ABSTRACT

Background: Antenatal care is a basic component of any reproductive health care programme and reproductive health is one of women’s fundamental human rights. It aims to achieve optimal health outcomes for the mother and the baby through early detection of complications and prompt treatment and it is one of the recommended interventions to reduce maternal and neonatal mortality. High quality antenatal care is desirable as only adequate utilisation is not enough to reduce the poor maternal indices in Nigeria and sub-Saharan Africa.

Objective: To assess the quality of antenatal services in primary health centres in Awka South LGA of Anambra State.

Methodology: This was a cross sectional descriptive study carried out in Primary health centres in Awka South LGA of Anambra State. It involved an audit of structures in the facility, equipment, drugs and supply. An interviewer- administered questionnaire was used to conduct an exit interview for 258 pregnant women attending antenatal care in the facilities.

Data was analyzed using SPSS version 20 and results presented in tables

Results:  Findings from this study showed good quality with regards to process of care and very good quality with regards to structural and outcome attribute of quality. There was a high level of client satisfaction with antenatal care received (86.8%). A significant association was observed between client satisfaction and marital status, educational level and occupational group (P<0.05) but no association was observed with parity (P>0.05)

Conclusion: The importance of high quality antenatal care cannot be overemphasized at it will not only ensure women attendance to the clinics but will also contribute in combating maternal mortality which is high in this part of the world. Clients’ perspective of quality of care with regards to their satisfaction with service provision is also a vital part that should always be considered to have an improved service delivery.

Keywords:  Antenatal care, Quality, Structure, Process of care, client satisfaction

CHAPTER ONE

1.0 INTRODUCTION

Antenatal care is the medical care that women receive during pregnancy¹ and it includes a variety of services ranging from screening for risk factors, providing clients with information, and treating existing conditions and complications.² It is considered a basic component of any reproductive health care programme³ and reproductive health is one of women’s fundamental human rights.⁴

Antenatal care aims to achieve optimal health outcomes for the mother and the baby through early detection of complications and prompt treatment (e.g., detection and treatment of sexually transmitted infections), prevention of diseases through immunisation and micronutrient supplementation, birth preparedness and complication readiness; health promotion and disease prevention through health messages and counselling of pregnant women.⁵

It is one of the recommended interventions to reduce maternal and neonatal mortality⁶ and its provision is regarded as a cornerstone of maternal and perinatal health care. It is expected to have considerable impact on achieving the Millennium Development Goals (MDG) goal 5, which aims to improve the health of mothers; a large part of goal 4, which focuses on reducing child mortality; and parts of goal 6, which seeks to combat AIDS, malaria and other diseases.^{7, 8} The target of MDG 5 is to reduce maternal mortality rate by 75% by 2015 among other things through a very effective antenatal service. The situation related to pregnancy, delivery and the postpartum period is still disquieting because too many mothers and newborns die annually in developing countries. Reducing these deaths must continue to be a top-priority challenge in reproductive health.⁹ Antenatal care is one of the recommended interventions to help reduce these alarming maternal and newborn mortalities^10-12 more so in Nigeria because of the risks of malaria and anaemia in poorly nourished women, as well as risk of tetanus.¹³

One of the four pillars of safe motherhood is antenatal care, together with family planning, clean and safe delivery, and essential obstetric care¹⁴ and of all of them, it is the one that has the potential to significantly reduce maternal morbidity and mortality when properly conducted.¹⁴ It is also worthy of note that one important function of antenatal care is to improve the woman’s awareness about warning signs of pregnancy complications, in order to be able to seek help early.³ This is very important as late presentation to a health facility can lead to poor outcome. But having presented to a centre where the quality of services rendered is poor, that means good outcome will still not be obtained. This calls for having high quality services.

Pregnancy can become complicated requiring more than prenatal screening but also the involvement of the community to which the woman belongs in addition to the health workers. The concept of antenatal care therefore has to be broadened to include the educational process of the health workers, the woman and her partner and the members of the community to which she belongs.³

The World Health Organization (WHO) advocated an improved model for antenatal care use for women without complicated pregnancies in developing countries and recommends at least four antenatal care visits which should include compulsory blood pressure measurement, urine and blood tests and non-compulsory weight and height check at each visit.¹ This is focused antenatal care which emphasizes evidence-based actions that  are goal-directed i.e. methods that work, individualized, woman-centered or family centered care, quality versus quantity of visits and finally care by skilled providers.¹⁵

Access to appropriate healthcare services during pregnancy and childbirth is mentioned as one of the means that will provide couples with the best chance of having a healthy infant.⁴ Appropriate here means a high quality antenatal service which is very essential to the survival of the mother and the child. The emphasis is not just having antenatal services but one that provides complete package of all that is supposed to be made available to the women.

In most Sub-Saharan African countries, high rates of ANC coverage coexist with high maternal and neonatal mortality and this disconnect has fuelled calls to focus on the quality of ANC services but little conceptual or empirical work exists on the measurement of ANC quality at health facilities in low-income countries.⁶   It was also observed that the level quality of antenatal care is scarce in developing countries. Models of care adopted in the western world and exported to the developing world have not been monitored early enough to discover their weak points promptly. This has transformed antenatal care into an empty and useless ritual.³ This therefore calls for an adequate assessment of ANC services rendered in the Nigerian setting as its maternal health indices continue to be poor despite increased utilisation of antenatal services. For antenatal care to be effective, it has to guarantee the availability and proper functioning of all factors that contribute to a safe pregnancy and delivery, from the remotest health post to the health centre and hospital where complicated cases need to be referred.³

Quality of care is historically derived from work in industry¹⁶ and various schools of thought have given different views about quality. Roemer and Montoya¹⁷ see quality of care as the performance of interventions according to standards that are known to be safe, which are affordable to the society and that have the ability to produce an impact on mortality, morbidity and disability.¹⁷ This tries to bring a distinction between the quality of the actual care and expected quality based on standards.

It was also seen as  a means of closing the gap between desired and actual health outcomes as Institute of Medicine defined it as  ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional practice’.¹⁸ Quality can be said to be a delicate balance of expectations from the patients, their relatives on one hand, the health service providers and the health institutional expectations¹⁹ or the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient where the domains of quality of life include physical, mental, social, and occupational function; health perceptions; and symptoms of disease.²⁰

Donabedian also defined quality as the degree to which health services to individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge and it ensures that services are safe, effective, patientcentered, timely, efficient and equitable.²¹ He also defined quality as the application of medical science and technology in a manner that maximises its benefit to health without correspondingly increasing the risk.²² He went further to propose a framework for assessing quality of care which distinguishes between the attributes of the health care setting (structure), the actual care delivered (process) and the end result of the interaction between an individual and the health care system (outcome).²³ In antenatal care services, the structural attribute of quality include the human, physical and financial resources that are used to provide reproductive health care while process is the set of activities that take place between the provider and woman. Therefore process is the actual transaction whereby the provider uses the available structural elements to manage the technical and personal aspects of health. The concept of outcome include the direct impact of treatment on the current or future health of a woman or her newborn and the indirect impact on her satisfaction with the services offered and her health-seeking behavior.²⁴

Maxwell also suggested six dimensions of quality²⁵ which can also be expanded to include availability of care, infrastructure, continuity of care, access to a referral system, management and process of care. These collectively define quality of Maternity Care, and have an impact on the outcomes which include maternal mortality and morbidity and also utilisation of services.²⁶ While Studies have shown that poor access to basic antenatal care is a major obstacle to improvement in pregnancy outcomes, there is a growing consensus that access to antenatal care alone is insufficient to alter the present maternal health profile and that the quality of antenatal services may be a key determinant of maternal and perinatal outcomes.²⁷

It has also been reported that ANC alone could reduce the maternal death rate by more than 20% provided that it is of good quality and regularly attended by pregnant women.^{28, 29} According to the World Health Organisation, in most African countries, less than 70% of the pregnant women get proper care throughout pregnancy and many of those who attend antenatal clinics come only once or twice and sometimes late in pregnancy and this is evidence of poor quality of care.³ Poor quality of antenatal care is likely to reduce its utilization.³⁰ Other studies have also suggested that poor quality, unfriendly treatment and less information sharing by health providers to the poor and disadvantaged women may lead to underutilization of health services by the poor women.^31-33

The world health organisation in 1978 recognised primary health care as the key to achieving a state of physical, mental and social well-being for all people of the world³⁴ and antenatal care being a component of primary health care needs to be strengthened. This is very important especially as primary health care is the entry point into the healthcare delivery system of the country and therefore an ideal setting for prevention of pregnancy complications by identification of risk-prone pregnancies and provision of immediate linkage of high risk women to specialist care.³⁵ High quality antenatal services have some characteristics which are also essentials of the primary health care services and the pillars of Safe Motherhood in Nigeria rest on the solid foundation of primary health care.³⁵ Some of these features include accessibility, acceptability, effectiveness and suitability for the community. Health centre is the most widespread and most numerous structure for the delivery of health services in many developing countries and because of their nearness to the population form the interface and link between the communities and the health sector.³⁴

The importance of high quality antenatal care service cannot be overemphasized as it has been calculated that for every dollar spent on antenatal care for high-risk women, more than three dollars(N450) are saved (compared to managing complications arising from pregnancy).³⁶ This goes to show that having a high quality antenatal care not only saves women’s life but has a positive economic implication to the family and the society in general. 

1.1 PROBLEM STATEMENT

Globally, women of reproductive age who die from pregnancy and childbirth related complications each year are close to 536,000³⁷ with approximately 99% of the deaths occurring in developing countries and about 10% of them are attributed to Nigeria.³⁸ A survey showed that in 2008, over 300,000 maternal deaths occurred worldwide and almost all of these are in low- and middle-income countries^{39, 40}  of which Nigeria is part of. Every day, approximately 800 women die from preventable causes related to pregnancy and childbirth⁴¹ with an estimated 3million newborn babies dying within the first month of life⁴² and between 2.1 to 3.8 million babies are stillborn.^43-45

Maternal mortality has remained stagnant in some developing countries especially in sub-Saharan Africa³⁷despite the launch of the Safe Motherhood Initiative in Nairobi Kenya in 1987.^{37, 46} According to Zambian national assessment of quality of antenatal care, the percentage of women attending ANC (for at least one visit) generally tends to be satisfactory even in low-income countries, but maternal and neonatal mortality remain high.⁶ This weak relationship between ANC use and maternal and newborn survival has motivated a recent call to focus on content and quality of care provided rather than mere ANC attendance as world aims at achieving MDG 4 and MDG 5.⁴⁷  

According to the Nigerian Demographic and Health Survey of 2008, the neonatal mortality rate is 40 deaths per 1,000 births while the maternal mortality ratio is 545/100,000 live birth.⁵ The same survey showed that 64% of women pregnant with their first child received antenatal care from a skilled health worker, compared with 47% of women with births of order six or higher. Also 58% of women age 15-49years received antenatal care from a skilled provider (doctor, nurse/midwife, or auxiliary nurse/midwife) during their last pregnancy of which 30% of them are from a nurse or midwife and 23% from a doctor. Only 3% of women received ANC services from a traditional birth attendant while 36% did not receive ANC services at all.⁵ From the above, one can see that utilisation of ANC service is fair but Nigeria still has poor outcomes probably due to poor quality of care.

Estimated 15% of pregnant women suffer from life-threatening complications which could have been detected during antenatal consultations.²⁸ ANC alone could reduce the maternal death rate by more than 20% provided that ANC is of good quality and regularly

attended by pregnant women.^{28, 29} Effective maternal health programmes are supposed to address all these poor indices but they have been found to be very deficient in developing countries⁴⁸ and studies that have been reviewed from most developing countries mostly report

low quality of antenatal services provided.⁴⁸  Case fatality rates for obstetric complications are often still above the United Nations level of less than 1%  in many hospitals because of  limited knowledge and skills of health care providers and a resulting poor quality of care.⁴⁹ 

1.2 JUSTIFICATION FOR THE STUDY

Despite the increasing importance of quality of antenatal care worldwide, many areas still lack detailed information about the quality or effectiveness of antenatal care practices as is seen in Nigeria, where healthcare service delivery is largely based on the primary health care system. Few studies that have addressed the issue of the quality of antenatal care have focused on private and referral or tertiary health institutions.^{50, 51} This therefore makes it imperative to examine the quality of ANC services at the primary health facilities as primary health care represents the entry point into the healthcare delivery system of a country. Information on the quality of the antenatal care services provided in the context of the primary health care system can be used to improve on the responsiveness of the health system to the needs of the majority of pregnant Nigerians.³⁵

Studies have also suggested that investment in the quality of care is most important in antenatal health care⁵² and the problem of maternal mortality in the country may not necessarily lie with utilization but with the quality of services.⁵³ Assessing and improving the quality of antenatal services can never be overemphasized as Archie Cochrane⁵⁴ rightly pointed out that “By some curious chance, antenatal care has escaped the critical assessment to which most screening procedures have been subjected” and recommended that “the emotive atmosphere should be removed and the subject treated like any other medical activity and investigated by randomised controlled trials.⁵⁴ This goes to show how important it is to match increased ANC coverage with improved quality of care in order to really influence health outcomes. Faye et al⁵⁵ noted that where the quality of care is poor (including non-

woman friendly care), women are less likely to access such care even if available.⁵⁵

Quality has many attributes and in this environment, there is paucity of data on quality from women’s perspective at the primary care level which could provide useful information. This therefore calls for a rigorous and regular appraisal of the quality of antenatal care services in the primary health care centres (PHCs) so as to identify specific problems and develop strategies for improvement.³⁵

Studies have addressed the socio-cultural barriers to the use of health services during pregnancy and childbirth^{56, 57} but relatively few studies have dealt with the factors that relate to health facilities themselves and to the quality of services provided. The rationale for assessing client’s satisfaction is that care assessed to be of high quality according to the provider–defined criteria is far from ideal if the client is dissatisfied with it.⁵⁸ Still on client satisfaction with ANC services, the knowledge about users’ views is still very limited, especially in developing countries.^{59, 60} Consequently, an inward look and assessment of the quality of ANC services provided becomes pertinent and this is what this present study hopes to achieve. Health centre is so widespread and numerous and because of their nearness to the population form the interface and link between the communities and the health sector.³⁴ Therefore it is a good place to study the quality of antenatal services.

Finally high quality ANC is one of the service interventions that have a potential to impact on the high maternal mortality. The majority of maternal deaths could be avoided if women had access to high quality medical care during pregnancy, childbirth, and postpartum.³⁷ Findings from this study will be fed into maternal health programs to improve quality of ANC in the country as this study will cover all the three attributes of quality according to Donabedian.^21-23 

1.3 OBJECTIVES

GENERAL OBJECTIVE

To assess the quality of antenatal care services in primary health centres in Awka South

LGA of Anambra State.

SPECIFIC OBJECTIVES

1. To assess the infrastructure and adequacy of equipment and supplies in the study

facilities.

2. To examine providers’ processes of care in delivering antenatal services at the study facilities.
3. To determine the level of client satisfaction with antenatal services provided. 

HYPOTHESIS

H₀: There is no significant association between client satisfaction with ANC and parity. H₁: There is a significant association between client satisfaction with ANC and parity