Perception of quality of maternal healthcare services among women utilising antenatal services in selected primary health facilities in Anambra State, Southeast Nigeria.

BACKGROUND: This is a cross-sectional descriptive study aimed at assessing antenatal care service attendees' perception of quality of maternal healthcare (MHC) services in Anambra State, southeast Nigeria.
MATERIALS AND METHODS: A total of 310 pregnant women utilising antenatal care (ANC) services in three purposively selected primary health centres (PHCs) in rural communities in Anambra State were studied. Reponses were elicited from the participants selected consecutively over a 4-month period, using a pre-tested, semi-structured interviewer-administered questionnaire on socio-demographic characteristics, utilisation and perception of MHC services. Data collected were analysed using SPSS version 17.
RESULTS: Findings showed that utilisation of facility for both antenatal (97.0%; 95% CI, 94.4-98.4%) and natal services (92.7%; 95% CI 89.2-95.2%) were quite high. Generally, most of the women were satisfied with MHC services (89.7%). Most of them were satisfied with the staff attitude (85.1%), waiting time (84.1%) and cost of services (79.5%). Being ≥30 years (X (2) = 4.61, P = 0.032), married (X (2) = 9.70, P = 0.008) and multiparous (X (2) = 9.14, P = 0.028), as well as utilisation of formal health facility for antenatal (X (2) = 26.94, P = 0.000) and natal (X (2) = 33.42, P = 0.000) services were associated with satisfaction with maternal health services.
CONCLUSIONS: The study showed high level of satisfaction with quality of maternal health services among antenatal attendees and highlights the need to strengthen interventions that increase uptake of formal MHC services.

INTRODUCTION

Nigeria has high maternal and infant mortality. In recent years the country has embarked on measures to reform the healthcare system, including maternal healthcare (MHC) delivery, in a bid to attain Millennium Development Goals (MDGs) 4 and 5. Most health reform efforts have been geared towards increasing availability of healthcare services, without commensurate increase in quality. Studies have shown that increased availability of service does not always translate to increased access to healthcare.12 Hence, for these interventions to deliver optimally there is need to ensure that quality of service is taken into consideration in the provision of maternal health (MH) services.

Most women who utilise antenatal care (ANC) services in sub-Saharan Africa (SSA) do not receive adequate attention; as care providers are overwhelmed by the number of pregnant women seeking ANC.3 Consequently, some have argued for the adoption of focused ANC, in which case a woman attends ANC four times during pregnancy at specific intervals for uncomplicated pregnancies. This allows for adequate attention to be given to each pregnant woman and provides opportunity for monitoring of high risk pregnancies. Advocates of this strategy believe that this will enhance the quality of ANC services provided as well as reduce morbidity and mortality associated with high risk pregnancies.4

Quality of care is imperative in optimising uptake (effective utilisation) of maternal and child health services.15 In the developing countries including Nigeria, standards of quality of care are often set by health managers and care providers. Although there are several policies and guidelines to ensure quality of care, the extent to which they are adhered to is not well known. According to Uzochukwu et al., many patients in southeast Nigeria are poor and ignorant, hence often feel that they are not in a good position to influence the type and quality of services they receive even if their expectations are not met.6

While many studies have reported high ANC attendance among pregnant women in southeast Nigeria, only few studies have assessed the quality of ANC services among pregnant women.1 Reducing maternal mortality and morbidity through increased service utilisation in turn requires public health interventions built on clear understanding of women's perception of maternal care services within their cultural context.7 Quality of healthcare services can be assessed either objectively or subjectively or by assessing the supply or demand component of health services. Subjectively, assessment of patients’ perception of healthcare services is one of the ways of measuring quality of healthcare. Beside using outcome of care as a basis for measuring quality of care, clients’ perception of care provides another opportunity of assessing quality of care based on their perspective. Patient perception of quality of care is one of the major determinants of uptake of healthcare services including MH services.6 It measures level of satisfaction of healthcare services received from health facility. Understanding clients’ perception of healthcare services provides opportunity for identifying deficiencies in healthcare as well as motivators and barriers to uptake healthcare services. It can also be used for gathering inputs of recipients of healthcare services for the purpose of establishing more patient-friendly services, and using the same to improve quality of care.8910 It is also important in setting standards for MH services in the country. This study therefore is an assessment of the perception of pregnant women attending ANC services in selected public primary healthcare facilities in Anambra State.

MATERIALS AND METHODS

The study was carried in three purposively selected health centres in Anambra State under the management of Nnamdi Azikiwe University Teaching Hospital. They are Primary Health Centre (PHC), Neni, Aniocha Local Government Area (LGA), Comprehensive Health Centre, Ukpo, Dunukofia LGA and PHC, Umunya, Oyi LGA. The health centres at Neni and Ukpo are supervised by the Department of Community Medicine while PHC, Umunya serves as a community outreach centre for the Department of Family Medicine. These health facilities are all located in the rural areas of Anambra State. Predominant economic activities in these communities are petty trading and farming. All the health centres provide primary healthcare services including maternal and child health services. These health services are provided by a team of doctors, pharmacists, nurses, community health extension workers (CHEWs), laboratory scientists and technicians. The study participants included pregnant women who attended ANC clinic in the three health facilities between September 2007 and August 2008. ANC and Infant welfare clinic (IWC) services are provided in the facilities on a weekly basis. Average ANC clinic attendance is 20-25 women per facility per week, while average booking rate for new clients per month is 8-10. All patients attending ANC within the period of the survey and who gave consent were recruited, until a total of 310 women were recruited. Only women with previous natal and postnatal experience were enrolled, so as to capture their natal and postnatal experiences. Nulliparous women were excluded in the survey.

Reponses were elicited from them using a semi-structured, pre-tested, interviewer-administered questionnaire on socio-demographic characteristics, pattern of MH service utilisation and their perception of MH services received during the last confinement. Only women who willingly consented after due explanation of the purpose, procedure, risks and benefits, and assurance of confidentiality were enrolled. The questionnaire was pre-tested using 10 pregnant women attending ANC services at Amaku General Hospital (now Anambra State Specialist Hospital), Awka, by the researchers ascertain to appropriateness of the wording and duration of the interview. Data collected were analysed using SPSS version 17 (SPSS Inc., Chicago Illinois, USA). Association between socio-demographic variables and utilisation MH services and perception of quality of MH was assessed using the chi-square (X)2 test, and the level of statistical significance was set at P ≤ 0.05.

RESULTS

Out of the total of 310 women recruited for the survey, 8 women did not complete the interview. The survey showed that the median age of the women was 27 years. Majority were married (94.7%), and all of them had at least primary education (88.2%). Most of them were multiparous (64.6%) as shown in Table 1.

Table 1

Socio-demographic characteristics of respondents

During their last confinement, four women (1.3%) did not attend ANC services. A total of 293 (97.0%) utilised the formal health facility for ANC services. Majority of them (78.8%) utilised the hospital during the last ANC, while 5 women (1.6%) utilised the services of traditional birth attendants/maternity. Only 57 (19.1%) booked for ANC during the first trimester and 174 women (58.4%) attended ANC at least four times.

Among those who attended ANC, 30 (10.1%) could not remember or did not know the number of times they attended ANC. Median ANC attendance among them was four times [Table 2]. A total of 277 women (92.7%) delivered in a formal health facility and they included hospital (78.8%) and health centres (13.8%). Sixteen women (5.3%) were delivered by traditional birth attendants/maternity, while six of them (2.0%) delivered at home. However, all the four women who did not attend ANC consultation were delivered by traditional birth attendants. Most of them delivered via spontaneous vaginal delivery (90.7%), while 4.6% delivered either by caesarean section or by assisted vaginal delivery. A total of 293 (97.0%) carried their pregnancy to term. About 90% of them had live births; the remainder (7.3%) were still birth. A total of 92% of the deliveries were attended to by skilled birth attendants including trained auxiliary nurses.

Table 2

Pattern of maternal healthcare service utilisation

Out of the 296 women who delivered either in a health facility or by traditional birth attendant/maternity, most of them (91.6%) expressed satisfaction with MH services received during their last confinement. The aspect they were most satisfied with was attitude of staff (86.8%), followed by time spent in the facilities (85.6%) and the cost of services provided (81.1%) [Table 3].

Table 3

Perception of maternal health services

Age, marital status and parity were significantly associated with overall satisfaction with MH services. Older (≥30 years) (X2 = 9.70, P = 0.008), married (X2 = 4.61, P = 0.032), multiparous women (X2 = 9.14, P = 0.028) were more likely to be satisfied with MH services. Older women were particularly satisfied with the staff attitude (X2 = 6.95, P = 0.031), waiting time (X2 = 14.05, P = 0.001) and cost services (X2 = 9.81, P = 0.007) [Table 4].

Table 4

Socio-demographic characteristics and perception of maternal health services

Those who were married were satisfied with the staff's attitude (X2 = 9.70, P = 0.008). Individuals with primary education were least satisfied with the time spent accessing MHC services (X2 = 12.37, P = 0.002), however, those with tertiary education were most satisfied with the cost of MH services(X2 = 14.03, P = 0.001). Primiparous were least satisfied with the waiting time (X2 = 11.58, P = 0.003), while almost all the grandmultiparous women were satisfied with cost of services (X2 = 10.68, F = 0.005) [Table 4].

Significant association was demonstrated between place of ANC attendance and overall satisfaction with MH services (X2 = 26.94, P = 0.000), staff attitude (X2 = 12.36, F = 0.002) and waiting time (X2 = 18.01, P = 0.000). Utilisation of health facility for ANC services was significantly associated with satisfaction with MHC services, while cost of service was associated with the number of ANC visits (X2 = 21.43, P = 0.000) [Table 5].

Table 5

ANC utilisation and perception of maternal healthcare services

Place of delivery and pregnancy outcome were associated with overall satisfaction of MH services. Delivery in a health centre (X2 = 33.42, P = 0.000) and adverse pregnancy outcome (X2 = 9.06, P = 0.007) were associated with non-satisfaction of MH services. Similarly, place of delivery and ANC attendance were found to be significantly associated with satisfaction with staff attitude and waiting time. Women who delivered in health centres were not satisfied with the staff attitude (X2 = 33.33, P = 0.000), while those who delivered outside the health facility were not satisfied with time spent on accessing services (X2 = 5.44, P = 0.020). Also, non-facility delivery (X2 = 9.70, P = 0.008) and delivery by caesarean section (X2 = 7.48, F = 0.018) were associated with non-satisfaction with the cost of MHC services [Table 6].

Table 6

Maternity service utilisation and perception of maternal healthcare services

DISCUSSION

The study revealed high level of utilisation of MH services among pregnant women accessing ANC services in rural communities in southeast Nigeria. Preferred place for MHC services was hospital, most of which were privately owned hospitals. High utilisation of hospital for maternal services is probably because their services are more convenient, readily accessible and are more likely to be staffed with a doctor than the lower levels of healthcare. An earlier study in southeast Nigeria reported that the presence of a doctor in a healthcare facility as one of the factors influencing pregnant women utilisation of MHC services.56 Compared to women in a rural community in Edo State of Nigeria where 25% of them utilised the services of TBAs for both ANC and delivery, there was less patronage of TBAs among them.11 Hence, majority of the births were attended to by skilled birth attendants including trained auxiliary nurses with obstetrics skills. Even though most hospitals in the region are manned by doctors, their nursing staffs often comprise auxiliary nurses who have been trained on obstetrics care.

Women utilising MH services are increasingly becoming aware and desirous of the need to improve quality of MHC services provided to them.9 Their utilisation of maternal care services has been shown to depend on their perceptions on these services.7 Hence, their perception of MHC services is an important measure for assessing the extent their expectations are being met by both the policy makers and the care providers.

There was high level of satisfaction with the quality of MHC services received. They were most satisfied with the attitude of healthcare staff (85%), and least satisfied with the cost of services (79%). Higher level of satisfaction (95%) has been reported among rural women utilising PHC services (including MH services) in the region, and most of them also did not consider cost of services and waiting time as barriers to accessing maternal services. However, other studies have highlighted poor staff attitude, long waiting time and relative high cost of services as disincentive to the utilisation of MHC services.611 High patronage of hospital services in the region is suggestive that most women are willing to pay for MH services, despite being relatively more costly than the lower levels of healthcare.6 Elsewhere in Africa, clients’ satisfaction with maternal services is generally high, even though service cost, payment mechanism and long waiting time were identified as barriers to MH service utilisation.12 While most patients individually often desire longer consultation with care providers, they often expressed dissatisfaction with long waiting time.13 There was also greater preference for private health facilities to public health facilities and this was not due to difference in technical competence but primarily due tothe process of service provision.5

Previous studies have not demonstrated consistent relationship between patient satisfaction and socio-demographic characteristics of users of healthcare services.14 This is because determinants of clients’ satisfaction are multi-factorial and no factor has been shown to contribute to satisfaction or dissatisfaction more than the other. Patients’ satisfaction with health services is purely individualistic and dynamic.10 On the contrary, more consistent association has been demonstrated between service satisfaction and age of patients. This study revealed that non-satisfaction with MHC services was significantly associated with age, marital status and parity. Women who were younger, not currently married and primiparous were less likely to be satisfied with MHC services. Specifically, younger women were not satisfied with attitude of the healthcare workers, waiting time and cost of services, while primiparous women though were satisfied with the attitude of care providers, were less satisfied with the time and money spent on accessing MHC services. Studies have shown that younger women are often less satisfied with healthcare services than older women.71315 Birhanu et al.,14 reported that older women were more likely to be satisfied with communication and attitude of healthcare staff, but are often less satisfied with outcome of care. Younger women were probably less satisfied because of their level of expectation were higher and their lack of previous experience.713 Previous obstetric experience has been shown to influence women’ level of satisfaction with MH, hence younger and primiparous women who have limited birth experience are less likely to be satisfied with MH received during pregnancy and delivery.7

Women with lower educational status were less satisfied with the time spent accessing services, while women with higher educational status were most satisfied with the cost of maternal services. In contrast, women with higher educational status play a greater role in decision-making process concerning their health than their counterparts who are less educated. This is because they are more socio-economically empowered and often have greater access to health information. Consequently, this category of women is more likely to value time and money spent on accessing quality healthcare. They are also more likely to access better quality of care and take measures to enhance their health status despite the cost. However, in India the case was converse, where an inverse relationship was observed between clients’ satisfaction and literacy status. It was believed that higher literacy status increases the level of expectation from MH services, and this results in lower level of satisfaction.15

Place of utilisation of MHC services was found to have significantly influenced maternal perception of quality of care. Utilisation of hospital for ANC and delivery services was associated with positive perception of quality of MHC services; however, increasing frequency of ANC visits was associated with non-satisfaction with service cost. Most of those who utilised higher levels of healthcare facilities also expressed satisfaction with staff attitude and time spent to access care. Although hospital care is relatively more expensive than the lower levels of care, it is believed that it provides better quality of care. It has been reported that women are more likely to deliver in health facility they consider to be safe and secure, a consideration often borne out of quality of care received and delivery outcome of previous pregnancies.7

In contrast, mothers who reported adverse birth outcome had a negative perception of MHC services. Also, women who delivered either at home, maternity or by TBA and those who delivered via caesarean section considered the cost of MHC services unsatisfactory. In Nicaragua, women's perception of cost of services influenced women choice of delivery care. Positive or good pregnancy outcome was associated with satisfaction with quality of maternal care services. In contrast, frequent assessment of labour by different providers was found to be in conflict with the cultural expectation of women in Uganda, and this explains among other reasons the level of patronage.712

In conclusion, the study showed high level of satisfaction with quality of MH services and highlights the need to strengthen interventions that encourage women's utilisation of formal healthcare services. However, the major limitation of the study was that it was conducted among women who are already seeking care in health facilities and may not reflect the opinion of those who never sought for care in health facilities.