Utilization Of Donabedian Model In Evaluation Of Maternal And Child Healthcare Quality Service
Several efforts aimed at improving maternal health indices in Nigeria, have not yielded much fruit, as women are still dying from pregnancy related causes. This raises some doubts over the possibility of achieving the Millennium Development Goal (MDG) 5 by 2015, if the provision of quality maternal health care services starting from the Primary Health Care (PHC) level is not scaled up. A cross- sectional descriptive study was carried out at the primary health care level in Ile-Ife Local Government Area. A total of two hundred and eighty (280) women attending maternal health services at the primary health care facilities in the local government area were selected by multistage sampling technique from four primary health care facilities and were studied. Data was collected from them using pretested semi structured interviewer-administered client exit questionnaires. The mean age of the respondents was 29.2±5.9 years. Majority of the clients were married and attained at least secondary level of education. One hundred and sixty eight (60.0%) of the women studied accessed antenatal care services, 70 (25.0%) of them accessed post natal care services, 26 (9.3%) utilised delivery services and the remainder 16 (5.7%), other services. Generally, the quality of maternal health services provided in the health facilities studied was poor. The level of clients’ satisfaction was high and may be attributed to affordable cost of services rendered, good staff attitude and perception of waiting time which was fair. However there is need to improve the quality of maternal health services through upgrading of these facilities, employing and training of health personnel, improving the supply of equipment, drugs and supplies particularly for providing essential obstetric care, and basic amenities both for clients and the staff.
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 International Children Fund (UNICEF), 2014).
Increased mothers and newborn death and morbidity has been linked to poor quality of healthcare services (USAID, 2013), and has been evident by increased death rates that inadequate availability of reproductive health services is an important challenge in Nigeria (WHO Nigeria, 2014). Although progress has been made in increasing the coverage of several key reproductive, maternal, newborn and child health interventions over the past two decades, there has been limited progress in improving maternal and paediatric outcomes because of a major gap between coverage and the quality of care provided in health facilities (WHO, UNICEF, 2014).
Also, it has been observed from clinical practice that there are still many cases of preventable pregnancy and delivery complications reporting in the teaching hospital in Ile-Ife on daily bases in spite of many healthcare facilities in the area. Improving the quality of facility-based health care services and making quality an integral component of scaling up interventions to improve health outcomes of mothers, newborns and children is of utmost importance (WHO, 2013).
Hence, the need to evaluate the maternal and child healthcare services in healthcare facilities in Ile-Ife for quality care to achieve Sustainable Development Goal 3 (SDG 3) which is good health and well-being.
1.3 Objective of the Study
The main objective of this study is to evaluate the Quality of Maternal and Child Healthcare Services in selected Healthcare Facilities Ile-Ife utilizing Donabedian model for Quality care
The specific objectives are to:
- Assess the structure of maternal and child healthcare services in Primary and Secondary health facilities in Ile-Ife based on Donabedian model;
- Determine the process of maternal and child healthcare services in Primary and Secondary health facilities in Ile-Ife based on Donabedian model;
- Assess the client’s satisfaction (outcome) with the maternal and child healthcare services in primary and secondary health facilities in Ile-Ife based on Donabedian model for quality care and
- Determine the categories of staff rendering maternal and child healthcare services in primary and secondary health facilities in Ile-Ife.
1.4 Research Questions
The following research questions were answered by the study:
- What is the structure of maternal and child healthcare services in selected health facilities in Ile-Ife?
- What is the process of maternal and child healthcare services in selected health facilities in Ile-Ife?
- What is the level of client’s satisfaction (outcome) with maternal and child healthcare services rendered in Primary and secondary health facilities in Ile-Ife?
- What categories of staff are rendering maternal and child healthcare services in health facilities in Ile-Ife?
The following hypothesis were tested at 0.05 level of significance.
HO1; There is no significant difference between the structure of Maternal and Child Healthcare services in Primary and secondary health facilities in Ile-Ife.
HO2; There is no significant difference between the process of Maternal and Child Healthcare Services in Primary and secondary health facilities.
HO3; There is no significant difference between the client’s satisfactions (outcome) with Maternal and Child healthcare services in Primary and Secondary health facilities in Ile-Ife.
1.6 Scope of the Study
The scope of this study was delimited to Primary and Secondary Healthcare Facilities in Ile-Ife and nursing mothers of children 0-1year attending infant welfare clinics in selected healthcare facilities in Ile-Ife. The study covers the four local governments in Ile-Ife, which are: Ife Central Local Government, Ife East Local Government, Ife south local government and Ife North local government respectfully.
1.7 Significance of the Study
According to World Health Organization Report (WHO 2008), maternal and newborn morbidity and mortality continue to be a problem with a huge disparity between developed and developing countries. Therefore, findings from this study might help with recommendations to improve the quality of maternal and child healthcare services thereby reducing maternal and child mortality and achieve Sustainable Development Goal 3 (SDGs) which is Good health and well- being.
The findings may assist the Federal Ministry of Health in adopting strategies to improve the quality of maternal and child healthcare services through collaboration between stake holders.
The findings may be useful in National Health Planning and Budgeting to improve the structure of healthcare facilities, training and retraining of staff, supervision, and provision of supplies and transportation for prompt referrals in healthcare facilities.
Findings may provide useful information on areas of partnering with local and international agencies for complementary role in maternal and child healthcare services.
The outcome of the study may be used to further challenge health professionals to identify factors influencing quality of maternal and child health care services in Nigeria and need for improvement.
Findings may add to the existing body of knowledge and would assist in achieving the desired goal of quality maternal and child healthcare services in Nigeria.
1.8 Operational Definition of Terms
Quality of Care:
Care rendered to women during pregnancy, childbirth, and post-delivery in healthcare facilities in Ile-Ife based on Donabedian Model of quality care, this include the structure, process and outcome of Maternal and Child Health Care services.
Maternal and Child Healthcare:
This is the care rendered to a pregnant woman from the time of conception to the delivery of the baby and care of the baby from birth to 2year in healthcare facilities in Ile-Ife .
These are Midwives, Nurses, Community Health officers and Community Health Extension workers that provides Maternal and Child Healthcare services in healthcare facilities in Ile-Ife by the virtue of their training or qualifications.
Women with babies 0-1year old who have received care during conception, delivery of the baby, after delivery, family planning, immunizations, care of the baby and attends immunization clinic at the time of the study in selected health facilities in Ile-Ife.
These are Primary Healthcare Centers (PHCs) and Secondary health facilities (General Hospitals and Comprehensive Health Centers) in Ile-Ife.
This is the conceptual model of quality care developed by Avedis Donabedian in 1966, reviewed in 1980 and 1988. The model was developed to assess quality of care in clinical practice; it has three categories in which information could be gathered for evaluating quality of healthcare services which are structure, process and outcome.
This is the physical facilities, human and material resources available in primary and secondary healthcare facilities for maternal and child healthcare services in Ile-Ife.
This is the care and all actions rendered in Maternal and Child health services by the healthcare professionals. It contains all acts of maternal and child healthcare delivery (i.e. antenatal, intra-natal, postnatal care, neonatal and children care etc.) in healthcare facilities in Ile-Ife and interactions between health personnel and clients including relationships and respectful maternity care in the course of interactions.
This is the effects of maternal and child healthcare services measured by mother’s satisfaction of the care received in Primary and secondary Healthcare facilities in Ile-Ife.
Conclusion and Recommendation
This study concludes through the Donabedian model that the facilities available for the provision of maternal health services in Ile-Ife LGA had most of the equipment, drugs and supplies available though they were inadequate.
Also the structures that house some of the facilities were not large enough to accommodate all the clients and providers. Water supply, power supply and refuse disposal system were not adequate. While factors reported to be responsible for difficulty in assessing services include: bad state of roads, high cost of transportation and payment before various services were received.
From this study, none of the health facilities had the capacity for even basic EOC. There were no laboratory technicians, no pharmacy technicians, only one of the facilities have a laboratory, while only one doctor covered the entire LG PHCs.
None of the facilities surveyed operated a Drug Revolving Fund scheme, nor had essential drugs list.
All the facilities received the available forms from the LGA health units regularly and on a monthly basis. However, the record system was found to be defective as there was no trained record officer in all the facilities studied. Some of the required forms were lacking and those available were incompletely and inaccurately filled.
Lack of vehicles designated for referral was also found as a factor that impeded the delivery of quality care.
The study found lack of comprehensive and integrated maternal health services, with ANC as the predominant service provided while others like delivery, PNC and family planning were underutilized.
This study showed that the disposition of the staff towards punctuality and interaction with clients was acceptable.
This may have been the reason for the high level of satisfaction with the maternal health services by the clients despite the poor quality of services provided.
The following recommendations are made based on the findings from the study.
- The NPHCDA as the main agency overseeing PHC should make available the list of all minimum resource requirements to all PHC departments nationwide and ensure strict compliance through regular inspection visits.
- The Ile-Ife Local Government should rehabilitate and ensure regular maintenance of the access roads to these facilities.
- The LGA should ensure regular supply of HMIS forms. In addition, they should employ record officers, while monitoring and evaluation officers should ensure these forms are available, timely, completely and correctly filled.
- Laboratory facilities for the routine investigations should be made available in the LGA, and laboratory technicians employed.
- The Ile-Ife Local Government through the PHC Department should strengthen the capacity of the existing PHC facilities to provide at least basic EOC through the employment of more health personnel, training of existing ones and the provision of equipment, drugs, supplies and other necessary logistics.
- Referral systems which should be supported by a reliable means of transportation should be established and strengthened by the LGA and the communities. Referral forms should also be made available.
- Infrastructure – There should be provision of adequate potable water, power supply, refuse disposal system and renovation of facilities in the health centres. The communities should liase with the government in this respect.
The health facilities in Ile-Ife Local Government should ensure the delivery to the clients of comprehensive and integrated maternal health services
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