Dimensions of quality of antenatal care sservice at suez, egypt.

INTRODUCTION: The 5(th) millennium development goal aims at reducing maternal mortality by 75% by the year 2015. According to the World Health Organization, there was an estimated 358,000 maternal deaths globally in 2008. Developing countries accounted for 99% of these deaths of which three-fifths occurred in Sub-Saharan Africa. In primary health care (PHC), quality of antenatal care is fundamental and critically affects service continuity. Nevertheless, medical research ignores the issue and it is lacking scientific inquiry, particularly in Egypt. AIM OF THE STUDY: The aim of the following study is to assess the quality of antenatal care in urban Suez Governorate, Egypt.
MATERIALS AND METHODS: A cross-sectional primary health care center (PHCC) based study conducted at five PHCC in urban Suez, Egypt. The total sample size collected from clients, physicians and medical records. Parameters assessed auditing of medical records, assessing provider and pregnant women satisfaction.
RESULTS: Nearly 97% of respondents were satisfied about the quality of antenatal care, while provider's satisfaction was 61% and for file, auditing was 76.5 ± 5.6.
CONCLUSION: The present study shows that client satisfaction, physicians' satisfaction and auditing of medical record represent an idea about opportunities for improvement.

Introduction

The 5th millennium development goal (MDG) aims at reducing maternal mortality by 75% by the year 2015.[1] According to the World Health Organization (WHO), there was an estimated 358,000 maternal deaths globally in 2008. Developing countries accounted for 99% of these deaths of which three-fifths occurred in Sub-Saharan Africa.[2]

Maternal mortality remains a major public-health issue in developing countries. According to the WHO, 536,000 women die every year in the world from causes relating to pregnancy, childbirth, or postpartum. The majority of maternal deaths avoided if women had access to quality medical care during pregnancy.[3]

According to Egypt demography and health survey, slightly more than one quarter of Egyptian pregnant women do not receive antenatal care. However, among those who receive antenatal care only one-third of them received advised about signs of obstetric complications and where and when to seek medical assistance[4] (El-Zanaty and Way, 2009). In Egypt, maternal mortality ratio has declined dramatically from 174/100,000 live births in 1992-1993 to 67.6/100,000 live births in 2005, a further decline to 44.6/100,000 was also reported by 2009[5] (Global Health Council, 2010; WHO, 2010)[6].

Great bodies of literature monitor to improve the quality of health care. In the developing countries, however, low interest in spite of overwhelming published evidence of low quality of care in these countries.[7]

In Egypt, health services are of poor quality and the country has poor health status relative to other low-income countries. The Government has focused on improving the quality of health services delivered to the population as a mean to attaining the MDGs. Thus, patient satisfaction is an integral component of health services provided to the population.[8] This situation raises the question of the quality of care offered in maternity health care.[9]

Measurement of patient satisfaction plays an important role in raising accountability among health care providers. It is an indicator of the quality of health care equation.[10] Although system aspects such as cost, access, availability and waiting time related to patient satisfaction, they have been less important than the human aspect of medical care.[1112]

Antenatal care is regarded as a cornerstone of maternal health care and better evidence about what works and what does not work to reduce maternal mortality exists.[1011] Many elements of antenatal care have no impact in reducing complications and maternal deaths, so the WHO guidelines are specific as regards the timing and content of antenatal care visits according to gestational age and the guidelines insist that “only examinations and tests that have been proven to be beneficial should be performed”.[13]

Quality improvement (QI) is an integral part of the reform model in Egypt. While the Ministry of Health and Population has made significant changes in the past few years in development of a QI program, health facilities still face challenges in improving the quality of services in this area.[14] Clinical audit is a QI process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria. Aspects of the structure, processes and outcomes of care selected and systematically evaluated against explicit criteria.[1516]

Materials and Methods

A cross-sectional primary health care (PHC) study was conducted from January 2012 to April 2012 at urban Suez, Egypt, primary health centers according to national quality standards in Egypt. All health centers included in the study are government run facilities.

Parameters assessed

Auditing of quality of care through medical records randomly selected from the registry using an audit checklist modified from Accreditation of PHC facilities in Egypt: Program policies and procedures[17]

Assessing satisfaction of providers: A comprehensive sample using a questionnaire modified from trustees of Dartmouth College, Godfrey, Nelson and Batalden[18]

Assessing pregnant women satisfaction by a consecutive sample derived from pregnant women attending the PHC, a questionnaire modified from patient satisfaction survey, the bureau of PHC and patient satisfaction survey, new river health association.[19]

Data collection

Data collected in the waiting area, for privacy. From records, we check if taking the client's history, examination and investigation. Likert scale used. The variables rated included; satisfaction with access, waiting time, privacy, staff attitude, counseling, time with health worker, information given by health team.

Results

Table 1 shows pregnant women satisfaction with a significant difference in (ease of the registration process and comfort of the waiting area) (P < 0.001), there were a significant difference in waiting time P < 0.001 between centers and providers-clients relationship (P = 0.007).

Table 1

Client satisfaction among participating women

Table 2 showing providers’ satisfaction, with a significant difference in physician respect (P = 0.045).

Table 2

Health care providers’ satisfaction in different centers (n=17)

Table 3 showed that the number of visits according to guidelines (P < 0.001, odds ratio [OR] = 1.05 [1.03 - 1.07]), fetal movement (P < 0.001, OR = 10.31 [3.25 - 32.73]), blood pressure (P < 0.001, OR = 0.00 [0.00 - 0.005]), fetal lie (after 32 weeks) (P < 0.001, OR = 3.34 [1.8 - 6.17]), engagement (P = 0.017, OR = 1.39 [1.06 - 1.83]), fetal heart sound (P < 0.001, OR = 5.57 [2.77 - 11.21]), urine examination (P = 0.008, OR = 26.69 [2.36 - 302.1]) and ultrasound (P < 0.001, OR = 2.260 [1.49 - 3.45]). All these factors are statistically significant.

Table 3

Logistic regression analysis for best predictors for completeness regarding file auditing at periodic visits of antenatal care (n=306)

Discussion

The total quality score of client satisfaction in urban health district was 79.2 ± 23.5 with statistical difference between centers (P < 0.001). This agreed with a study done in South Nigeria by Oladapo et al., 2008 where the respondents expressed a high level of overall satisfaction (81.4%) with the care received.[20] These results disagreed with a study in private health facilities in llorin, of Nigeria by Balogun 2007 where only 64% of women showed satisfaction with service they had.

The difference could be explained by the difference of the study type and site that the current study was a cross-sectional study for pregnant women in public facilities while the other study was a retrospective study for women after delivery in private facilities where clients’ expectation may differ.[21]

The current study showed that the most dissatisfying items for clients were:

Registration process and waiting area by 24%

Relation with nurses and medical assistant staff by 20%

Waiting time by 15.4%.

The total quality score of physicians satisfaction in the present study was 61.0% with no statistically significant difference between the centers (P = 0.572), which agreed with a study done in Bahrain by Sharaf et al., 2008 where the study has revealed that primary care physicians in Bahrain, were satisfied (mean = 3.46, SD = 0.67) according to job satisfaction survey.[22] Furthermore, these results agreed with a study in Al-Madinah.

Munawwara by Al Juhani and Kishk, 2006 where the overall mean score of physicians satisfaction was 65.53%[18] and agreed with a study at capital health region, Kuwait by Al-Eisa et al., 2005 which showed that the overall satisfaction was 61.8%.[19] Nevertheless, these results disagreed with a study done in Oman by Taman, 2009 which showed that the overall staff satisfaction score with their profession was 79.44%. This difference could be due to the difference in sample size and characteristics as the current study include only 17 physician most of them recently graduated while other study included 390 staff with years of experience were more than 10 year.[11]

The current study showed that the most dissatisfied items for providers were:

Suitability of the work place than it was 12 months ago by 64.7%

The available tools, equipment and encouragement they had by 64.7%

Unrespectful treatment they had by 47.1%.

The total quality score of file auditing was (76.5 ± 5.6) with statistically significant difference between centers (P < 0.001) which disagreed with a study in Kingdom of Saudi Arabia by Al-Momen et al., 2003 where the total assessment score approached was 71 out of 100 for primary health centers. The difference could be explained due to the difference in both sample size and sampling methods and might be due to the difference in both guidelines used as in the current study the Egyptian guidelines was used, while in other studies, the policy of antenatal care formed by co-operation from Department of Obstetrics and Family and Community Medicine in Saudi Arabia.[12]

The current study showed that the most deficient items in the file registration were:

Recording of the immunization, of pregnant was (28.8%)

Recording of the fetal heart sound (18.3%)

Recording of the ultra sound (11.3%)

Recording of screening of diabetes in pregnant women (2.5%)

Recording of the diagnosis according to the clinical guideline (12.4%)

Referral of high risk pregnancies to specialist according to clinical guideline (4.1%).

In the current study, showed that client satisfaction was higher in accredited centers than non-accredited center with a significant difference P = 0.002. This agreed with a study in Alexandria by Gadallah et al., 2010 where patient satisfaction was higher in accredited family health units compared to non-accredited units in all aspects: As cleanliness, doctors and nurses competency and attitude, waiting area and waiting time[13] while provider satisfaction was higher in non-accredited center than accredited centers with insignificant difference P = 0.533 which disagreed with a study in Alexandria By Gadallah et al., 2010 showed that providers in the reformed PHCs were more satisfied, than providers in non-reformed PHCs, regard availability of equipments, job satisfaction and income satisfaction. The difference explained that the current study involved only one non-accredited center while other study involved four non-accredited unites, also due to the difference in assessment methods as the current study involved only questionnaire while other study involved questionnaire and focus group discussion (different study methodology).

Limitations of the study

There was bias during the assessment of client satisfaction in the presence of health providers of the service

A lot of illiterate refused to share in the study, as they feel unsafe by sharing in something they cannot read

It was difficult for clients to understand Likert scale and to select between different choices

Regarding the auditing part, the problems of incompleteness and inaccuracy of the medical records constituted an obstacle in assessing the process of antenatal care.

Conclusion

This study gives important baseline information used in intervention design and implementation of projects that seek to improve maternal health. Major gaps exist in the staffing levels, adequacy of infection control facilities and provision of the full package of ANC especially with regard to carrying out essential tests, counseling for risk factor recognition and birth preparedness. The erratic availability of drugs and supplies coupled with the long waiting hours are also major challenges.

The district health teams should work with facility managers to ensure the availability and use of infection control practices. Refresher training of health workers, assessment of workloads and recruitment of more health workers recommended ensured through investing more resources in procuring them and improving on the supply chain efficiency at all levels of procurement and supply.