Quality of delivery service in ethiopian hospitals

UNIVERSITY OF GONDARUNIVERSITY OF GONDARCOLLEGE OF MEDICINE AND COLLEGE OF MEDICINE AND

HEALTH SCIENCESHEALTH SCIENCESSchool of public healthSchool of public health

Thesis defense:-By: Azmeraw Tayelgn(RH)

Advisors:Dr. Desalegn Tegabu (MD,MPH)Professor Yigzaw Kebede04/12/23 1Thesis presentation, Azmeraw

RESEARCH TOPICRESEARCH TOPIC

Quality of institutional delivery service in referral hospitals of Amhara region, Ethiopia

04/12/23 2Thesis presentation, Azmeraw

IntroductionIntroductionPregnancy and childbirth claim the lives of an estimated

half a million of women globally each year.More than half of these deaths occur in AfricaEthiopia has one of the highest maternal mortality rates in

the world(673/100,000 live births)The proportion of births attended by a skilled personnel in

Ethiopia(6%) is much lower than developing countries(59%), sub Saharan regions(44%),very far from MDG target of 90% coverage

The reasons forwarded for the higher maternal mortality, morbidity and lower coverage of skilled delivery in Ethiopia include poor quality of obstetric care.

04/12/23 Thesis presentation, Azmeraw 3

Introduction con…Introduction con…Evidence suggests that the quality of maternity care in

Ethiopia is poor. Assessment of the HSDP III identified poor quality skilled

birth attendance as one of the critical bottlenecks for improving the lower utilization of institutional delivery.

In Amhara region only 3.5% of deliveries were health professional assisted. ◦ The smallest magnitude in all regions of the country where poor

quality health facility delivery experience could be one justification Assessing the quality of health facility delivery services is

thus important in the country particularly in Amhara region


JustificationsJustificationsMuch had been invested to enhance health facilities and

services that focus on improving maternal health but the desired results are often not seen. Why?

There is little information on how well already obstetric services are being provided.

Only few studies has been conducted to assess the quality of delivery service in health facilities of the Ethiopia.

I did not come across with any study in Amhara region.This study will assess the quality of delivery service in

referral hospitals of Amhara region to fill this gap.


Quality assessmentQuality assessment

•Defining quality of care is complex. Several authors and/or organizations have defined quality according to a set of dimensions-

Donabedian (1980) J.Bruce (1990) United states institute of

medicine(IOM) (1990)Department of Health UK

(1997)

Council of Europe (1998), WHO (2000) Joint Commission on

Accreditation of Healthcare Organizations in the United States of America (JCAHO) (2006)


Donabedian defined quality in Donabedian defined quality in threethree different aspects as different aspects as: : Structure, Process, Output/outcome Structure, Process, Output/outcome


Structure/Input Health institution related factors:•Trained staff availability •Transportation and communication•Waiting room and Examination room (Availability, Comfort and cleanness)•Availability of drugs, supplies equipment, guidelines, electricity, water, fuel, and vehicles•Access (distance, Waiting time, Cost of services, referral ) Care provider related: (Sex, qualification, availability during client visit)Client related factors:•Expectations and Perceived needs due to (age, educational status, residence Economical status…)

Elements in theprocess

•Client-care provider interaction•Skill to follow standard procedures•Information provision•Respect to client•Privacy•Confidentiality

Outcome

Clients’ satisfaction

Quality of delivery service

ObjectivesObjectivesGeneral ObjectiveTo assess the quality of institutional delivery service in

referral hospitals of Amhara regional state, Ethiopia.

Specific ObjectivesTo assess the structural qualities of institutional delivery

care.To assess the process qualities of institutional delivery care. To assess the quality of institutional delivery care provided

in terms of clients’ satisfaction.To explore factors associated with clients’ satisfaction.


MethodologyMethodology

Study DesignA hospital based cross sectional survey with both

quantitative and qualitative component was conducted from September 2009 to November 2009.

Study Area This study was conducted in three public referral

hospitals of Amhara region(UOGTH, FHH,, and DH).

Source populationAll delivering mothers of Amhara region who visited the

three hospitals for delivery service.


Methodology con…Methodology con…Study populationAll delivering mothers who visited the three hospitals for

delivery service from September 2009 to November 2009 and who were selected through systematic random sampling technique.

Inclusion & exclusion criteriaInclusion criteria: All delivering mothers who visited

UOGTH,FHH and DH.Exclusion criteria: Those delivering mothers who were

critically sick to be interviewed were excluded.


Methodology con…Methodology con…


Methodology con…Sampling procedure

Proportional allocation based on the expected mothers

Systematic sampling


Referral hospitals of Amhara

region

University of Gondar teaching

hospital

Felege Hiwot referral hospital

Dessie referralHospital

146 delivering mothers



417study subjects

Methodology con…Methodology con…Variables of the Study

Dependant variable: -

Degree of mothers’ satisfaction with delivery serviceIndependent variables: -

Client socio-demographic variables(age, educational status, marital status, occupation, income, residence)

Health facility related factors Distance of the facility, Availability, and cleanness of waiting place, examination room and latrine, Availability of supplies, service cost.

Care provider related (Sex, qualification, skill to give client- centered care)

Qualitative variables(Structural and process qualities of delivery service 04/12/23 Thesis presentation, Azmeraw 13

Methodology con…Methodology con…Operational definitions

Client satisfaction: 19 Questions were presented using a 5- scale likert scale.

Very satisfied and satisfied Satisfied Very dissatisfied, dissatisfied and neutral Dissatisfied.

◦ Those who were satisfied in >75% of the items were categorized under “satisfied” and

◦ Those who were satisfied in <75% of the items were categorized under “unsatisfied”.

Structural quality: The availability of essential drugs without stock out in the last-12 months. And the availability and functionality of logistics, equipments and basic infrastructures.


Methodology con…Methodology con…Process quality: relates with the use of partograph, and

monitoring of intrapartum care and post partum care according to the WHO standard.

Overall quality of safe delivery services

The overall appropriateness of institutional delivery services. That includes:◦Availability and functionality of basic infrastructures,

equipments, and availability of essential drugs.◦Use of partograph and monitoring of intrapartum care

with WHO standards.◦Treating clients with client centered care principle.◦Providing care that satisfies delivering women and their

families.04/12/23 Thesis presentation, Azmeraw 15

Methodology con…Methodology con…Data collection procedure

Data Collection Instruments

For exit interview Structured Amharic questionnaire .Which was pre tested in UOGTH

For the observation WHO standard intrapartum and postpartum midwifery

care assessment checklist was used .

For the health facility assessmentA check list prepared by UNICEF/WHO/UNFPA) and

Columbia University’s School of Public Health (AMDD) program was adopted.


Methodology con…Methodology con…Data collection

Exit interview and observation of procedures Six diploma female nurses(Day and Night) .Three supervisors were recruited.

◦ Three days (two days theoretical and one day practical) training.Data collectors wore white coat to observe the

procedures but not during exit interview. Operational deliveries were not observed.

The health facility assessmentMade by the principal investigator. Heads of the maternity department were interviewed.


Methodology con…Methodology con…Data Analysis procedures

A)Quantitative section: Data was entered and analyzed using Microsoft excel

2007 and SPSS version 16.0.Descriptive statistics was computed for the study

variables. To determine factors associated with satisfaction bivariate

binary logistic regression and multivariate stepwise binary logistic regression were applied.

Odds ratio was used to determine the strength of association between selected variables.

B) Qualitative section: The qualitative section was described based on content analysis technique.


Methodology con…Methodology con…Ethical issues

Ethical clearance from ethical committee of CMS UG. Letter of cooperation was written to UOGTH, FHH, and

DH. Oral consent was obtained for exit interview and for the

observation.Response of clients was unnamed.The respondents were made free to refuse or stop the

interview at any moment.


Results and Discussion Results and Discussion


A) Exit Interviews

Socio-demographic characteristicsA total of 417 delivering mothers were interviewed.

35.0%(UOGTH),36.0%(FHH)and the rest 29.0%(DH).The mean + SE age of the mothers was 25.9 + 0.26 years.372(89.2%) of the mothers were married. 296 (71.0%) of the mother are from the urban areas. The median family monthly income of the delivering

mothers was 765 ETB. 391(98.3%) paid for the services.

Results and Discussion con…Results and Discussion con…Obstetrics characteristics of delivering mothers308(73.9%) of the pregnancies were wanted. 148(35.5%) of the mothers had previous history of

health facility delivery experience.Majority of the mothers 351(84.2%) were having ANC

follow up.More than half 222(53.7%) were SVDs. 91(21.8%) of the mothers delivered through C/S.


Results and Discussion con…Results and Discussion con…


Results and Discussion con…Results and Discussion con…Mothers satisfactionThe overall proportion of mothers who were satisfied

with delivery care in this study was 61.9 %. ◦ Very low compared to a study _92.5% in Côte d’Ivoire but it is

comparable to a study in Nairobi, Kenya-56% and greater than a study in Sri Lanka_48%. This variation may be due to difference in quality of services or the difference in the study setting.

The overall mean (95%CI) satisfaction score of this study was 67.9% [62.9, 73.0]. ◦ This score is below the Gold standard of 70%.◦ Of all satisfaction scores client privacy satisfaction score

(46.7%), health facility distance satisfaction score (51.4%), and amount of cost paid satisfaction score (52.7%) were the three least values.

04/12/23Thesis presentation, Azmeraw 23



Results and Discussion con…Results and Discussion con…Factors associated with clients’ satisfaction

1) Socio-demographic factorsNo relationship has been observed between delivering

mothers level of satisfaction and socio demographic variables. ◦ This is actually in agreement with a study in Kenya, Nairobi.


Results and Discussion con…Results and Discussion con…2) Obstetric experience related factors

◦ Wanted status of the pregnancy(Wanted VS unwanted)◦ Maternal condition(Normal VS With complication)◦ Waiting time to see the health worker◦ Perceived availability of waiting area◦ Health professionals measure taken to assure privacy during

examinations and ◦ Service cost paid were predictors of delivering mothers

satisfaction. This finding is consistent with other studies in Africa

(Kenya, Côte d’Ivoire, and Ghana)


Results and Discussion con…Results and Discussion con…Mothers who wanted their pregnancy were more likely

to be satisfied than mothers who did not[AOR=2.2(1.20, 3.93)]. ◦ This could be due to the association between unwanted

pregnancy and unhappy birth. ◦ In such cases family planning counseling would be important.

Mothers without complication were more likely to be satisfied than mothers with complication[AOR=2.1(1.12, 3.93)]. ◦ Women who experience no complications may simply be glad

that they survived or had a good health outcome.




Results and Discussion con…Results and Discussion con…Similar to a study in Oromia and Afar regions, privacy

and cost incurred for service were associated with mothers’ satisfaction. ◦ Mothers who reported privacy during physical examination

were more satisfied than those who perceived poor privacy [AOR=2.1(1.13, 3.83)].

◦ Mothers who paid less than or equal to157ETB were more satisfied than those who paid greater than157 ETB [AOR=1.9(1.15, 3.60)]. This might be due to the low socio economic status of the mothers or/and

mothers may have paid unexpected costs such as cost for travel and charge for supplies.


Result and Discussion con…Result and Discussion con…


Result and Discussion con…Result and Discussion con…B) Process quality (result of the observation) A total of 94 deliveries were observed(34 Midwife

nurses). In 89(94.7%) of the cases, the exam area and

equipments were ready before each procedure. But only 34 (36.2%) maternal examinations were

performed in a private room or within curtain.

Communication: Poor interpersonal interactions were observed.

Prior to the procedure 2(2.1%) mothers were introduced with the name of the care provider and

Smaller proportion 53(56.4%) of the procedures were introduced to the mothers.

Similar reports were found in a study in Gambia’s referral hospital04/12/23 Thesis presentation, Azmeraw 31

Result and Discussion con…Result and Discussion con…Intrapartal careLabour progress was not routinely monitored, not with

standards; the partograph was not filled during labour.In this study partograph was not almost in use only_2

(2.1%) filled partographs were found. This was not in line with African countries studies which have consistently

shown incorrect use of the partograph rather than non-use.

Vaginal examination was performed more frequently than the recommended standard.◦ Vaginal examination was performed every 2.5+ 0.16 hour.

Uterine contraction, maternal pulse and FHB monitored lately that is every 2+0.19hour, 2.1+0.19 hour, and 1.4+ 0.16hours respectively.◦ This is not in line with the WHO standard.


Result and Discussion con…Result and Discussion con…Infection prevention/Universal precaution: 93(98.9%) of the vaginal examinations/deliveries/ cord

cuttings/ episiotomies were performed with a sterile glove. ◦ But only in 27(28.7%) of the cases that the care givers washed

their hands before gloving.

Postnatal care:

For the mother or baby was also found poor. Only 65(69.1%) mothers were checked for uterine

retraction after delivery. Maternal blood pressure was unchecked in all procdures. Antibiotics were put in 43(45.7%) of the neonates eye.


Result and Discussion con…Result and Discussion con…The placenta was examined for its completeness only in

35(37.2%) of the cases. ◦ Similar findings were reported in Jamaica and Ecuador

A positive finding regarding postnatal care was that active management of third stage of labour and oxytocics administrations.


Result and Discussion con…Result and Discussion con…


Result and Discussion con…Result and Discussion con…C) Structural assessment

Staffing: The hospitals had no perceived shortage of manpower.◦ There were a total of 46 health professionals.

Materials, drugs and supplies Vitamin K for newborns, eye ointment, GV, anti-tetanus

serum, and anti Rho (D) immunoglobin were not found in the stock of the three hospitals.

Kenya, Rwanda, southern Sudan, and Uganda

Oxytocics were found in UOGTH and FHH. ◦ But there were frequent oxytocics stock outs in the last 12 months. ◦ In the absence of adequate structural inputs improving the process

quality of delivery care could be challenging.04/12/23 Thesis presentation, Azmeraw 36

Result and Discussion con…Result and Discussion con…Infrastructure: Except in DH there was no waiting area. There was a single separate examination room in

UOGTH. In FHH delivery rooms have partitions. Electricity, running water, functioning toilet were

available in the hospitals. Essential consumables like disposable gloves, suturing

materials, cord tie, cloth/towel and blankets were available inadequately in the hospitals.

Partograph was found in none of the hospitals. In DH there was no blood bank (supply) for transfusion.

◦ Without life-saving services such as blood transfusion, women with severe complications may perhaps die 04/12/23 Thesis presentation, Azmeraw 37

Result and Discussion con…Result and Discussion con…Transportation and communication: The hospitals had no landline telephone in the maternity

ward. The hospitals had no dedicated vehicle (ambulance, car,

motorcycle) for emergency transportation.

Supervision: Monthly reports were sent to the regional office and

MOH in the last 12 monthsNo regional and/or federal official supervised the

activities of delivery service in the hospitals.


ConclusionConclusionThe existing quality of delivery care was rated poor. The technical quality of care and mother-provider interaction

was not up to the expected standard.Partograph was rarely used in monitoring of labour. Several constraints including: drugs and supplies unavailability,

poor maintenance of clients privacy, poor monitoring of labour, poor patient centered care, absence of waiting areas and nonexistence of WHO standard Partograph were identified.

Limitation of the studyThe exit interview was done immediately after care in the

health facility. Operative deliveries were not observed.


RecommendationsRecommendationsThe MOH and Amhara regional health bureau should

adequately supply the deficit structural inputs.The management bodies of the hospitals should improve

the supervision of the hospital delivery wards.The hospital administrators shall work in preparing

waiting area.Care givers of the hospitals are recommended to maintain

delivering mothers’ privacy and to provide client-centered care. .

The MOH and NGOs shall advocate the use of partograph in monitoring of labour.


AcknowledgmentAcknowledgmentMy sincere and deepest gratitude goes to my advisors My sincere and deepest gratitude goes to my advisors Dr. Desalegn TegabuDr. Desalegn Tegabu and Professor Yigzaw Kebede. and Professor Yigzaw Kebede.

My special thanks also go to heads of the maternity ward at UOGTH, FHH and DH and delivering mothers who participated in the study.

My gratitude also goes to Ato Yirga Gismu, Ato Animaw Alemu and Ato Abdurrahman

Mohammed.

I am also grateful to Ato Fekadu Mazengia, Ato Zewdie Aderaw

and Ato Solomon Meseret.


04/12/23 42Thesis presentation, Azmeraw

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Quality of delivery service in ethiopian hospitals

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