Conceptual bases and methodology for the evaluation of women's and providers' perception of the quality of antenatal care in the WHO Antenatal Care Randomised Controlled Trial

Are Kazakhstani Women Satisfied with Antenatal Care? Implementing the WHO Tool to Assess the Quality of Antenatal Services

Women’s satisfaction is a part of the quality assurance process with potential to improve antenatal health services. The objective of this study was to assess the prevalence of women’s satisfaction with antenatal care in an urban Kazakhstani setting and investigate associated factors. A total of 1496 women who delivered in all maternity clinics from 6 February through 11 July 2013 in Semey, East Kazakhstan, filled out a standardized pretested questionnaire on satisfaction with antenatal care. Independent associations between dissatisfaction and its correlates were studied by logistic regression. Ninety percent of the women were satisfied with the antenatal care. Women who were dissatisfied had lower education. These women would have preferred more checkups, shorter intervals between checkups, more time with care providers, and shorter waiting times. The overall dissatisfaction was associated with long waiting times and insufficient information on general health in pregnancy, results of laboratory tests, treatment during pregnancy, and breastfeeding. Although most of the women in the study setting were satisfied with the new antenatal care model, we identified the main sources of dissatisfaction that should be addressed. Given that Semey is a typical Kazakhstani city, the results can be generalized to other Kazakhstani urban settings.

Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review

Background

High maternal mortality and morbidity persist, in large part due to inadequate access to timely and quality health care. Attitudes and behaviours of maternal health care providers (MHCPs) influence health care seeking and quality of care.

Methods

Five electronic databases were searched for studies from January 1990 to December 2014. Included studies report on types or impacts of MHCP attitudes and behaviours towards their clients, or the factors influencing these attitudes and behaviours. Attitudes and behaviours mentioned in relation to HIV infection, and studies of health providers outside the formal health system, such as traditional birth attendants, were excluded.

Findings

Of 967 titles and 412 abstracts screened, 125 full-text papers were reviewed and 81 included. Around two-thirds used qualitative methods and over half studied public-sector facilities. Most studies were in Africa (n = 55), followed by Asia and the Pacific (n = 17). Fifty-eight studies covered only negative attitudes or behaviours, with a minority describing positive provider behaviours, such as being caring, respectful, sympathetic and helpful. Negative attitudes and behaviours commonly entailed verbal abuse (n = 45), rudeness such as ignoring or ridiculing patients (n = 35), or neglect (n = 32). Studies also documented physical abuse towards women, absenteeism or unavailability of providers, corruption, lack of regard for privacy, poor communication, unwillingness to accommodate traditional practices, and authoritarian or frightening attitudes. These behaviours were influenced by provider workload, patients’ attitudes and behaviours, provider beliefs and prejudices, and feelings of superiority among MHCPs. Overall, negative attitudes and behaviours undermined health care seeking and affected patient well-being.

Conclusions

The review documented a broad range of negative MHCP attitudes and behaviours affecting patient well-being, satisfaction with care and care seeking. Reported negative patient interactions far outweigh positive ones. The nature of the factors which influence health worker attitudes and behaviours suggests that strengthening health systems, and workforce development, including in communication and counselling skills, are important. Greater attention is required to the attitudes and behaviours of MHCPs within efforts to improve maternal health, for the sake of both women and health care providers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-015-0117-9) contains supplementary material, which is available to authorized users.

Perceptions of antenatal care services by pregnant women attending government health centres in the Buea Health District, Cameroon: a cross sectional study

INTRODUCTION

User'sperception of quality of ANC services crucially impacts continuity of use of these services and hence pregnancy outcome. However in our community, ANC user's perceptions of quality are not known.

METHODS

An observational analytic cross-sectional study was carried out amongst pregnant women attending selected government health centres in the Buea Health District. We recruited 385 consenting pregnant women for the study. Demographic and clinical data were collected using structured questionnaires. The data was entered into Microsoft Excel and exported toEpi-Info (Version 3.5.1) for analysis.

RESULTS

Geographical accessibility and perceived quality of care were the predominant reasons for choosing or changing a site for ANC. One third of respondents (30.1%) attended a health centre out of their catchment health area with Buea Town health centre receiving the highest proportion of women out of the health area (56.8% of attendees). Knowledge about antenatal care varied and majority of respondents (96.4%) were satisfied with the antenatal services received. However, there were elements of dissatisfaction with health centre services, poor sitting facilities, amenities, few health education talks and poor nursing skills. High educational level (high school and university) (X(2) = 8.714; p = 0.01) and first time pregnancy(X(2)= 4.217; p= 0.04) were significantly associated with poor satisfaction.

CONCLUSION

Policy makers should implement changes in the health care delivery system taking into account the users' preferences, more so in the light of increasing female education in Cameroon.

Health education during antenatal care: the need for more

The aim of health education during antenatal is to provide advice, education, reassurance and support, to address and treat the minor problems of pregnancy, and to provide effective screening during the pregnancy. Exploring current practices in this regard revealed the need for more organized educational activities to ensure high quality and clients satisfaction.

Quality of prenatal care questionnaire: instrument development and testing

Background

Utilization indices exist to measure quantity of prenatal care, but currently there is no published instrument to assess quality of prenatal care. The purpose of this study was to develop and test a new instrument, the Quality of Prenatal Care Questionnaire (QPCQ).

Methods

Data for this instrument development study were collected in five Canadian cities. Items for the QPCQ were generated through interviews with 40 pregnant women and 40 health care providers and a review of prenatal care guidelines, followed by assessment of content validity and rating of importance of items. The preliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratory factor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women to establish its construct validity, and internal consistency and test-retest reliability.

Results

Exploratory factor analysis reduced the QPCQ to 46 items, factored into 6 subscales, which subsequently were validated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testing approach; there was a significant positive association between women’s ratings of the quality of prenatal care and their satisfaction with care (r = 0.81). Convergent validity was demonstrated by a significant positive correlation (r = 0.63) between the “Support and Respect” subscale of the QPCQ and the “Respectfulness/Emotional Support” subscale of the Prenatal Interpersonal Processes of Care instrument. The overall QPCQ had acceptable internal consistency reliability (Cronbach’s alpha = 0.96), as did each of the subscales. The test-retest reliability result (Intra-class correlation coefficient = 0.88) indicated stability of the instrument on repeat administration approximately one week later. Temporal stability testing confirmed that women’s ratings of their quality of prenatal care did not change as a result of giving birth or between the early postpartum period and 4 to 6 weeks postpartum.

Conclusion

The QPCQ is a valid and reliable instrument that will be useful in future research as an outcome measure to compare quality of care across geographic regions, populations, and service delivery models, and to assess the relationship between quality of care and maternal and infant health outcomes.

Clients' perceptions of the quality of antenatal care

OBJECTIVES

To assess perceptions of pregnant women about quality of antenatal care.

METHODS

Descriptive cross-sectional study in a developing country setting. Three-hundred-ninety-five previously booked pregnant women randomly selected from private and public health facilities at the 3 levels of care were interviewed using a 52-stem interviewer-administered, semistructured questionnaire. The questionnaire sought information about bio data, health information and services, interpersonal communications, amenities and constellation of services.

RESULTS

Mean gestational age at booking was 18.5 +/- 6.3 weeks. Only 25.8% of respondents booked in the first trimester. Mean number of antenatal visits was 4.0 +/- 2.4. Mean time spent during clinic visits was 3.9 +/- 1.4 hours. Waiting time was rated as appropriate by most women (67.1%). Women with high education and in upper socioeconomic class tended to rate the waiting time as too long. Counseling for HIV was the predominant health education subject. More than half (53.9%) of respondents did not receive information about cervical cancer. About 10% of patients did not receive information about danger signs during pregnancy, breast self-examination, family planning and prevention of sexually transmitted infections. Clinic amenities and constellation of services were rated highly. Most women (96.5%) were satisfied with the care received, would use the same facility in future pregnancies and would recommend it to friends.

CONCLUSIONS

The majority of pregnant women were satisfied with the care they received. However, frequent antenatal visits and long waiting times are the norm of our antenatal service. Measures for improving elements of quality of antenatal care are imperative.

Do sociodemographic characteristics of pregnant women determine their perception of antenatal care quality?

OBJECTIVES

To explore sociodemographic determinants of perceived quality of antenatal care (ANC) at the primary care level.

METHODS

A survey of 452 randomly selected pregnant women accessing antenatal care at the primary healthcare facilities in Sagamu Local Government Area (LGA) of Ogun State, southwest Nigeria. The relationships between 13 sociodemographic characteristics of women and their overall perception of the quality of care (expressed by their level of overall satisfaction) were examined through bivariate analyses, by computing odds ratio at 95% confidence interval. Multivariate logistic regression analyses were used to determine independent sociodemographic determinants of overall satisfaction with quality of care received. A P-value <0.05 or CI which did not embrace unity was considered as statistical significance.

RESULTS

From bivariate analyses, increasing parity, increasing number of living children, gainful employment of client and Islamic religion increases the likelihood of positive perception of antenatal care quality. Characteristics such as age, being married, women's monthly earning, ethnicity, employment status of husband, educational level, duration of pregnancy, frequency of antenatal visits, and previous use of antenatal care at the same centre were not associated with overall satisfaction with antenatal care quality. Independent predictors from multivariate regression analyses include parity (adjusted OR 0.13; CI: 0.05-0.33, P = 0.005) and religion (other religions vs. Islam; adjusted OR: 0.14, CI: 0.04-0.40, P = 0.0003).

CONCLUSIONS

The study suggests that sociodemographic characteristics of women have limited impact on their perception of ANC quality. The identified predictors may serve as the criteria for selecting women that require intensive health centre-specific antenatal interventions aimed at improving perceived quality and thus sustained utilization of antenatal care services in these primary health care facilities.

Barriers to high-quality primary reproductive health services in an urban area of Iran: views of public health providers

OBJECTIVE

to explore public primary reproductive health providers' views on their own roles and tasks in their present organisation, and the perceived barriers to providing high-quality services.

DESIGN

a qualitative approach using semi-structured, audio-taped focus group discussions (FGDs). The discussions were held in Farsi or Turkish, transcribed verbatim, translated into English and analysed using content analysis.

SETTING

family health units of public health facilities, Tabriz, Iran.

PARTICIPANTS

two FGDs with 12 midwives and two FGDs with eight other family health providers working at the facilities.

FINDINGS

the providers identified the most satisfying part of their duties as working with clients. A dominant theme in all FGDs was the providers' frustration about a number of factors, most of which were beyond their control. The identified system and organisational barriers were grouped into five categories: multiplicity of tasks and incompatibility with the providers' own basic training; suboptimal supervision and management; too little time for clients; lack of privacy and appropriate materials for education and counselling; and inadequate opportunities for continuing education.

KEY CONCLUSIONS

this study highlighted the providers' satisfaction in working with clients, and their dissatisfaction with not being used to the best of their capabilities due to a number of systemic and organisational barriers.

IMPLICATIONS FOR PRACTICE

based on these findings, multifaceted interventions seem to be necessary to improve staff productivity and service quality. The interventions should include needs-based pre-service education, supportive supervision and management, provision of educational materials, simplifying record management, and appointing more staff in socio-economically deprived areas. Research is needed to identify the best way to integrate the services, as well as basic and continuing educational needs of staff.

Please understand when I cry out in pain: women's accounts of maternity services during labour and delivery in Ghana

BACKGROUND

This study was undertaken to investigate women's accounts of interactions with health care providers during labour and delivery and to assess the implications for acceptability and utilisation of maternity services in Ghana.

METHODS

Twenty-one individual in-depth interviews and two focus group discussions were conducted with women of reproductive age who had delivered in the past five years in the Greater Accra Region. The study investigated women's perceptions and experiences of care in terms of factors that influenced place of delivery, satisfaction with services, expectations of care and whether they would recommend services.

RESULTS

One component of care which appeared to be of great importance to women was staff attitudes. This factor had considerable influence on acceptability and utilisation of services. Otherwise, a successful labour outcome and non-medical factors such as cost, perceived quality of care and proximity of services were important. Our findings indicate that women expect humane, professional and courteous treatment from health professionals and a reasonable standard of physical environment. Women will consciously change their place of delivery and recommendations to others if they experience degrading and unacceptable behaviour.

CONCLUSION

The findings suggest that inter-personal aspects of care are key to women's expectations, which in turn govern satisfaction. Service improvements which address this aspect of care are likely to have an impact on health seeking behaviour and utilisation. Our findings suggest that user-views are important and warrant further investigation. The views of providers should also be investigated to identify channels by which service improvements, taking into account women's views, could be operationalised. We also recommend that interventions to improve delivery care should not only be directed to the health professional, but also to general health system improvements.

Adequação do pré-natal e peso ao nascer: uma revisão sistemática

Esta foi uma revisão sistemática da literatura de publicações em que o pré-natal foi investigado com uma das variáveis preditoras do peso ao nascer. Os bancos de dados MEDLINE, Cochrane Library e SciELO foram rastreados usando-se a combinação dos seguintes descritores: "prenatal care", "antenatal care", "quality", "adequacy", "birthweight", e "low birthweight". Foram localizados 25 estudos: 17 transversais, quatro coortes, três caso-controle e um ensaio randomizado. Os indicadores de adequação empregados foram os de utilização (quantitativos) e os de conteúdo do cuidado (de processo ou qualitativos). A maioria dos autores aplicou indicadores de utilização, principalmente o Índice de Kessner e o Adequacy of Prenatal Care Utilization Index. Somente dois estudos usaram critérios qualitativos. De modo geral, os estudos transversais detectaram efeito protetor do pré-natal sobre o baixo peso ao nascer, enquanto que os resultados de investigações com outros desenhos foram conflitantes. Os achados desta revisão evidenciam que o impacto do pré-natal sobre o peso ao nascer não é inequívoco, principalmente devido ao efeito do viés de auto-seleção. Há a necessidade de realização de ensaios randomizados para esclarecer essa relação.

Examining within-country variation of maternity costs in the context of a multicountry, multicentre randomised controlled trial

Understanding why healthcare costs vary between patients and between health facilities is important in guiding health policy decisions as well as in research. However, there is no comprehensive framework that analysts commonly use for expressing and examining causes of cost variation in the field of healthcare. The aim of this study is to better understand the size and causes of within-country healthcare cost variation, through presenting evidence for size and sources of such variations for two countries (Cuba and Thailand) in the context of a randomised controlled trial on antenatal care. The article separates total costs into their two components: unit costs and health service use. Unit costs are further separated into input quantity per patient visit or day, and the prices of these resources. The results show that the main determinant of average cost is the staffing pattern and productivity, whereas the main determinants of health service use include the model of antenatal care being practised and the risk status and illnesses suffered by patients. However, variations in inpatient health service use between facilities are largely related to unexplainable variations in practice between facilities, irrespective of the trial arm. In conclusion, cost variations have important implications for the design of clinical trials and for policy makers using evidence from trials in planning health services and budgets.

Womens' opinions on antenatal care in developing countries: results of a study in Cuba, Thailand, Saudi Arabia and Argentina

BACKGROUND

The results of a qualitative study carried out in four developing countries (Cuba, Thailand, Saudi Arabia and Argentina) are presented. The study was conducted in the context of a randomised controlled trial to test the benefits of a new antenatal care protocol that reduced the number of visits to the doctor, rationalised the application of technology, and improved the provision of information to women in relation to the traditional protocol applied in each country.

METHODS

Through focus groups discussions we were able to assess the concepts and expectations underlying women's evaluation of concepts and experiences of the care received in antenatal care clinics. 164 women participated in 24 focus groups discussion in all countries.

RESULTS

Three areas are particularly addressed in this paper: a) concepts about pregnancy and health care, b) experience with health services and health providers, and c) opinions about the modified Antenatal Care (ANC) programme. In all three topics similarities were identified as well as particular opinions related to country specific social and cultural values. In general women have a positive view of the new ANC protocol, particularly regarding the information they receive. However, controversial issues emerged such as the reduction in the number of visits, particularly in Cuba where women are used to have 18 ANC visits in one pregnancy period.

CONCLUSION

Recommendations to improve ANC services performance are being proposed. Any country interested in the application of a new ANC protocol should regard the opinion and acceptability of women towards changes.

Are women and providers satisfied with antenatal care? Views on a standard and a simplified, evidence-based model of care in four developing countries

BACKGROUND: This study assessed women and providers' satisfaction with a new evidence-based antenatal care (ANC) model within the WHO randomized trial conducted in four developing countries. The WHO study was a randomized controlled trial that compared a new ANC model with the standard type offered in each country. The new model of ANC emphasized actions known to be effective in improving maternal or neonatal health, excluded other interventions that have not proved to be beneficial, and improved the information component, especially alerting pregnant women to potential health problems and instructing them on appropriate responses. These activities were distributed within four antenatal care visits for women that did not need any further assessment. METHODS: Satisfaction was measured through a standardized questionnaire administered to a random sample of 1,600 pregnant women and another to all antenatal care providers. RESULTS: Most women in both arms expressed satisfaction with ANC. More women in the intervention arm were satisfied with information on labor, delivery, family planning, pregnancy complications and emergency procedures. More providers in the experimental clinics were worried about visit spacing, but more satisfied with the time spent and information provided. CONCLUSIONS: Women and providers accepted the new ANC model generally. The safety of fewer visits for women without complications with longer spacing would have to be reinforced, if such a model is to be introduced into routine practice.

WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care

BACKGROUND

We undertook a multicentre randomised controlled trial that compared the standard model of antenatal care with a new model that emphasises actions known to be effective in improving maternal or neonatal outcomes and has fewer clinic visits.

METHODS

Clinics in Argentina, Cuba, Saudi Arabia, and Thailand were randomly allocated to provide either the new model (27 clinics) or the standard model currently in use (26 clinics). All women presenting for antenatal care at these clinics over an average of 18 months were enrolled. Women enrolled in clinics offering the new model were classified on the basis of history of obstetric and clinical conditions. Those who did not require further specific assessment or treatment were offered the basic component of the new model, and those deemed at higher risk received the usual care for their conditions; however, all were included in the new-model group for the analyses, which were by intention to treat. The primary outcomes were low birthweight (<2500 g), pre-eclampsia/eclampsia, severe postpartum anaemia (<90 g/L haemoglobin), and treated urinary-tract infection. There was an assessment of quality of care and an economic evaluation.

FINDINGS

Women attending clinics assigned the new model (n=12568) had a median of five visits compared with eight within the standard model (n=11958). More women in the new model than in the standard model were referred to higher levels of care (13.4% vs 7.3%), but rates of hospital admission, diagnosis, and length of stay were similar. The groups had similar rates of low birthweight (new model 7.68% vs standard model 7.14%; stratified rate difference 0.96 [95% CI -0.01 to 1.92]), postpartum anaemia (7.59% vs 8.67%; 0.32), and urinary-tract infection (5.95% vs 7.41%; -0.42 [-1.65 to 0.80]). For pre-eclampsia/eclampsia the rate was slightly higher in the new model (1.69% vs 1.38%; 0.21 [-0.25 to 0.67]). Adjustment by several confounding variables did not modify this pattern. There were negligible differences between groups for several secondary outcomes. Women and providers in both groups were, in general, satisfied with the care received, although some women assigned the new model expressed concern about the timing of visits. There was no cost increase, and in some settings the new model decreased cost.

INTERPRETATIONS

Provision of routine antenatal care by the new model seems not to affect maternal and perinatal outcomes. It could be implemented without major resistance from women and providers and may reduce cost.

Epidemiological issues in perinatal outcomes research

Outcomes research takes an expansive view of health and seeks to improve the science of evaluating the quality of health care by refining traditional clinical measures and including measures of overall patient well-being. This broader view of health (rather than disease) is especially appropriate in perinatal research. Attention to the perinatal period requires recognition that pregnancy is in most cases a healthy life event, that there is a predictable progression and time course with a key definable outcome (delivery) and that there are two patients, mother and infant. Two issues stand out as methodological challenges in the design and conduct of perinatal outcomes studies. The first is to establish baseline comparability across study groups with regard to case-mix or perinatal risk, and also comparability of services other than the one under study. The second is the refinement of traditional perinatal outcomes, such as low birthweight and Caesarean section, and the inclusion of patient-based health status measures, such as health-related quality of life, for the peripartum woman and her newborn.