ABSTRACT

Improving the quality of obstetric, neonatal and child care in facilities has been identified as a neglected and essential approach to reducing maternal deaths and enabling developing countries to achieve Millennium Developments Goals 4 and 5 which are reduction in maternal and infant mortality, and also, Sustainable Development Goal 3 (SDG 3) which is good health and well- being especially for women.

 This study employed a descriptive design to evaluate the quality of Maternal and Child Health care (MCH) services in selected health facilities in Ile-Ife utilizing Donabedian model for quality care. Sample size was determined using Leslie Kish formula. Data were collected in selected 45 Primary Health Care centres (PHCs) and 7 Secondary health facilities (SHFs) using an adapted checklist. Data were also collected from 330 selected nursing mothers using an adapted questionnaire on client’s satisfaction (outcome) with the maternal and child healthcare services. Four research questions were answered and three hypotheses were tested at 0.05 level of significance.

Findings of the study reveal that majority of the Heads of the Maternal and Child Health Care units surveyed are females (90.4%), all the SHFs are charged by professional Nurses and Midwives while only 13 out 45 PHCs are charged by professional Nurses/Midwives. Three hundred and thirty (330) nursing mothers participated in the study, 180 (54.5%) mothers were 19-28 years, and only 5 (1.5%) respondents were below 19 years. 232 (70.3%) of the mothers were from PHCs and 98 (29.7%) were from secondary health facilities. In terms of structure, 34 (75.6%) of PHCs and 5 (71.4%) of SHF have personnel with inadequate training in MCH services mean 2.67±2.50 and 3.29±2.36 respectively. Thirty six (80%) of PHCs and 3 (42.9%) of SHFs have physical facilities that were not in good working condition mean 57.29±11.48 and 44.4±12.23 respectively.  In terms of process, finding shows that majority of MCH services rendered in both the PHCs and SHFs are sometimes (100%) done, mean 70.22±8.64 and 73.29±9.98 respectively. The clients’ satisfaction survey reveal that majority of clients were satisfied with the MCH services in both Primary and Secondary health facilities in Ile-Ife, mean were 115.1±15.86 and 110.37±14.71 respectively. Findings of the study also show that most staff rendering MCH services in PHCs are Community Health Extension Workers and Health attendants There is a significant difference between the structure of MCH services p = 0.04, no significant difference between the MCH services p = 0.46 and client satisfaction p = 0.10 in PHCs and SHFs, p = 0.10.

The quality of Maternal and Child health services in both Primary and Secondary health facilities in Ile –Ife was below the standard as reflected in the findings. Therefore, government efforts at all levels should be directed towards improving the structure of healthcare facilities, training and retraining of staff, supervision, and provision of supplies and transportation for prompt referrals in health facilities through a robust National Health Planning and collaboration between stake holders.

Keywords: Evaluation, Quality, Maternal and Child Health services, Structure, Process

                    Outcome.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

The quality of care received during pregnancy and the place of delivery are great determinants of maternal and child morbidity and mortality. Improving and sustaining the quality of care in healthcare institutions has been an area of concerns and recurrent issue over the year. The client’s expression of satisfaction with the quality of health care can provide insightful feedback for healthcare providers, managers and policy makers to direct quality improvement efforts in a right direction (Beattie, Lauder, Atherton, Murphy 2014). Quality assessment is an important aspect of quality assurance which focus on identification of barriers and challenges in a system and not just bad performers (Tobin-West and Anastasia 2016).

 On yearly basis, an average of 289 000 women reportedly die as a result of complications associated with pregnancy and child delivery. Also, about 6.6 million under 5 year old children death resulted from complications in the neonatal period and early childhood illness (World Health Organization (WHO), 2013). These deaths are preventable with provision of quality and optimal maternal and child health care in health facilities.

Although remarkable achievement has been recorded in some areas of reproductive, women and children health interventions over the years, little progress has been recorded in efforts directed towards improvement of maternal and child health outcomes due to a wide gap between the scope and the quality of health care provided in facilities (WHO, UNICEF, 2014). Quality of care is considered very important in the international initiatives and Global Strategy for Every Woman and Child.

Yearly, about 500,000 women and girls die due to complications arising from pregnancy, labour and or the 6 weeks post- delivery. Majority of these mortality happen in less developed countries (United Nations Millennium Development Goals 2009), making the process of delivery one of the most dreaded journeys for women of child bearing age. This is worrying some as statistical findings showed that the extent of maternal mortality in low and middle income countries resulting from pregnancy and childbirth is on the increase (United Nations Children Fund     (UNICEF) Nigeria, 2014).

 Similarly, the risk of death from conception and child delivery in Nigeria is ratio 1 to 13. On daily basis, about 2,300 under-five year old children and 145 women in their reproductive years die in Nigeria. With these figures, Nigeria was rated the second largest country contributing to the under–five and maternal death in the world. Many of these deaths could be prevented but for Nigeria’s coverage and quality of health care services that continue to fall short of expectation for women and children. According to United Nations International Children Fund (UNICEF), Nigeria (2014) report, less than 20% of health facilities in the country provide emergency obstetric care (Eoc) and about 35% of deliveries are taken by health professionals.

 A national health policy formulated for Nigerians in 1988 was targeted at achieving quality health for all.  Emerging health issues and the realities to focus on new trends prompted the review of the policy over the years to improve quality in health care services across the nation (Nigeria Demographic Survey, 2013). A health delivery system targeting reduction in maternal morbidity and mortality must ensure quality reproductive care for this group of people (United States Agency for International Development (USAID), 2013).

 Donabedian model was developed in 1966 for assessing healthcare services and to evaluate quality of health care.  The model was revised in 1988 and provides information about quality of care using three categories which are structure, process, and outcomes. Structure describes the context in which care is delivered, including hospital buildings, staff, financing, and equipment. Process involves the transactions between patients and healthcare professionals throughout the delivery of healthcare. Outcomes refers to the effects of healthcare on the health status of client and client satisfaction. Since then other quality of care frameworks, including the World Health Organization (WHO) recommended Quality of Care Framework and the Bamako Initiative etc. have been developed but the Donabedian Model continues to be the dominant framework for assessing the quality of health care up till today (Lawson and Yazdany 2012). In 2013, World Health Organization and Partnership for Maternal, Newborn, and Child Health used Donabedian model to develop key indicators for quality in Maternal, Newborn, and Child Health care.

Maternal health care is the care a woman receives during conception, delivery, and post- delivery, it is crucial for the survival and well-being of mother and child. It comprises a broad range of services like family planning, prenatal, intrapartum, and postpartum care with the focus of minimizing maternal death and disability (Franny, 2013).

 Improving the quality of obstetric care in facilities has recently been identified as a neglected and essential approach to reducing maternal deaths and enabling developing countries to achieve Sustainable Development Goal 3 (SDG 3) which is good health and well- being especially for women (Van den Broek and Graham 2009). Postpartum hemorrhage is the most frequent cause of maternal deaths globally and in developing countries, accounting for 25% of maternal deaths. Next are hypertensive disorders in pregnancy (PE/E) at 15%, sepsis (8%) and obstructed labor (7%).2 Effective interventions exist for screening, preventing and treating obstetric and newborn complications, and they can be readily provided by skilled providers in facilities. However, achieving both high quality and coverage of these interventions is essential in order to reduce maternal and newborn deaths globally. International evidence suggests that the most important factor in reducing maternal and early neonatal mortality is the attendance of a skilled birth provider and provision of quality care (USAID/MCHIP 2013).

According to Kana, Doctor, Peleteiro, Lunet and Barros (2015), poor maternal and child health indicators have been a recurrent issue in Nigeria since the 1990s, and many interventions have been instituted to reverse the trend and ensure that Nigeria provides quality maternal and child health care.

However, various intervention reports have documented mixed findings of the successes and challenges as well as threats to the attainment of quality maternal and child health care in Nigeria. It has been observed that Nigeria is lagging behind in meeting MDG 4 and according to the United Nations mortality estimates, Nigeria has only achieved an average of 1.2% annual reduction in under-five mortality since 1990. And in order to meet MDG 4, Nigeria needed to have achieved an annual reduction rate of 10% in the five years leading to 2015 (Rajaratnam , Marcus , Flaxman , Wang , Levin-Rector , Dwyer , et al 2010).

Therefore, improving and ensuring quality of health care services in health facilities, developing strategies for quality serve as an integral component of scaling up interventions to improve health outcomes of mothers, newborns and children is of utmost importance (WHO, 2013).

1.2   Statement of the Problem

The quality of care received during pregnancy and the place of delivery are great determinants of maternal and child morbidity and mortality (United States Agency for International Development (USAID), 2013).Worldwide significant number of women and girls yearly (almost half a million) die as a result of complications during conception, delivery or 6 weeks post childbirth. Majority of these deaths happen in underdeveloped nations (United Nations Millennium Development Goals, 2009). The risk of death from conception and delivery is in Nigeria is 1 in 13, many of these deaths could have been averted with good coverage and quality maternal and child health care (United Nations Inter

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