional study in Anambra State southeast Nigeria in 2002 to determine the use of maternal services by parturient mothers. He posited that the problem
of maternal mortality in Nigeria may not necessarily lie with utilization but with the quality of service. The study further reported that there are too many countries with high levels of mortality and morbidity among women even with the widespread coverage of population by maternal health care services. 36 In Nigeria for instance, all local government areas have maternity centres in addition to private hospitals and other levels of health facilities.36 Despite this level of coverage, maternal mortality in the country remains high.36 This suggests that while coverage is necessary, the provision and use of quality maternal health care by the clients is the key to reducing maternal mortality.
Some of the reasons that have been attributed to the unacceptably high maternal mortality in Nigeria, include: poor socioeconomic development, weak health care system, low socioeconomic status of women and socio-cultural barrier to care utilization.34, 36. These factors prevent women from accessing quality maternal health care services. Available evidence also suggests that substantial proportion of maternal deaths result from poor technical quality of care.37 Chassin and Galvin,38 also linked poor quality of care; to underutilization of effective services, the over use of services when the potential for harm exceeds the potential benefit, or the misuse of services to preventable complications and maternal deaths. Tinker,39 in a study on improving women’s health in Pakistan also concluded that improvement of quality is an effective strategy to reducing maternal mortality in all types of settings and thus an improvement in maternal health.
2.3 OUALITY OF HEALTH CARE
The definition of quality varies with respect to the concept of usage. According to the World Health Organization (WHO), “quality of health care is defined as that care which consists of the proper performance according to standards.”19 Quality has been defined by Juran, as “fitness for purpose”, and by Crosby, 7 as “Conformance to specifications.” Goings, put quality service as one in which the guiding principle is “doing the right thing to the right patient, right away.” 9 Reenink, 6 defined quality of care as the degree to which health services for individuals and populations increase the likelihood of desired outcomes
and are consistent with current professional knowlegde. Therefore quality of maternal health care services is the degree to which maternal health care services for individuals and populations increase the likelihood of desired outcomes that are both consistent with current professional knowlegde and uphold the basic reproductive rights.
Obviously from these definitions, quality is a multifaceted concept with many dimensions. Donabedian and Maxwell have taken a holistic approach to the concept of quality and have identified several dimensions of “Quality of Health Care” which encompasses: availability, accessibility, adequacy and continuity of care, acceptability of care, technical competence, coverage, clients’ satisfaction and waiting time.7, 40, 41. Other aspects of quality of health care are interpersonal relations, safety, amenities and utilization of health services.7, 40, 41. Despite the lack of a generally accepted definition of quality health care, numerous tools purporting to measure quality are being developed and disseminated. Traditionally as postulated by Donabedian, quality of care has been assessed in three general domains: 41 structure, process, and outcome. Structure assessment concerns the characteristics of the care environment, including material resources (i.e., facilities and equipment), personnel (e.g., number, credentials, and qualifications), and organizational characteristics (e.g., methods of reimbursement and peer review).41 Process assessment concerns the characteristics of the care provided, including appropriateness, adequacy, technical competence, coordination, and continuity.41 Outcome assessment concerns the results of care on the health status of patients, including changes in patient knowledge and behaviour, patient satisfaction with health and medical care, biologic changes in disease, complications of treatments, morbidity, and mortality.41
Also in a study by Kelman and Lane,8 the indicators of quality suggested incorporate structural, process and outcome variables, and link medical and consumer criteria in a comprehensive community level approach to quality assessment. The community defined dimensions of quality of care include: access to a maternal facility in the community; treatment that is delivered in a respectful and timely fashion; respect for traditional
practices and use of indigenous language; a clean and well equipped facility, transportation, and free services. 42
Clients, providers, managers, policy makers and donors all have different legitimate perspectives of what constitute good quality of care.11 These dimensions of quality suggest that quality health care responds to the needs of its clients, and demands not only sound technical skills but also excellent interpersonal skills. It also helps in identifying various problems in the health care system which can be tackled individually. Hence the basis and need for quality assessment and assurance.
A quality assessment and assurance is an ongoing global system that compares the structure, process and outcome of care provided with established criteria or standards. Quality maternal health care services as stated by the WHO through the Mother Baby Package are those that meet the criteria below.43
2.3.1.THE ELEMENTS OF QUALITY OF MATERNAL HEALTH CARE SERVICES. 43
1. Promotion and protection of health. People need to know about pregnancy and childbirth and to understand the danger signs and symptoms.
2. Accessibility and availability of services: Women should be able to benefit from quality of care, understand the full range of services available to them and receive care at the lowest appropriate level of the system close to where they live.
3. Acceptability of services: Women need privacy, they may prefer to consult a female health worker, and they should be assured of confidentiality.
4. Continuity of care and follow up: Maternal health care should be part of a continuum of care compromising pre-pregnancy, prenatal, delivery and postpartum care. Clients must be seen as people with health needs that continue throughout their lives.
5. Comprehensiveness of care and linkages to other reproductive health services. Maternal health care is a unique opportunity to provide women with comprehensive reproductive health care and to address issues such as nutrition and sexually transmitted diseases.
6. Technical competence of health care providers: Technical competence depends on regular training and retraining, and on clear guidelines for clinical treatment.
7. Essential supplies and equipment: Norms and standards should be established for the necessary supplies and equipment at each level of care and their availability should be ensured.
8. Quality of client – provider interaction: Providers must treat clients with respect, be responsive to their needs and avoid judgmental attitudes.
9. Information and counselling for the client: Clients should have the opportunity to talk to health care providers and should be offered guidance on any health problems identified.
10. Involvement of clients in decision making: Providers should see clients as partners in health care and should involve them in decision making as active participants in their own health care.
11. Support to health care providers: Health care providers at all levels need the back – up and economic and social support of the authorities and the communities in which they work.
2.3.2HISTORICAL PERSPECTIVE OF QUALITY OF HEALTH CARE.
Medicine historically has taken a watch dog approach on standards governing who could practice the profession. This dates back to the first century AD in parts of India, China and Mesopotamia.44 Hammurabi, the great king of Babylon who lived around 2000 B.C formulated a set of draconian laws known as the code of Hammurabi. This governs the conduct of physicians and provided for health practices. Doctors whose proposed therapy proved wrong risked being killed. Laws related to medical practices including fees for satisfactory services and penalties for harmful practices are contained in the Babylonian Code of Hammurabi, the very first codification of medical practice.44
The concern about the quality of care can also be deduced from the Hippocratic oath “do no harm “which implies that right things must be done to safeguard the client.44 Doing the right thing to the patient, at the right time, technically as well as possible in a manner acceptable to the patient and within available resources-- care of good quality.19 The Physicians Oath also draws from this – “the health of my patient will be my first consideration.”
In Europe, efforts to license medical practitioners developed as early as 1140AD in Italy and evolved into uniform educational standards, state examinations and licensing in the 19th century. In Nigeria, the Medical and Dental Council of Nigeria has been established to act as a regulatory body aimed at ensuring the delivery of quality health care services in the country. However, according to Goings, 45 it was Florence Nightingale who by her activities during the Crimean war about 100 years ago, first drew attention to the benefits of good quality health care.
The modern concept of quality management was developed in Japan and in the USA in the early 1900s. In the United States of America, the modern Quality Assurance Movement in health began in 1917, when the American College of Surgeons compiled the first set of minimum standards for United States hospitals to find out and eliminate care of poor quality. This approach evolved into an accreditation process now managed by the Joint Commission on the Accreditation of Health care Organizations.11 Interest in quality then in the USA was aimed at cost containment and litigation avoidance. This was because of concern over variation of care being offered by different health institutions even at high cost. Those concerns led to the establishment of the Professional Standards Review Organization (PSRO) which encouraged peer review e.g. medical audit, utilization review as well as such recent trends as Total Quality Management (TQM) and Continuous Quality Management (CQM).
In the mid-1980s, health care professionals became more interested in the study of management and quality of care. All these were however derived from the work in the United States by such pioneers as N. Edwards Deming (the father of the quality movement); Joseph. M. Juran, Crosby P B, and Feigenbaum, A.V. A common trend in the contribution of these eminent persons is the restructuring of attitude that is necessary at all levels of any organization which desire to manage the quality of its service.
2.4 CURRENT SITUATION AND CHALLENGES OF HAVING QUALITY MATERNAL HEALTH CARE SERVICES IN NIGERIA
Nigeria is the most populous country in the African Continent. Nigeria had a population of 140 million people in 2006, with women of child bearing age constituting about 31 million. It constitutes only 1.7% of the total world population yet contributes 10% of global maternal mortality ratio (annually, an estimated 52,900 Nigerian women die from pregnancy related complications. out of total 529,000 global maternal deaths).30,49 A
woman’s chance of dying from pregnancy and childbirth in Nigeria is 1in13, while it is 1 in 5000 in developed nations. 49 More than half of women who had a live birth in the five years preceding the 2008 NDHS received antenatal care from a health professional (58 percent), 23 percent from a doctor, 30 percent from a nurse or midwife. And 5 percent from an auxiliary nurse or midwife. Thirty- six percent of mothers did not receive any antenatal care. 14 Also thirty-nine percent of births in the same period, were assisted by a skilled health worker 14, 49 Out of this were 9 percent by a doctor, 25 percent by a nurse or midwife and 5 percent by an auxiliary nurse or midwife.14 In the absence of a skilled health worker, a traditional birth attendant was the next most common person assisting a delivery (22 percent). Nineteen percent of births were assisted by a relative or other person, and an equal proportion of births were attended by no one.14 However, results from the 2008 NDHS show that the estimated maternal mortality ratio during the seven year period prior to the survey is 545 maternal deaths per 100,000 live births.14
Therefore the high mortality indicates that efficacious interventions were not used by women who needed them. Other reasons that could be responsible for these include: lack of trained personnel at the various health facilities and poor quality of care at the health facilities, lack of political will and committment of government, poor socio-economic situation in the country amongst others.
Maternal deaths are strongly linked in terms of place of deaths and the three “delays’ associated with health care delivery. In recent decades, many strategies have been implemented in an attempt to improve maternal health outcomes around the world. Programs aimed at reducing the three delays in seeking care in line with the three levels of prevention include: improving primary prevention through education and services; developing secondary prevention through early detection and treatment of conditions; and advancing tertiary prevention through treatment of conditions to reduce case fatality.50 But analysis of recent trends according to the Mid-Point Assessment Overview, MDGs Nigeria done in September 2008, shows that Nigeria is making only marginal progress in reducing
these rates and attaining the MDGs. 49 Even when most of the causes of these deaths are either preventable or treatable, it is sad to note that in spite of all previous efforts, the maternal mortality ratio have shown only marginal reductions in the last five years, from 704 deaths per 100,000 livebirths to 545 deaths per 100,000 livebirths, making the MDGs targets by 2015 clearly unachievable using current strategies alone. 49
In order to stop and indeed reverse this trend, the lntegrated Maternal Neonatal and Child Health Strategies was developed. 49 The Strategy has identified three healthcare service delivery modes namely: Family/community based service; population oriented services; and clinical based individual services. These services are usually delivered by skilled health attendants in the health facility. This has been shown to be highly effective, having high impact on maternal and newborn mortality and internationally recommended, as demonstrated by the British Medical Journal, Lancet Child Survival series and the Cochrane review [Lancet Maternal Survival September, 2006].49 Therefore there is growing consensus that the reduction of maternal deaths is impossible without skilled care during pregnancy, labour and puerperium.26, 49 The National Primary Health Care Development Agency (NPHCDA) has established the Midwives Service Scheme (MSS), a public sector collaborative initiative, designed to mobilize midwives, including newly qualified, unemployed and retired midwives, for deployment to selected primary health care facilities in rural communities. The aim is to facilitate an increase in the coverage of skilled birth attendance to reduce amongst other indices, maternal mortality.49
While many strategies have attempted to address some of the economic, social, and physical factors and barriers contributing to poor maternal health outcomes, women’s utilization of maternal health services is often influenced by perceived socio-cultural, economic, and health system factors operating at the community, household, and individual level as well as within the larger social and political environments. There is therefore need for improvement on the provision, utilization, adequacy and continuity of maternal health care services.
2.4.1 PROVISION OF MATERNAL HEALTH CARE SERVICES
In most health facilities in the developing countries maternal health services are often not available and as such, clients are asked to come back at another time or day to receive services of their choices.25 This should not be the case as it is stipulated under international law, that the realization of the right to health requires that a sufficient number of health care facilities, goods and services be provided throughout the country’s territory.25 It therefore suffices that the service delivery point must also be open at the right time and the supplies must be available too.
Olumide, Obionu and Mako, 18 in a needs assessment survey carried out in Nigeria, by the NPHCDA revealed that,” none of the sampled Local Government Areas met the minimum standard of providing all the basic primary health care services which include treatment of minor ailments, immunization, antenatal care, delivery services, family planning, health education, growth monitoring and control of locally endemic diseases. They reported that the proportion of health facilities offering delivery care services are far less than that offering ANC in all the six geo-political zones of country. They estimated that overall, 42.9% of PHC centres provides delivery care.” 29 According to the 2008 NDHS, in Anambra southeast Nigeria, “97.7 % of women received antenatal care services, 87.8% delivered in health facilities but only 26.1% deliveries occurred in public health facilities.”14 These probably point out that some health facilities only conduct ANC to prepare the pregnant women for delivery elsewhere.29 It is however important to note that the type and quality of delivery care provided to women often determine whether pregnant women will survive the processes or not, as it has been estimated that quality delivery care can prevent 50% to 80% of maternal death.29
In a study by Mandy et al, 51 conducted in 2001 to systematically assess health system capacity to provide maternal health services in a representative sample of 333 public and private facilities, it was also reported that whereas most facilities in Kenya provided antenatal care, only 37% provided delivery care. Of these, 43% provided post abortion care,
and 28% caesarian section. Although most facilities were equipped for providing routine care, many lacked medicines and supplies; only 44% had ANC cards and 10% lacked iron supplements.51 Facilities were not well equipped for emergencies; only 47% of delivery facilities had emergency transport available.51 Less than 60% of hospitals had the essential equipment and drugs for the management of haemorrhage and sepsis.51 Also an assessment of structure and process of antenatal care in Zimbabwe using clients interview, process observation and inventory of equipment revealed that limited availability of equipment as well as poor know–how on the available equipment, contributed significantly to the provision of poor services at the health centre by staff. 52
The component of the provided maternal health care service from the clients’ perspective also connotes quality. In a study on mothers’ perspectives of the quality of postpartum care in Central Shanghai, China, the mothers indicated that to improve quality of services further, greater emphasis should be placed on: health education on child care; more time allocation for discussion with health workers during their postpartum home visit so that their questions and concerns should be addressed effectively; access to health workers in times of need rather than during official prescribed home visits; provision of continuous training for maternal and child health workers with respect to child care. 53
The performance of health systems is dependent on the availability of drugs, equipment and other materials, supplies and health infrastructure.12 A study in Pakistan showed that at the Primary Health Care facility, partographs were not available. Also basic supplies like iron and folate tablets, broad spectrum antibiotics, oxytocics, gloves and sutures were not available at the primary or secondary facilities, while magnesium sulphate was only available at the tertiary facility.54 An evaluation report on the primary health care systems project in 10 LGAs in Katsina, Kebbi and Oyo states of Nigeria, reported that many of the PHC facilities were dilapidated with little or no evidence of preventive maintenance or repair, and no provision for consultations in privacy. Most of the facilities visited also lacked sources of potable water.12 A Nigerian study reported that water supply was
adequate in only 42% of facilities, while refuse and sewage disposal were adequate in 50%, and only 67% of health facilities had clean furniture and walls. 18
Availability also refers to that of human resources or skilled personnel capable of responding to obstetric emergencies. While human resource development is key to ensuring the provision of services, a Kaduna study showed general poor resource availability in terms of lack of health personnel as well as inadequate supply of drugs and lack of equipment at the first level health facilities.55 It has also been noted that in some settings, even where the health personnel are available they are either not skilled or are not trained and retrained on the necessary skills required to offer the needed quality services. The Kenyan study further revealed that only 20% of delivery staff had ever had any refresher training on managing complications.51
In relation to the reduction of maternal mortality, there are public health indicators that can be used to judge availability and subsequently the provision of maternal health care services. The World Health Organization and UNICEF recommend one comprehensive and four basic EOC facilities for every 500,000 population. Approximately two-thirds of all Nigeria women deliver outside of health facilities and without medically skilled attendants being present.14, 56. It has also been reported in a study in Kenya that most maternal deaths should be prevented if women are provided with timely and appropriate care, particularly in the event of an emergency.51 Furthermore, with increased access to EOC, Sri Lanka and Malaysia were able to reduce their maternal mortality ratios from 500 deaths per 100,000 live births in 1950 by half every six to 12 years.57
A study conducted in Cebu, Philippines showed that improved quality as measured by the availability of services and supplies, provider training, facility size, price and distance increased the probability that women used formal services.58 It has been reported by a number of researchers that even when the quality of services rendered is good, distance
may constitute a barrier to the utilization of the maternal health care services so provided.59-61. This situation is worsened when there are no means of transport to the facility. However, it has also been reported that availability of maternal health care services can influence the decision to seek care that even when, for example, health facilities are so scarce that distance is a discouraging factor, availability influences utilization of care. This was shown in a study in Pakistan, where utilization patterns were skewed to the tertiary facility for normal and complicated deliveries because of availability of the needed services at this level even when these facilities are farther than the other levels of care where these services were not readily available.54
2.4.2 UTILIZATION OF MATERNAL HEALTH CARE SERVICES
About half a million women die each year from complications related to pregnancy, 99% of whom are citizens of developing countries including Nigeria.62 Maternal mortality in developing countries can be analyzed through what the clients experience in order to utilize maternal health care services.
In a study by Tunde, 63 on factors enabling and constraining the use of maternal and newborn health services in northern Nigeria in 2007, findings revealed that women prefer to deliver in hospitals. The enabling factors as reported by this study include: willingness of women to deliver in hospitals and women’s perceptions that health facilities can provide quality services.63 Several studies have reported that women who were knowledgeable of risk factors were more likely to utilize health facilities for delivery compared to those with no knowledge of risk factors.60, 64, 65. Nwakoby,66 in a study on the pattern and determinants of maternal service utilization in a rural Nigerian community, reported that factors found to be most consistently associated with the use of health institutions for delivery were maternal highest level of educational attainment, occupation, religion, and occupation of the husband.
The factors reported as preventing women from delivering at health facilities are: dominance of men in decision making; rude behaviour of clinicians; traditional use of Hannu (a hand-like fruit) as a delivery warning sign; cost of delivery at hospitals; religious beliefs forbidding male health care providers from touching women; and distance to the facilities.63 Osubor et al,65 in an assessment of health services and health-seeking behaviour in a rural community (Ologbo), located in the South-south zone of Nigeria in 2006 reported that Private maternity centre was the most preferred place for childbirth (37.3%), followed by traditional birth attendants (TBAs) (25.5%). Government facility was preferred by only 15.7%: reasons for the low preference included irregularity of staff at work (31.4%), poor quality of services (24.3%), and high costs (19.2%).
Access barriers would be considered better indicators to utilization of health care services than population per facility.25, 67, 68. Barriers such as lack of roads, the time taken to reach a facility, absence of convenient and affordable public transport, conditions that prejudice clients access; high fees for health services, authorization by spouse, parent or hospital authorities. It has been reported that economic and social dimensions of the distribution of power between spouses influence access and use of maternal health care services.69 In other studies, respondents cited some problem areas that needed improvement; difficulty reaching the clinic 54%, service fees 47%, clinic hours 24% and information on maternal health services 22%.17, 70.
According to the 2008 NDHS, women were asked whether each of the following factors would be a big problem in seeking medical care: getting permission to go for treatment, distance to health facility, transport cost, not wanting to go alone, concern that there may not be a female provider or any health provider, and concern that drugs may not be available. Three-quarters of women reported that they have at least one serious problem in accessing health care. The leading barrier to health care for Nigerian women is getting money for treatment.14 Fifty-six percent of women said that getting money for treatment was a serious problem in accessing health care.14 Forty-one percent of women said they were concerned that there would be no drugs available at the health facility. About one in three women reported that transportation, distance to the health facility, and not having a
provider to attend to them are big problems.14 Twenty-one percent of women were concerned that there would be no female provider to attend to them. Not wanting to go alone (17 percent) and problems getting permission to go for treatment (14 percent) were less likely to be reported as a hindrance to seeking health care.14
Accessibility and perceived quality of care have been identified as important determinants for the use of facility-based maternal health care services.63 One of the targets of the fifth MDG is to ensure access to maternal health care services for all. This if achieved could help avert up to 35% of maternal deaths.71 Access to care for delivery is complicated by the unscheduled nature of labour, by women’s responsibility, and by fears for women’s safety during night travel.72,73. The service delivery point should not be far from clients and transportation to the clients should be with ease.74 According to the Basic Health Services Scheme a typical PHC should serve a population of 20,000 people. The ultimate objective however will be to have a PHC centre for every 10,000 persons; implying that in densily populated areas, such a centre need only serve an area within a radius of 5 kilometre or half an hour to one hour of travel time.75,76. The 1999 NDHS shows that 53% of the population lives within 1kilometre of a health centre, clinic or hospital and 73% within 5 kilometres.28 But this is not the case in most parts of the developing world. It is estimated that in most rural areas one in three women lives more than 5 kilometres from the nearest health facility, and 80% of rural women live more than 5 kilometres from the nearest health facility.28 Similar findings was observed in a study carried out in Ghana.77 In rural Tanzania for example, 84% of women who gave birth at home intended to deliver at a health facility, but did not due to absence and lack of transportation. Similarly, in Malawi, a study found that 90% of women wanted to deliver in a health centre, but only 25% of them did. The most reason given by 53% of the women was that by the time thay realized they were in labour, they did not have enough time to get to a health facility.78
A study on inequality in the utilization of maternal health care services in South East Nigeria showed that socio economic conditions of households have also been noted to
influence maternal seeking behaviour.79 It was also reported that utilization is worse among poorer families than among the relatively rich, even within a rural society where poverty gradient is not easily discernible.79 In Burkina Faso, the cost for obstetric emergency transports are covered by the health services through fuel vouchers. Other interventions especially in the face of limited resources include making maternal health care services more user friendly and receptive to the social and medical needs of potential users.80 These may include interventions such as preferential treatment for referred patients, 24-hours service delivery, culturally appropriate attitudes, provision of privacy and allowing for an accompanying support person.80-82 Emergency loans to improve access to obstetric care has been practiced in Ekpoma, Nigeria.
When the waiting time is unduly long the client is unable to get to work or other activities early and this might discourage some clients from attending the clinic as they would not be able to carry out other daily activities without much delay and interferences. A study in Ile Ife Nigeria, 83 found the minimum time spent for ANC was 1 hour while the maximum was 6 hours 51 minutes. The average doctor-client interaction time was found to be 5.8 minutes. Ninety seven percent of the respondents felt that the time was not good enough and the majority felt that the clients should not spend more than 3 hours. Similarly, long waiting time was a principal factor leading to high rate of discontinuity of service utilization.12 In another study, long waiting time was among the main causes of inaccessibility to maternal health care services mentioned by respondents. 84
Lindsey et al, 85 in Nicaragua in 2007 reported that delays in seeking health care during pregnancy are influenced not only by poor access to care and economic barriers but also by individual and community knowledge and acceptance of maternal health services. Other factors that affect women’s decisions to seek care include: partner support, previous maternal health care experiences, and the degree of communication with other women and health workers. Common factors contributing to maternal mortality include: lack of access to services, high fertility, domestic violence, complications of unsafe abortions, a large
young reproductive age population, and hypertension.86-89. Indirect costs such as financing travel to and from the clinic, leaving work to seek care, and paying for prescribed drugs were also reported as considerable barriers to accessing care and treatment.85 Women also cited their need to prioritize spending money on food and school-related expenditures for children and other family members as an economic barrier to service utilization. 85
Women’s perceptions of the cost of delivery care services, including the cost of using a partera (traditional birth attendant) and staying at the casa materna (maternity house), contributed to their decisions to seek delivery care. 85 The findings indicate that financial obstacles, especially in relation to transportation, time constraints, and availability of health care staff and services influence women’s utilization of prenatal and delivery services. 85
Women’s low status in the society relative to the status of men contributes to maternal mortality.88 The role of men or partners in the decision-making process regarding women’s prenatal and delivery care has been noted as a factor influencing women’s health care– seeking behaviour.65, 89-92. Women’s husbands’ or mothers-in-law’s belief that maternal services are inappropriate or irrelevant has been shown to influence women’s perception and utilization of care.92
Perceptions of quality of care- including promptness of care, competence of health workers, desire for privacy, perceived availability of equipment, disempowerment, abusive behavior, and friendliness of staff- often influence women’s decisions to seek maternal health care. 90, 94-96. Women’s fear of doctors, medical examinations, and health procedures such as caesarean sections may influence their decision to seek care and the type of provider they use. 66, 90, 97. Religion, spirituality, and traditional beliefs have also contributed to women’s perceptions and utilization of prenatal and delivery care services.65, 66, 98, 99. In addition, while a woman’s knowledge regarding pregnancy and delivery risks is an important factor contributing to her decision to seek care, it may not change her reproductive health behaviors due to conflicting priorities. For example, due to the influence of cultural norms irrespective of a high level of awareness of the potential risks, a woman may still choose to use traditional methods rather than take advantage of institutional maternal services.