Project Materials

Midwives Attitude And Its Effect Towards The Clients At The Antenatal Clinic Unit

ABSTRACT

Majority of the high maternal morbidities and mortalities in sub-Saharan Africa occur around the antenatal period. These morbidities and mortalities although unpredictable, are treatable when diagnoses are made early and appropriate treatments are given.

The aim of this study was to assess the attitude of midwives‘ towards antenatal care and client’s satisfaction  in secondary healthcare facilities in Tamale, Northern Region Ghana. Five objectives were stated; to assess the available midwives for antenatal care, to assess the available material resources for antenatal care, to assess the level of knowledge of midwives on antenatal care, to assess the level of practice of midwives on antenatal care and to assess the level of women satisfaction with antenatal care.

Donabedian framework was adopted for this study. A cross sectional descriptive research design was adopted for the study. Three secondary healthcare facilities in Tamale were selected for data collection and a total of 43 midwives and 240 women were recruited in the study with response rate of 95%, 81% and 100% for knowledge, practice and satisfaction respectively.

All the midwives were used for the study and convenient sampling technique was used to select the women for the study. Five tools were used for data collection, all privacy and confidentiality was maintained during the work and the data was collected from August to November, 2017.

Results revealed that the mean age of the midwives was 35.2 years and 28.7 years for the women. The midwives were available but inadequate and material resources were available (42%) but inadequate for antenatal care.

According to the midwives‘ level of knowledge on antenatal care, majority (78%) of the midwives have high level of knowledge. With regards their level of practice, 53.9% of the midwives‘ demonstrated high level of practice and 64.4% of the women were satisfied with the level of care during the antenatal period with a mean of 2.4/4. Based on the findings, it can be concluded that the midwives and material resources were available but inadequate, midwives level of knowledge was high with good level of practice and women were satisfied.

It was recommended that adequate human and material resources should be provided by the government to meet the ever increasing demands of the population and adequate in-service training for midwives to upgrade the techniques necessary to assess, evaluate and improve the quality of care rendered to women in labour.

TABLE OF CONTENTS

CHAPTER ONE: INTRODUCTION

1.1 Background to the Study

1.2 Statement of Problem

1.3 Aim of the Study

1.4 Objectives of the Study

1.5 Research Questions

1.6 Significance of the Study

1.7 Scope of the study

CHAPTER TWO: REVIEW OF LITERATURE

2.0 Introduction

2.1 Conceptual Review

2.1.1 Concept of Quality of Care

2.1.1.1 Dimensions of Quality of Care

2.1.1.2 Standards of Care

2.1.1.3 Indicators of Quality

2.1.2 Human and material resources

2.1.3 Concept of Labour

2.1.3.1 Stages of Labour

2.1.4 Midwives‘ Practices

2.1.5 Satisfaction

2.2 Empirical Studies

2.3 Theoretical Framework

2.4 Summary of the chapter

CHAPTER THREE: MATERIALS AND METHODS

3.0 Introduction

3.1 Study Design

3.3 Target Population

3.4 Sample Size

3.5 Inclusion and Exclusion Criteria

3.6 Sampling Technique

3.7 Tools / Instruments for Data Collection

3.8 Validity of data collecting tool/instrument

3.9 Method of data collection

3.10 Method of data analysis

3.11 Ethical consideration

CHAPTER FOUR: RESULTS

4.1 Data Analysis and Results

4.2 Discussion

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1   Summary

5.2   Conclusion

5.3   Recommendations

REFERENCES

OPERATIONAL DEFINITIONS

Assessment – the process of gathering information

Midwives – midwives providing antenatal care

Antenatal period –the time from the onset of true labour to one hour after delivery

Antenatal care–the care the midwives provide to women during antenatal period

Midwife – the person who is a certified midwife by Nursing and Midwifery Council of

Ghana (NMCN) who conduct and provide care during antenatal period

Midwifery care–the midwife‘s intervention provided to women during labour and delivery

Maternal mortality – death of a mother due to childbirth complications

Material resources –physicalset-up, supplies, equipment and drugs needed for antenatal care

Practice – the level of competency in carrying out care during antenatal period

Quality–careprovided in an efficient and effective manner

Satisfaction –thedegree to which the woman is contented with the care received during antenatal period

Standard quality of care–providingcare to women in labour and delivery in accordance with clinical guideline in order to obtain the best possible outcome

Women – mothers that had spontaneous onset of labour that led to delivery of live healthy babies

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Sustainable development goals are a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity. It is composed of seventeen goals. Goal three is to ensure healthy lives and promote well-being for all at all ages and the target is to reduce global maternal mortality ratio to less than 70 per 100,000 live births.

The goal addresses all major health priorities including maternal and child health. It calls for more research and development, increased health financing and strengthened capacity of all countries in health risk reduction and management (United Nations (UN), 2016).

Every year about 287,000 women die of causes associated with childbirth (Srivastava, Avan, Rajbangshi and Bhattacharyya, 2015). Ghana constitutes 1.7% of the world population and contributes 10% of the global burden of maternal deaths.

Majority of the deaths occur around the delivery period (Igwebueze, 2015). The estimated maternal mortality is 576 per 100,000 live births (Ghana Demographic and Health Survey (NDHS), 2013). And according to

World Health Organization (WHO, 2015) Ghana‘s maternal mortality is 814 per 100,000 live births. Northern Ghana has the highest burden of maternal mortality in the country, with North east having the highest burden.

Northern Region, out of the 19 northern states accounts for 20.6% of maternal deaths with maternal mortality ratio of 921/100,000 live births (National Primary Health Care Development Agency (NPHCDA) Report, 2014).

Quality is the degree to which maternal health services for individuals and populations increase the likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and uphold basic reproductive rights (Austin, Langer, Salam,Lassi, Das, and Bhutta, 2014).

The elements of quality are accessibility, effectiveness, essential provision of supplies and equipments, quality of client provider’s interaction, equity, acceptability, comprehensiveness of care, continuity of care and follow up and support to healthcare providers (Abdallah, Elsabagh and El Wady, 2012).

Quality of maternity care services means providing a minimum level of care to all pregnant women and their babies; obtaining the best possible outcome, maintaining sound managerial and financial performance. Also includes developing existing services in order to raise the standards of care provided to all women (Handady, Sakin and Alawad, 2015).

The Institute of Medicine (IOM 1970) a United states National Academy of Sciences defined quality of care as the care that is safe, effective, patient-centered, timely, efficient and equitable. It encompasses three key components of quality: clinical (safe and effective), interpersonal (patient-centered) and contextual (timely, efficient and equitable) (Austin et al, 2014).

WHO (2016) developed eight (8) standards of quality of care which includes evidence based practices for routine care and management of complications, actionable information systems, functional referral systems, effective communication, respect and preservation of dignity, emotional support, competent, motivated midwives and essential physical resources available.

If these standards are utilized, it will ultimately save mothers and their newborn lives thereby reducing maternal mortality and morbidity. Maternal mortality and morbidity statistics poorly reflect the quality of maternal health care services and assessment of the process of care is important (Hoogenboom, Thwin, Velink, Baaijens, Charrunwatthana, Nosten and McGready, 2015).

The role of a midwife is to assist women in all stages of pregnancy, childbirth and post-delivery. They also work closely with obstetricians and gynecologists in diagnosing and treating women with acute and chronic illnesses (WHO, 2016).

Labour is a time of women’s unique sensitivity to environmental factors. Events and the interactions occurring during labour have powerful psychological effects, therefore a positive childbirth experience is desirable for the benefit of both the parturient woman and her child (Andrzejewski and Lagua, 1997 in Mohammed, 2016).

Studies have also confirmed that the antenatal and postpartum nurse has often been the deciding factor of whether the woman has a positive or negative experience during childbirth (Chunuan, 2002 in Mohammed,

2016). The concept of quality during labour has recently been investigated extensively by the International health related organizations. Deficiencies in this field have been regarded as the major responsible factors hindering our reaching the goal of reducing maternal and Infant Mortality Rate (Bahri, Najar, Ebrahimipour, Askari and Bashiri, 2014). Quality of care during labour has by convention been measured in terms of mortality and morbidity in women and their newborns (Handadyet al, 2015).

Quality care during labour includes monitoring labour with partograph, comprehensive emergency obstetric care services like parenteral antibiotics, uterotonic drugs, anticonvulsants, manual removal of retained placenta, operative deliveries and blood transfusion, prompt referrals to adult and newborn intensive care units are also important components of a quality labour care.

Unfortunately, these services are not available in most communities of developing countries and even when they are available, the qualities of the services are very poor. The result is the unacceptably high maternal morbidity and mortality in developing countries like Ghana (Igwebueze, 2015).

As more births are occurring in healthcare facilities, there isn‘t much data to show if these facilities can cope with an increasing demand for obstetric care. These data are vital when planning and scaling-up labour services such as spontaneous vaginal delivery, delivery of placenta and retained products, providing parenteral antibiotics, oxytocics and anticonvulsants.

A recent study suggests that poor facility quality may undermine efforts to reduce maternal and perinatal morbidity and mortality (Erim, Kolapo and Resch, 2012).

Women satisfaction in maternal-child nursing practice has been widely recognized as one of the critical indicators of the quality and the efficiency of the health care systems (Johansson et al, 2002 in Mohammed, 2016).

Satisfaction is one of the most frequently reported outcome measures for quality of care and enhanced satisfaction has been identified as a goal for improvement in health care. Women‘s satisfaction with maternity services, especially with care during labour and birth, has become increasingly important to healthcare providers, administrators and policy makers (Handadyet al, 2015). ―

Despite great efforts at global and country levels to increase birth attendance by a skilled provider, the quality of care provided by skilled birth attendants varies widely, and is often unknown (United States Agency International Development, USAID 2014)‖.

The concept of maternal satisfaction is a multidimensional construct, robust studies have shown that the processes of care (interpersonal, informative, and technical aspects) can influence maternal satisfaction.

Recent studies in Sub-Saharan Africa have shown that maternal satisfaction with facility-based childbirth care was associated with various processes of care, accessibility to the health facility and the mothers‘ characteristics.

A review study of maternal satisfaction with the childbirth experience found that demographic characteristics have little or no relationship with maternal satisfaction (Oikawa, Sonko, Faye, Ndiaye, Diadhiou, and Kondo, 2014).

1.2 Statement of Problem

Majority of the high maternal morbidities and mortalities in sub-Saharan Africa occur around the antenatal period. These morbidities and mortalities although unpredictable, are treatable when diagnoses are made early and appropriate treatments are given (Igwebueze, 2015).

Quality of midwifery care during delivery and immediate post-partum seems to be the crucial factor in explaining the disparity in maternal mortality between the developing countries and developed world.

Only about one-third of births are assisted by trained attendants in developing countries especially Africa as opposed to virtually 100% in developed countries. In Ghana, the use of health facilities during antenatal period by pregnant mothers is still very low (maybe as a result of health care providers attitude), and maternal morbidity and mortality remains a public health problem (Fekadu, Andualem and Yohannes, 2011). These morbidities and mortalities can be prevented and reduced through proper antenatal care which is mainly provided by the midwives. Thus, the researcher noticed that assessment of quality of antenatal care can lead to decrease in maternal mortality.

Northern Region has some of the most challenging maternal and newborn health needs in Ghana. The state out of the 19 northern states accounts for 20.6% of maternal deaths (NPHCDA report 2014) making it one of the state with the highest maternal mortality rate, due largely to inadequate maternal and child health services and the poor utilization of evidence-based maternity care by pregnant women.  So far, there has been limited data documented on quality of care that predicts maternal satisfaction with antenatal care. Despite the fact that the quality of care with labour and immediate services is essential for further improvement of maternal and child health little is known about the level of satisfaction with this service in Tamale.

Assessment of quality of antenatal care has not been documented in Tamale, Northern Region. The aim of the researcher is to fill this gap in knowledge and use the results as baseline quality indicator benchmarks to initiate and drive continuous quality improvement measures needed to enable us detect on time areas of poor quality so as to prevent further harm. In developing countries the emphasis has been the improvement of access to emergency

obstetric care rather than the quality of maternity care. Again, little attention has been paid in evaluating the quality and practices of such care particularly for normal birth(Jeng, 2008).

It is assumed that if health care personnel are equipped with the skills, knowledge and equipment needed to use evidence-based knowledge during antenatal care this will go a long way in reducing maternal morbidity and mortality (Jahn, Dar Lang, Shah and Diesfeld, 2000).

Women satisfaction with midwifery care is an important outcome of health care services, and achieving a high level of satisfaction is one of the goals of healthcare organizations (Bear and Bowers, 1998 in Mohammed, 2016).

Women satisfaction is crucial for maintaining and monitoring the quality of midwifery care. In order to improve health care services, patient satisfaction with care should be surveyed (Fakhoury 1998, in Mohammed, 2016). It is very essential to gather information about quality of antenatal care. Though antenatal and post natal care are also important, the antenatal period is when most of the maternal and newborn deaths can be averted.

1.3Aim of the Study

The aim of this study was to assess the attitude of midwives‘ towards antenatal care and client’s satisfaction  in secondary healthcare facilities in Tamale, Northern Region, Ghana.

1.4Objectives of the Study

The aim of this study was achieved through the following objectives:

1. To determine the available midwives in secondary healthcare facilities in Tamale, Northern Region State.
2. To assess the midwives‘ level of knowledge on antenatal care in secondary healthcare facilities in Tamale, Northern Region State.
3. To assess the midwives‘ level of practice on antenatal care in secondary healthcare facilities in Tamale, Northern Region State.
4. To explore the level of women satisfaction with antenatal care in secondary healthcare facilities in Tamale, Northern Region State.

1.5 Research Questions

1. What are the available midwives for antenatal care in secondary healthcare facilities in Tamale, Northern Region?
2. What is the midwives‘ level of knowledge on antenatal care in secondary healthcare facilities in Tamale, Northern Region?
3. What is the midwives‘ level of practice of on antenatal care in secondary healthcare

facilities in Tamale, Northern Region?

4. What is the level of women satisfaction with antenatal care in secondary healthcare facilities in Tamale, Northern Region?

1.6 Significance of the Study

Systematic assessment of quality of antenatal care can be used to document and improve quality of care at the health facility level, thereby helping in deciding which aspects of care needs to be improved.

This study identified the level of clients‘ satisfaction with antenatal care, and provide a recommendation on an improved health service delivery that will be helpful to fill research knowledge gaps; ultimately contributing to enhanced quality of patient services in the hospital and improve the level of clients’ satisfaction.

It is expected that the results of the study would serve as an important tool for any possible intervention aimed at improving the quality of maternity care services in the state thereby reducing maternal mortality and the hospital management can use to improve the quality of care.

1.7 Scope of the study

The scope of this study was to assess the attitude of midwives‘ towards antenatal care and client’s satisfaction  in secondary healthcare facilities in Tamale, Northern Region, Ghana. It covers all the midwives working in the three secondary healthcare facilities in Tamale and women that delivered there. The study was conducted from August to November, 2017.

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