i

CLIENT SATISFACTION WITH MIDWIFERY SERVICES RENDERED AT

EMPILWENI GOMPO AND NONTYATYAMBO COMMUNITY HEALTH CENTRES

IN THE EASTERN CAPE, SOUTH AFRICA

BY

NOKWAMKELA PEARL MFUNDISI

MINI-DISSERTATION PRESENTED IN PARTIAL FULLFILMENT OF THE

REQUIREMENTS FOR THE DEGREE OF MASTERS OF NURSING SCIENCE

(MAGISTER CURATIONIS) (MIDWIFERY & NEONATAL NURSING)

IN THE

FACULTY OF SCIENCE AND AGRICULTURE

SCHOOL OF HEALTH SCIENCES

DEPARTMENT OF NURSING SCIENCE

SUPERVISOR:

DR. B. NZAMA

brought to you by COREView metadata, citation and similar papers at core.ac.uk

provided by South East Academic Libraries System (SEALS)

ii

Declaration

I hereby declare that this descriptive study on patient satisfaction with midwifery

services rendered at EmpilweniGompo and Nontyatyambo Community Health

Centres is my work that has not been submitted before for any degree or

examination in any other University and that all the sources I have used or quoted

have been indicated and acknowledged as complete references.

Name: Nokwamkela Pearl Mfundisi

Signature: ---------------------------------------- Date submitted: -------------------------------

iii

Dedication

This work is dedicated to the Sovereign God who gave me the strength to complete

this dissertation and also to a loving and supportive husband and children.

iv

Acknowledgements

The author would like to thank Doctor B. Nzama for supervising the researcher

throughout the study.

The author would like to thank managers at Empilweni Gompo and Nontyatyambo

Community Health Centres for allowing the researcher to conduct the study in their

facilities.

The researcher would like to thank Ms. Funeka Pretty Wongama, Mr. Lukhanyo

Matina and Mr. Vusumzi Ncontsa for their assistance and encouragement to

complete the study.

v

ABSTRACT

The aim of this study was to investigate whether patients were satisfied with

midwifery services rendered at the two Community Health Centres in the Eastern

Cape Province.The study sites were Empilweni Gompo and Nontyatyambo

Community Health Centres.

Descriptive quantitative study design was employed, using a questionnaire with

closed and open ended questions as the data collecting tool. Likert Scale was used

to measure the following variables: quality care variables to measure level of

satisfaction with midwifery services rendered and to determine positive and negative

perceptions regarding quality of care received during antenatal, labour and postnatal

period.

Non-random convenience sampling of sixty pregnant women, thirty from each

Community Health Centre, with two or more antenatal subsequent visits and forty

postpartum women, twenty from each health facility, six hours after delivery if there

were no complications.

Out of 60 participants interviewed n=60 (100%) agreed that individual counseling

and importance of HIV testing was explained.The majority of participants n=53(88%)

disagreed that they were educated about focused antenatal visits. Out of 60

participants interviewed n=41(68%) agreed that delivery plan formed part of their

ANC visits and n=18 (30%) disagreed. Of the 60 participants interviewed n=11(18%)

agreed that they were told that they had the right to choose labour companions and

n=48 (80%) disagreed.Out of 60 participants interviewed n=23 (38%) stated that they

waited a long period of time without being attended to by midwives.

In general, the study revealed high satisfaction level with intrapartum and postnatal

care due to functional accessibility of both Community Health Centres. Both health

centres delivered normal healthy babies and mothers. However, the participants

were dissatisfied with antenatal care rendered at the two facilities.

The researcher’s recommendations were based on the closing of gaps that were

identified with regard to the implementation of Basic Antenatal Care; birth

companions: health education deficiency; community involvement and participation.

vi

This study is very valuable in that it can be a good reference for all midwives in order

to improve their performance and effectiveness in the execution of their duties.

vii

TABLE OF CONTENTS

Declaration…………………………………………………………………………………….i

Dedication…………………………………………………………………………………….ii

Acknowledgements ………………………………………………………………………...iii

Abstract………………………………………………………………………………….... ...iv

Table of Contents………………………………………………………………………… ....v

Acronyms…………………………………………………………………………………. ...ix

Chapter 1……………………………………………………………………………………..1

1.1 Introduction………………………………………………………………………………1

1.2 Background…………………………………………………………………………….2

1.3 Research Questions…………………………………………………………………..3

1.4 Purpose of the Study………………………………………………………………….7

1.5 Objectives of the Study…………………………………………………………………7

1.6 Significances of the Study……………………………………………………………...7

1.7 Summary …………………………………………………………………………….......8

Chapter 2: Literature review

2.1 Introduction………………………………………………………………………………9

2.2 Description of Midwives and Midwifery services…………………………………….9

2.3 Factors that enhance patient satisfaction…………………………………………….9

2.3.1 Accessibility …………………………………………………………………………..9

2.3.2 Availability.........................................................................................................10

2.3.3 Affordability.......................................................................................................10

2.3.4 Cultural Acceptance..........................................................................................11

viii

2.3.5 Communication................................................................................................11

2.3.6 Interpersonal relations between clients and health care providers..................11

2.3.7 Addressing the needs, wishes, desires and perception of clients....................11

2.3.8 Availability of resources...................................................................................14

2.4 The relationship between quality care and patient satisfaction...........................15

2.5 Quality related definitions....................................................................................16

2.6 Respect of technical standards of Health care....................................................16

2.7 Monitoring and Evaluation Framework................................................................17

2.8 Written Guidelines...............................................................................................18

2.9 Implementation of Batho Pele Principles and Patient’s Rights Charter...............19

2.10 Intersectoral Collaboration.................................................................................22

2.11 Community involvement and perception............................................................22

2.12 Summary...........................................................................................................22

Chapter 3: Research Methodology

3.1 Introduction..........................................................................................................23

3.2 Research Design.................................................................................................24

3.3 Study Population..................................................................................................24

3.4 Sample.................................................................................................................25

3.5 Measurement.......................................................................................................26

3.6 Data collection.....................................................................................................26

3.7 Ethical consideration............................................................................................27

3.8 Data analysis.......................................................................................................28

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Chapter 4: Data Presentation and Analysis

4.1 Introduction..........................................................................................................29

4.2 Findings...............................................................................................................29

4.2.1 Antenatal services............................................................................................29

4.3 Positive and negative perceptions experienced by women during

Antenatal and postnatal period..................................................................................45

Chapter 5: Discussion of Findings and Recommendations

5.1 Introduction..........................................................................................................50

5.2 Discussion...........................................................................................................51

5.3 Positive perceptions during antenatal care..........................................................51

5.4 Negative perceptions during antenatal care .......................................................52

5.5 Positive perceptions during postnatal care..........................................................52

5.6 Negative perceptions during postnatal care .......................................................53

5.7 Level of satisfaction during antenatal care..........................................................53

5.8 Level of satisfaction during postnatal care..........................................................54

5.9 Human quality of obstetric care...........................................................................54

5.10 Implications for Nursing Practice.......................................................................54

5.11 Implication for the system..................................................................................57

5.12 Implications for research...................................................................................59

5.13 Recommendations: nursing practice................................................................59

5.14 Recommendations to the system......................................................................61

5.15 Recommendations for research........................................................................62

5.16 Summary...........................................................................................................63

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LIST OF ANNEXURES

Annexure A: Permission granted by the Deputy Director Epidemiological Research

and Surveillance Management..................................................................................70

Annexure B: Permission Granted by Mother and Child Manager..............................71

Annexure C: Request by Researcher to conduct research at Empilweni Community

Health Centre...........................................................................................................72

Annexure D: Permission Granted by Empilweni Nursing Manager...........................73

Annexure E: Request by Researcher to conduct research at Nontyatyambo

Community Health Centre.........................................................................................74

Annexure F: Permission Granted by Nontyatyambo Nursing Manager....................75

Annexure G: Informed Consent in Xhosa..................................................................77

Annexure H: Informed Consent in English.................................................................79

Annexure I: Antenatal Questionnaire

Annexure J: Postnatal Questionnaire

Annexure K: Permission Granted by University of Fort Hare Ethics Committee

List of Tables

Table 1: Shows the Statistical exposition of women who attended antenatal care and

delivered in both facilities (study population).............................................................31

Table 2: Shows the Statistical exposition of the Sample of the study .......................34

Table 3: Shows mode of transport and hours travelled ............................................44

Table 4: Shows perceived efficiency of health care staff on patient education

Table 5: Shows fetal outcome

xi

LIST OF FIGURES

Figure 4.1: Distribution of Antenatal Care (ANC) clients by age group.....................26

Figure 4.2: Distribution of Antenatal Care (ANC) clients by gravidity .......................27

Figure 4.3: Distribution of Antenatal Care (ANC) clients by weeks of gestation........27

Figure 4.4: Geographical access to health services..................................................28

Figure 4.5: Equitable access during Antenatal Care (ANC)......................................29

Figure 4.6: Experience of clients during Antenatal Care (ANC) visits .......................30

Figure 4.7: Obstetric competences during Antenatal Care visits...............................32

Figure 4.8: Competences skills of Midwives at different facilities during...................33

Antenatal Care visits..................................................................................................34

Figure 4.9: Community participation..........................................................................34

Figure 4.1.1: Distribution of postnatal clients by ethnical group................................35

Figure 4.1.2: Distribution of postnatal clients by age group.......................................35

Figure 4.1.3: Distribution of postnatal clients by gravidity..........................................36

Figure 4.1.4: Expression of birthing environment......................................................36

Figure 4.1.5: Human quality of obstetric care............................................................37

Figure 4.1.6: Technical factors..................................................................................38

Figure 4.1.7: Companionship given to clients............................................................39

Figure 4.1.8: Communication and interpersonal skills...............................................39

Figure 4.1.9: Maternal outcomes...............................................................................40

Figure 4.2.1: Positive perception during postnatal care clients.................................40

Figure 4.2.2: Positive perception for antenatal care clients.......................................41

Figure 4.2.3: Negative perception for antenatal care clients.....................................42

xii

Figure 4.2.4: Negative perception for postnatal care clients.....................................43

xiii

ACRONYMS

AIDS: Acquired Immune Deficiency Syndrome

ANC: Antenatal Care

BANC: Basic Antenatal Care

CBH: Chris Hani Baragwannath Hospital

CD4 Count: Cluster of Differentiation Four Count

ELHC: East London Hospital Complex

ENA: Enrolled Nursing Assistant

EOC: Essential Obstetric Care

GAC: General Assistant Care Worker

HAART: Highly Active Anti- Retroviral Treatment

HCT: HIV Counseling and Testing

HIV: Human Immunodeficiency Virus

LMP: Last Menstrual Period

MOU: Midwife Obstetric Units

OM: Operational Manager

PCR: Polymerase Chain Reaction

PHC: Primary Health Care

PMTCT: Prevention of Mother to Child Transmission

RH: Rhesus Factor

RPR: Rapid Plasma Reagin

UNFPA: United Nations Fund for Population Activities

UNICEF: United Nations International Children’s Emergency Fund

WHO: World Health Organisation

xiv

WR: Wassermann Reaction

1

CHAPTER 1

INTRODUCTION

Dennil, King and Swanepoel (1999:2) define Primary Health Care (PHC) as the

essential care based on practical, scientifically sound and socially acceptable

methods and technology. They further argued that PHC is made accessible to

members of the community through their active participation, and at a cost that the

community and country can afford to maintain every stage of their development in

the spirit of self-dependence and self–determination. Maternal and Child health care

is one of essential components of PHC.

In 1995 the Maternal, Child and Women’s Health Plan was developed and South

African government became a signatory to the Convention of the Children’s Rights.

The government of National Unity announced free health care services for pregnant

women and children below five years. The implementation of Maternal, Child and

Women’s Plan resulted in the increased attendance at the public health facilities by

both pregnant women and children under five years old. This resulted in the increase

of the volume of expectant women and the imbalance between available resources

and service utilisation. In 1995 the infant mortality rate for black children in South

Africa was 30-73 per 1000 live births, which was seven times higher than other

population groups in the country (Dennil et al, 1999: 185).

Clients perceived patient satisfaction differently, what makes one client to be

satisfied cannot make another client satisfied due to uniqueness of people. Patient

satisfaction survey need to be conducted to evaluate satisfaction of the users

regarding services rendered to them. This may lead to the identification of gaps and

come up with strategies that may be used for quality improvements.

National Core Standards for Health Establishments in South Africa National

Department of Health, 2011 developed standards against which the quality care

rendered in health facilities are evaluated. The following quality variables should be

considered when defining client satisfaction: client involvement and participation;

availability of resources including drugs, material, enough personnel to ensure

enough time for health providers to attend to clients. Attitude of midwives towards

2

clients and their relatives, cleanliness of environment, competency of midwives when

rendering midwifery services to ensure patients’ safety to avoid litigations against

government (National Core Standards for Health Establishments in South Africa

National Department of Health, 20110). Equal access to basic antenatal, intra-

partum and postnatal care should be ensured at all times.

The constitution of the Republic of South Africa, 1996 Act 108 of 1996 concurs with

the above statement and the Quality Assurance Policy, 2007 was derived on this act.

The right to quality health services is a constitutional obligation in a democratic

society and is to ensure that the vulnerable (children and those who are mentally

compromised) are protected and all citizens have equal access to health care. All the

citizens in the Eastern Cape should be able to count on receiving care that meets

their needs and is based on continuous quality improvement (Eastern Cape Quality

Assurance Policy, 2007:2). According to World Health Organization report, 2000 on

equity further argued that the goals of health systems are the level of healthy

population, the level of responsiveness of the health system to the expectation of the

people and the equality of that responsiveness across population and the fairness of

financial contributions. Facilities rendering midwifery services that are nearer to the

people make the clients to be satisfied because they (pregnant women) can travel on

foot to the facility and make use of the taxis to avoid ambulance delay.

1.2 BACKGROUND

Prior to the introduction of the recently established East London Hospital Complex,

most of the primary health care services in the Buffalo City area were rendering

midwifery services on a 24 hour basis. In 1996 there were some contributory factors

such as the lack of resources, poor security services, a high rate of crime and an

ineffective referral system that led to the cut down of services to 8 hours. As a result,

all Mdantsane urban and rural clinics, namely: Mpongo, Mncotsho, Newlands,

Potsdam, Tshabo and Zikhova clinics were affected.

Some of these factors that lead the then health authorities to change the hours of

operation of services in this area included:

3

1.2.1 Lack of resources including lack of equipment

This led midwives to leave the services in this area, seek better services elsewhere

within the country, or to follow the trend that was in vogue then, which was to

emigrate and seek greener pastures in other health services, locally and abroad.

This mass exodus of staff caused the facilities to be short-staffed, led to a possible

rendering of poor quality services, and may have affected patient satisfaction the end

users, because there were few midwives, and at times, the quality of patient care

might have been compromised. Booth (2002) concurs with the above factor and

identified nursing shortage as a world-wide problem. He further argued that there

was not only scarcity of human but also material resources to such an extent that the

attendees at American Nurses’ Association reported that nurses used plastic

shopping bags when delivering newborns in some parts of Africa to protect

themselves from contracting HIV/AIDS. The migration of nurses from developing to

developed countries posed a problem and the people who were poor were greatly

affected due to health crisis (the poor people cannot afford to pay medical aid)

(Booth, 2002:4).

Cullinan, 2006 argued that in order for the hierarchy of services to work, every level

has to be functional. He further argued that resources are limited at Primary Health

Care level and nurses are overwhelmed, a number of patients that should have been

treated effectively at primary level are transferred to hospitals (Cecilia Makiwane and

Frere hospitals).

1.2.2 Poor security services and high rate of crime

There were reports of security personnel being disarmed, and the perpetrators

coming to the sites when there were few staff members, especially during the

evening and night shifts. This factor created fear and an unsafe working environment

for health care workers. The midwives cut down the range of services that they

provided after hours, and the pregnant women who were in labour during the night

ended up being transported to Cecilia Makiwane Hospital at short notice, including

those patients who did not qualify for referral, according to the Eastern Cape

Province referral criteria. This was being done for safety reasons, for mother and

4

baby, but affected the recipients of that service in that during antenatal care, the

pregnant women had developed mutual respect and trust with the midwives who

served them and they found themselves being delivered by strange midwives at the

hospital). When asked about this situation, the midwives had learned that it had

affected the labouring women’s trust, and patient satisfaction.

1.2.3 Referral system

The referral system was disrupted because of the changes that had to be made at

short notice. For instance, according to the standing criteria, clinics were supposed

to refer the women to Community Health Care Centres, but instead they referred the

expectant women to Cecilia Makiwane Hospital, which is a tertiary hospital. The

range of reasons for referral of maternity cases was wide, and sometimes that

caused influx at the referral hospital. Most peripheral hospitals were referring to

Frere and Cecilia Makiwane Hospitals also, as they are both tertiary hospitals which

jointly form the East London Hospital Complex. Because the clinics closed at 16h00,

the midwives came to a point where they referred all the women who were in labour

at the clinics at this time to tertiary hospitals for delivery, even if there were no

obstetrical indications for referral. This also affected services at the referral sites.

Cullinan (2006) conducted interview at Cecilia Makiwane Hospital in East London

establishing how health services are delivered in South Africa. The researcher

quoted one of the sisters saying “The patient load has increased since 1994. This is

partly because of primary health care not taking off. The whole of Eastern Cape is

referring here. We often see people who should have been attended to by the clinic

nurse but, because of the problems there, they end up coming here.” Cullinan

recommended that in order for the hierarchy of services to work, every level has to

be functional. It was further identified that resources were limited at Primary Health

Services and nurses were often overwhelmed. Therefore, a number of clients that

should have been treated effectively at primary level were transferred to hospitals,

such as Cecilia Makiwane and Frère hospital.

Prior to 2007, Empilweni Gompo Health Care Centre, one of the sites in this study,

was only rendering antenatal care, but did not accommodate deliveries. All pregnant

women who were in labour were referred to Frere Hospital. The referral of the

labouring women resulted in the flooding of the East London Hospital Complex

5

(ELHC), leading to the displeasure of staff working in this facility. It was observed

that pregnant women residing in remote areas of the Eastern Cape Province,

especially those from the former Transkei which is located 239 kilometres from the

East London Hospital Complex, also formed part of the catchment area of the ELHC.

The majority of these pregnant women did not attend antenatal services to their

respective area, instead when they are at term they visit their relatives who stay

nearer to the East London Hospital Complex where they would deliver. Collectively,

these factors created a burden on the patient referral system and for the patients and

their families. This situation led to the overpopulation of labour wards in the ELHC.

1.2.4 Implications of handling increased numbers of pregnant women

The implementation of the Maternal, Child and Women’s Health Plan has resulted in

increased attendance at the public health facilities by both pregnant women and by

children under six years old. The closure of clinics at 16h00 and the referral of

pregnant women to ELHC made the midwives to be unable to cope with the

demands. This resulted in ELHC being swamped and over-extended to meet the

needs of the people. This has resulted in an often frustrated and demotivated

workforce, and at times, dissatisfaction of patients was reported (Dennil et al,

1999:185). The midwives in ELHC became demotivated and felt overburdened by

having to cater for large numbers of women in labour, despite the fact that they were

short-staffed. They reported having to conduct normal vertex deliveries

predominantly, instead of concentrating on complicated deliveries, research and

similar activities.

1.2.5 Transformation of services

In 2007, the Eastern Cape Department of Health mandated Empilweni Gompo

Community Health Centre to extend their working hours and operate for 24hours and

Nontyatyambo commenced on the 8th June 2008 (Eastern Cape Department of

Health Service Delivery Charter, 2007:9). This was meant to alleviate the workload

of midwives working in these tertiary hospitals. It was the collective effect of the

preceding factors that inspired the researcher to investigate the perceptions of

patients relating to the restructured midwifery services that had been reorganized to

make them more accessible to them.

6

1.3 Research problem

The researcher is a midwife who has been working in the clinics for twenty years,

and was actively involved in peri-natal review meetings that were conducted at

Cecilia Makiwane Hospital. During this time, the researcher learned that some of the

complications that affected labouring women were avoidable, but occurred as a

result of women in labour having to travel long distances to reach the referral

hospitals. The researcher also observed that with proper scheduling of the available

personnel, referral of labouring women from one hospital to another could be

avoided. It was also noted that some of the district hospitals referred women in

labour, because there was no anaesthestist on duty after hours, and in some

instances no surgeon to conduct caesarean section. This problem was frequently

reported.

The researcher was concerned about the effect of cutting down services to eight

hours by Mdantsane clinics which led to all pregnant women and women who were

in labour coming to East London Hospital Complex (ELHC). This led midwives in

ELHC to be overburdened due to influx and staff shortage. Now that Empilweni

Gompo is conducting deliveries that were not conducted previously, both Empilweni

Gompo and Nontyatyambo health centres operate for twenty four hours and are in

close proximity to pregnant women the researcher would like to investigate whether

the patients were satisfied or not with the quality of care and services rendered in

two community health centres by midwives.

1.4 RESEARCH QUESTION

The key research question that is being investigated is: “Are the clients receiving

midwifery services from Empilweni Gompo and Nontyatyambo Community Health

Care Centres satisfied with the quality of care rendered to them?

1.5 THE PURPOSE OF THE STUDY

The purpose of the study was to investigate whether the clients that receive

midwifery services from Empilweni Gompo and Nontyatyambo Community Health

Care Centres were satisfied with the quality of care provided to them at these

maternity health care facilities.

7

1.6 THE OBJECTIVES OF THE STUDY

The objectives of the study were to:

Identify the perceptions of women in relation to the maternal health care services

rendered at Empilweni Gompo and Nontyatyambo Community Health Centres

during antenatal, intra-partum and postnatal periods.

Determine the level of satisfaction of women attending antenatal care and delivery

at these facilities in relation to the quality of care variables cited above.

THE SIGNIFICANCE OF THE STUDY

This research study will contribute to the body of knowledge on patient satisfaction in

relation to the maternity care services provided. The results obtained from this

investigation will be communicated to the Eastern Cape Department of Health, and

be used in the planning of health services in the future. Furthermore, they can be

used by other health professionals and researchers when planning to undertake

similar research studies.

This study will elicit factors leading to satisfaction or dissatisfaction of patients with

given changes within the context of a specific health care system context, thereby

prompting the health care providers to consider the effect of change on the clients.

The information gained from the study participants will help the policy makers to

modify the existing policies in order to enhance patient safety and satisfaction.

If the clients are satisfied with the care rendered subsequent to the changes being

effected, the morale of the health practitioners will be elevated when they observe

this and they will be more inclined to demonstrate more consideration to patients’

needs.

The study will alert the midwives to the aspects needing improvement at Empilweni

Gompo and Nontyatyambo Community Health Centres in relation to the factors

pertaining to the delivery of midwifery services.

The evaluation of midwifery services by clients who are the end-users can help

health professionals to improve their performance and the quality of maternity care

rendered, and this in turn would lead to client satisfaction.

8

SUMMARY

In this chapter the researcher was introducing the study, giving a background on how

midwifery services were rendered prior the Eastern Cape Department of Health

mandated the two community health centres to operate for 24 hours. The next

chapter would present the literature review.

9

CHAPTER 2

LITERATURE REVIEW

2.1 INTRODUCTION

In this chapter the researcher reviewed the literature to establish what has been

found by other researchers relating to the problem (patient satisfaction with

midwifery services) to identify some gaps and to suggest how those gaps could be

filled (Brink, 2000:67).

Creswell (2003) argues that when writing literature review it is important to introduce

the section by telling the reader about the sections included in the literature review.

The literature review for this study is divided into three sections. The sections are:

description of midwives and midwifery services; factors that enhance client

satisfaction and the relationship between quality care and patient satisfaction.

2.2 DESCRIPTION OF MIDWIVES AND MIDWIFERY SERVICES

The researcher would first start by defining or explaining what midwifery

encompasses.

According to New Zealand College of Midwives (1990: 1) midwifery is defined as

“Midwifery is a profession with a distinct body of knowledge and its own scope of

practice, code of ethics and standard of practice. The midwifery profession has

knowledge, skills and abilities to provide complete maternity services to childbearing

women on its own responsibility. All midwives are expected to work in partnership

with women, providing or supporting continuity of midwifery care throughout the

woman’s childbirth experience’’.

Midwives provide comprehensive maternity care thus midwifery is a demanding

profession due to dedication and commitment of health professionals in the provision

of high quality client-centred maternity care (Ontario Midwives, 2007:3).

Every woman has a right to reproductive health care and the government is obliged

to provide these services (antenatal, postnatal, family planning, etc) and should be

executed with the active participation of the members of the community (Kajuri,

Karimi, Shekarabi and Hosseini, 2005:3).

10

2.3 FACTORS THAT ENHANCE PATIENT SATISFACTION

2.3.1 Accessibility

In accordance with the collaborative report of WHO, UNICEF and UNFPA,(1999)

Women- friendly health services must be available, geographical accessible,

affordable and culturally acceptable to reduce maternal morbidity and mortality.

Services should include Essential Obstetric Care (EOC) at the primary and referral

levels in order to reduce delays in deciding to seek care, reach a treatment facility

and receive adequate treatment at the facility.

2.3.1.1 Geographical accessibility

The geographical accessibility of the health facility and the availability and efficiency

of transportation affect women’s ability to access health services. Fast and easy

access to health services is critical when it comes to treatment of life threatening

complications. Women with pregnancy complications need to be transported and

treated in a facility providing EOC (WHO, UNICEF and UNFPA, 1999:8). According

to Saving Mothers Saving Babies Third Report on Confidential Enquiries into

Maternal Deaths in South Africa 2002-2004:10, transport problem from home to

institution was 3.0% whereas between institutions was 9.7% . Transport problem

was identified as one of avoidable factors. Kekana and Blaauw, (2002) concur with

this statement. They further point out that ambulance delay at night or poor response

leads to pregnant women to hire private transport. In some instances women could

not have money to hire a car thus the woman delay in seeking Essential Obstetric

Care. Complications can arise and this could lead to family and patient

dissatisfaction. This could be achieved by ensuring that there are stand-by

ambulance services in all facilities rendering maternity services to curb infant and

maternal deaths in South Africa. This could also lead to patient satisfaction.

Kekana and Blaauw,( 2002) recommended an hour’s travel time to the facility

providing Essential Obstetric Care and set as an objective that no woman should be

more than an hour away from a facility.

A study carried out looking specifically at how women who were in labour travelled to

health facilities have been done at Chris Hani Baragwannath Hospital in Soweto. Out

of 100 postnatal women who delivered at Chris Hani Baragwannath Hospital (CBH)

11

interviewed, 59 of them used private transport, 25 had used public transport, 11 had

used ambulance and 5 had walked. This study also found out that women were

paying large amounts of money to hire private transport to travel to hospital at night.

This has been identified as a problem in other studies and by health care workers

(Kekana and Blaauw, 2002:22).

WHO, UNICEF and UNFPA, (1999:9 ) suggest that an indicator for measuring

accessibility could be the percentage of complications treated in Essential Obstetric

Care facilities and another indicator could be the existence of a transportation

system, e.g. an ambulance, network or a reliable transportation system. To ensure

smooth running of midwifery services, government has an obligation to provide a

reliable transportation system and network so that when midwives have detected

abnormality that is above their (midwives) scope of practice should be able to

summon an ambulance, refer the woman from level one to level two and three.

2.3.1.2 Functional accessibility

All women should have access to a skilled attendant during pregnancy, childbirth

and postpartum period. This attendant should be able to provide basic Essential

Obstetric Care and refer women to comprehensive Essential Obstetric Care as the

complications occur (WHO, UNICEF, UNFPA, 1999:9). According to the study on

understanding geographical imbalances in the distribution of the health workforce

conducted by Dussault and Franceschini, (2006) argue that improvement of health

outcomes depend on the access to good quality health services. For example, the

reduction of maternal mortality by 75% in 2015 depends on access to skilled care

during pregnancy and at birth. This refers to Millenium Development Goals number

5. Dussault and Franceschini, (2006) further argue that often services are not

available at a reasonable distance, or are available, but people cannot afford them,

or are not accessible for some organisational reason such as limited hours of

presence of staff, unfriendly behaviour towards users, cultural barriers. These factors

can be of assistance to hamper or delay use of services.

12

2.3.2 Availability

According to WHO, UNICEF and UNFPA, (1999) argue that the most important

criterion for provision of women-friendly health services especially maternal health

services should be as close as possible to the community.

2.3.3 Affordability

WHO, UNICEF and UNFPA, (1999) argue that access to health services is

influenced by both direct costs (for example services, drugs and supplies, food

during hospitalisation) and direct costs (for example transport). WHO, UNICEF and

UNFPA further argued that when a complication occurs, the woman often needs

access to specialised care at additional costs to her and her family. According to

The Constitution of the Republic of South Africa, Act 108 of 1996 section number 27

“Everyone has the right to have access to health care services, including the

reproductive health care’’. WHO, UNICEF and UNFPA, 1999 concur with The

Constitution of South Africa, Act 108 of 1996 and elaborate further that prenatal,

intra-partum and postpartum care should be accessible to all women; women could

not be attended to due to inability to pay for the service.

2.3.4 Cultural Acceptability

WHO, UNICEF and UNFPA, 1999 argued that cultural barriers to health care, lack

of autonomy and decision – making power restrict women’s access to health care.

Some religions believe that family planning should not be practiced. WHO, UNICEF

and UNFPA further argued that in order to eliminate these barriers, health services

should be organised in such a way that norms and values of women is respected.

2.3.5 Communication

Alasad and Ahmad (2003) argued that patient satisfaction is considered as a

requirement for therapeutic treatment and sometimes as equivalent to self therapy.

Alasad and Ahmad (2003) further argued that satisfied patients help themselves to

heal faster because they are more willing to comply with treatment and adhere to

health education given by midwives and thus have a shorter recovery time. Good

communication skills of midwives during information sharing provide appropriate

13

opportunities for providing their compliance in the process of health care (Kajuri et al,

2005:5).

Chin and Amir, (2008) argued that satisfaction survey on assessment of quality on

Breastfeeding Education and Support Service (BESS) was generated from the list of

variables namely: access, facilities, technical performance, interpersonal skills and

communication. Chin and Amir, (2008) further argue that access includes issues

such as satisfaction with the location of Breastfeeding Education and Support

Service, the service hours and issues with appointment making, interpersonal skills

reflect on the emotional side of consultation and facilities include the competence

and knowledge of staff.

Donabedian (1988), in his model of care drew attention on interpersonal relations.

This included the communication between client and the provider for the purpose of

both diagnosis and the determination of preference for treatment. Donabedian

(1988) indicated that understanding relates specific experiences of care and the

extent to which the woman feels she understands what is going on and feels that her

questions have been answered adequately. Midwives when educating pregnant

women should ensure that pregnant women and their relatives receive sufficient

information they are entitled to know.

Bergstrom (2003) argued that it is important to involve the woman in decision making

and regard her as a partner in maternal health care. Health professionals have to

ensure that they are given consent by pregnant women before performing any

procedure to the woman.

A study conducted by Hulton, Matthews and Stones (2000), examining the influence

of support in labour ward in a Social Security Hospital in Mexico, discovered that

there was lack of information amongst medical staff regarding their health and that of

their babies, the hospital routines and the medical interventions. The clients felt that

the information given was given in an authoritarian and vertical manner; women were

not given a chance to speak or ask some questions. The researcher observes that

this scenario still prevails in the South African context.

14

2.3.6 Interpersonal relations between clients and health care providers According to Bergstrom (2003), good quality maternal care should be staffed by care

practitioners that are non judgemental, respectful and responsive to women’s needs.

According to the study conducted by Hulton et al (2000) point out a woman’s

experience of care for an uncomplicated delivery is likely to influence her to seek

medical help in future. They further argued that if the woman experienced good but

disrespectful treatment in a previous normal delivery, a woman with a complication

may delay accessing care from a facility that provides maternity care of high quality.

The researcher shares the same opinion in that according to the researcher’s

experience pregnant women came to the clinic with head on perineum or delivered

at home, when asked the reasons for home delivery some argued that they did not

want to deliver in hospital due to maltreatment in their previous pregnancy or

delivery. According to the study conducted by Jewkes, Abraham and Mvo (1998),

many patients reported clinical neglect, verbal and physical abuse by midwives in the

maternity services. They further point out that this occurrence of abusing patients is

common due to lack of local accountability of services and lack of action taken by

managers and the higher level of the profession against nurses who abuse patients.

According to the researcher’s opinion patient abuse is not common as it was

because patients are knowledgeable of their rights. The causes of abuse of pregnant

women who are in labour could be institutional or the system, patients and midwives.

If the pregnant woman does not co-operate or does not respond to instructions of the

midwives positively during delivery, the midwife panics a lot because she is dealing

with the lives of two persons and during this process no one should die due to

childbearing. Midwives should ensure that they deliver a normal, healthy infant and

mother.

Education and preparation of pregnant woman for labour and delivery should be

given throughout antenatal care. During information sharing the midwife should

explain clearly the “DO’S and DON’TS” during labour to promote co-operation

between the pregnant women and midwives in maternity wards. According to the

WHO Report 2003, a patient’s opinion directly influences her compliance with

treatment and nurse-patient rapport is established. If nurse-patient relationship is

good, education given to pregnant women when attending antenatal will make

15

pregnant women to adhere to health practices advised by midwives. This can result

to good infant and maternal outcomes.

A patient–centred approach will improve patient satisfaction. Patient centred-

approach involves shared control of consultations, decision about interventions or

management of the problems with the patient (Orchard, Curran and Kabene,

2005:3).

Alasad and Ahmad, (2003) argued that the nurses’ kindness and warmth, their skills

and the amount of information they give to clients as well as the respect given to

relatives and friends enhanced the level of satisfaction.

According to Donabedian 1988, in his interpersonal model of care the relationship

between the client and midwife should be charactarised by privacy, confidentiality

informed choices, concern, empathy honesty, tact and sensitivity.

Midwives build a trust relationship with their clients; work with them to make informed

choices about their care. Women value the relationship they build with their midwives

which allows the midwife to provide individualised and responsive care (Association

of Ontario Midwives, May 2007:1).

Patient satisfaction with care is an important element of quality care. Patient –

perceived quality of maternal health services- particularly provider attitudes and

behaviour- has influence on women’s willingness to use skilled maternity care.

Health professionals view competent clinical care as quality care while patients

consider caring and interpersonal interactions when defining quality care. Research

has documented increasing neglect, verbal abuse and intentional humiliation of

women during childbirth. Negative perceptions about the quality of services,

including inattentive, disrespectful staff behaviour, lack of co-operation and lack of

privacy constitute serious barriers to care and contribute to under-utilisation of public

health facilities. Improved caring behaviors’ will increase patient satisfaction, improve

the quality of care provided and increase the number of women and families who

utilise skilled birth attendants thus reducing maternal and infant mortality ( www,

family care int./.org/ User Files modified 29-12-2010).

16

In a survey conducted by family care international in Kenya skilled attendants were

described as physical and emotionally abusive and neglectful. Nurses/midwives are

feared and disliked for their maltreatment of women. The maltreatment impeded

utilisation of maternity health services. Women and community members complained

of disrespectful attitude of facility-based providers. Nurses/midwives were described

as abusive, cruel, impatient, unsympathetic and insulting. The community members

reported that women are physically abused by midwives to such an extent that they

(midwives/nurses) beat them (Family International http:// 0sm skilled care php at

Kenya as accessed on 29.12.2010.

Of the 1000 written complaints received by Gauteng Province as part of their

complaints system was about doctors’ behaviour (Kekana and Blaauw, 2002:23).

A qualitative study conducted in a number of Midwife Obstetric Units (MOU) in

Western Cape, both nurses and clients were interviewed. The researchers found an

environment charactarised by’’ humiliation of patients and physical abuse’’. Women

interviewed labelled nurses as ‘’rude’’, inhuman and not caring’’ and the unbooked

pregnant women reported the most abuse (Kekana and Blaauw 2002:22). Jewkes et

al (1998) conducted a study to investigate experiences of women during labour, one

teenager reported that the midwife told her that she (midwife) was not there when

the client was making love with her partner in the shack.

2.3.7 Addressing the needs, wishes, desires and perception of clients

The opinions of women play a major role in measuring the quality of health services

with the aim of promoting health care indices (Kajuri et al, 2005:5). The needs of

the mother and her baby are the centre of the midwifery model of care (Association

of Ontario Midwives, May 2007:1).

According to Kajuri, et al (2005), impact of contributory factors to service delivery to

clients as well, the positive results the pregnant women have on midwives due to

quality care received during antenatal, intrapartum and postnatal period will make

them (pregnant women) utilise the services, to use correctly the educational points

and recommend others and use health care services. Kajuri et al (2005) further

argued that the satisfaction of pregnant women by addressing their needs and

expectations can result to a pleasant feeling in them, treat them (clients)

17

psychological and bring about a feeling of calmness and security. Any effort made to

satisfy the population receiving a service without complete identification of their

(clients or community) perceptions and expectations, services rendered will be

defective. Investigation of client satisfaction and evaluation of the opinions of the

users (population) regarding maternity health care services they (women) receive

can lead to effectiveness, acceptance and collaboration in all health programs (Kajuri

et al, 2005:7).

Certified Nurse-Midwives (CNMS) provide cost effective care to the population they

serve, often as substitutes for physicians and their care results in equal and

sometimes better outcomes. It has been found that CNMS have lower cesarean

section rates and fewer low birth weight babies as compared with physicians thus

reducing expenses, give their clients enhanced adherence to care regime and the

guaranteed benefits increase consumer choice and satisfaction (American College of

Nurse Midwives, 1997:9).

According to Lafferie (1996), assessing the clients’ satisfaction is a basis to develop

service delivery which in turn can strengthen their satisfaction.

A cross sectional study using pre-tested questionnaire and focus group discussions

undertaken by Uzochukwu, Jekwe and Akapla (1999) assessing community

perception, practices and satisfaction with the quality of maternal and child health

services and the willingness to pay for services. Most respondents 90.6% rated the

services to be at least good, 95.9%, 94.3% and 95.8% of the respondents were

satisfied with the childhood immunisations antenatal care and childbirth services.

89% of respondents were willing to pay for health services if the drugs were

available while 92.4% would pay if there is overall improvement in quality care. Long

waiting queues, providers behaviours and lack of doctors militated against the

utilisation of maternal and child health services.

2.3.8 Availability of resources

Availability of resources in the provision of maternal health services are basic

necessities. According to Cullinan (2006) Equipment, instruments and supplies such

as drugs oxygen and water are essential for proper functioning of any maternal and

child health unit and the presence of qualified and skilled staff is necessary.

18

WHO, UNICEF, UNFPA (1999) argued that good basic infrastructure and an

adequate quality and quantity of personnel, drugs supplies and equipment including

clean birth kits will ensure good woman to health care and enable women to use the

health services effectively. WHO, UNICEF, UNFPA (1999) further argued that

Infrastructure should include EOC and referral facilities, a hygienic environment, an

adequate supply of water proper waste disposal will help to ensure safe health care

service is provided.

According to a situational analysis carried out in a region in the Eastern Cape by

Kekana and Blaauw (2002) it was discovered that out of seven district hospitals, one

was not providing caesarean section due to lack of sufficiently skilled staff. Kekana

and Blaauw (2002) also carried studies at Mpumalanga and concluded that some

level-one hospitals were not able to provide Comprehensive Essential Obstetric Care

(CEOC) due to lack of working operating theatres, lack of emergency blood supply

and lack of skilled staff. Dussault and Franceschini (2006) argued that the

distribution of health personnel between rural and urban areas is unbalanced.

Dussault and Franceschini (2006) further argued that urban areas are more

attractive to health care professionals for their comparative social, cultural and

professional advantage and large metropolitan centres offer more opportunities for

career and educational advancement, better employment prospects for health

professionals and their families hence the remote areas are understaffed as

compared to urban facilities yet health problems are more prominent in rural areas

than urban.

According to a cross sectional study undertaken by Uzochukwu and Onwujekwe

(1999), “When assessing community perception, practices and satisfaction with the

quality of maternal and child health services, willingness and ability to pay, most

respondents 90.6% rated the services to be at least good and 95.9%, 94.3%, and

95.8% of the respondents were satisfied with the childhood immunisations antenatal

care and childbirth services. 89% of respondents were willing to pay for health

services if the drugs were available, while 92.4% would pay if there is overall

improvement in quality”.

19

2.4 The relationship between quality care and patient satisfaction

According to Cullinan (2006) Quality of care is defined as the extent in which actual

care given is in conformity (line) with the present criteria for good care. He further

argues that to assess the quality of care of an institution, one need to consider the

quality of the provision of care (care provided) and the quality of care as experienced

by users (clients) (Cullinan, 2006:15).

Christopher (2007) argued that there are several measurable dimensions, for

example:

Safety: Every maternity ward should ensure that written guidelines, protocols are in

place and are followed to prevent potential harm to the patient.

Provider competence: Midwives should do procedures that are within their scope of

practice to prevent medico legal hazards.

Acceptability: Midwifery services should meet the needs of the specific community.

Accessibility: Midwifery services should operate for twenty four hours.

Efficiency: Midwives when performing procedures should be considerate of time

spent and waste.

Appropriateness: Midwives when preparing pregnant women who would undergo

caesarean section should ensure that the right procedure is done to the right patient.

2.5 Quality-related definitions

WHO, UNICEF and UNFPA, (1999) define criterion as the principle used to judge a

service whereas an indicator is a pointer used to measure a situation or

characteristic of a service.

WHO, UNICEF and UNFPA, (1999) define a standard as a reference value for

judging the quality of a process or variable, also defined as the degree of excellence

of a particular component. Maternity wards should set standards against which the

performance of midwives is evaluated to ensure quality care is rendered and patient

satisfaction is considered.

20

WHO, UNICEF and UNFPA, (1999) suggest that one indicator for measuring the

availability of maternal health services could be the proportion of women who receive

Essential Obstetric Care and another indicator for measuring the availability of births

attended by a skilled attendant. WHO, UNICEF and UNFPA, (1999) further argue

that the universal standard for these indicators would be 100% of women and

intermediate goals should be set to attain these universal standards.

A primary Health Care approach that is designed as the foundation of the health

system for promoting lifestyles; prevention of diseases including early detection,

provision of early and quality antenatal, intrapartum and postnatal services as well as

essential infant and child health services and nutritional advice will be used in

reducing the unacceptable maternal and child mortality rates in South Africa

(Negotiated Service Delivery Agreement 23 July 2010:13).

2.6 Respect of technical standards of health care

The provision of quality care is measured in accordance with respect of standards

and this refers to the compliance with measurable technical norms, to the way

services are organised and to whether the health policies support standard (WHO,

UNICEF and UNFPA, 1999:11). The national policies on maternal and child health

must be reviewed in accordance with ‘’women-friendliness’’ and amended in the

context of ongoing health sector reforms in the country. International Conventions

and human rights instrument pioneered that national policies should respect the

rights of women, the indicator and standard (of national policies) should comply with

this declaration (declaration of International Conventions and legal rights (WHO,

UNICEF and UNFPA, 1999:11).

The core standards addresses key areas essential to preceding quality care and

capture the basic required for decent safe care in South Africa. Facilities will be

assessed against core standards using validated methodology and tools/ measures

(The National Quality Programme undated).

The aim of The National Quality Campaign is to improve the quality of care and

patient experiences at all facilities throughout the health system. There are six key

priorities that are reported have significant impact on patient experiences and

outcomes at facility level.

21

Improve patient safety: Action to reduce unintended harm to patients arising from

the operations or failures of the health system or its staff for example incompetence

of midwives to use partogram.

Infection control: Intervention should focus on health care acquired infections as one

kind of unintended harm to patients in facilities. Midwives should ensure that aseptic

technique is maintained during delivery to prevent introduction of infection to both

mother and the baby.

Availability of medicines: Health facilities should ensure that drugs are available,

safer prescription of medicine is given and stock control management. Operational

managers OM should ensure that drugs are requisitioned in accordance with the

policy of the institution.

Reduce waiting hours: Reducing the total time of patients must wait for

administration assessment, diagnostics and pharmacy or other processes of care as

well as reducing the delay in time of referral or transfer for care when needed.

Improve cleanliness: The degree to which health facilities – its buildings, grounds,

equipment and staff are spotlessly clean and tidy. Intervention examples: cleanliness

in public waiting areas, toilets and patient care areas, waste removal.

Positive attitude: values and the way caregiver supervisors and managers interact

with patients, colleagues and the system (National Core Standards for Health

Establishments in South Africa National Department of Health, 2011:15).

2.7 Monitoring and Evaluation- Framework

Implementation and monitoring of standard policies and guidelines is important for

the provision of high quality care. Quality should be included into strategic plans for

programs at all levels and their (programs) implementation should be monitored. A

comprehensive monitoring and evaluation framework will identify gaps in current

performances and allows the system managers at all levels to monitor progress

towards closing the gaps (The National Quality Programme, undated).

Muller, (2002) proposed that for quality improvement programme to be successful at

maternity wards depends on the following principles: Informed commitment,

22

empowerment, management support and the establishment of a quality improvement

culture.

Informed commitment and group co-operation: Informed commitment will arise when

the group members at the maternity wards are knowledgeable about what the quality

improvement programme entails as well as its implications.Adequate information

regarding what is expected from each group member will make the group to own the

programme and work together to achieve the desired goal (quality improvement).

Written commitments to the quality improvement programme should be done by

each group member (Muller, 2002:202).

Empowerment: For maternity wards to be able to render quality midwifery services,

require competent health professionals (knowledge, skills, values and attitudes).

Empowerment entails training of personnel and the establishment of an

infrastructure, mechanisms, equipment, secretarial services in the maternity wards in

order to implement the programme according to its exclusive needs (Muller,

2002:202).

Management support: For the quality improvement programme to be successful the

management support is necessary. Midwives in maternity wards should develop their

own programme and accept the necessary ownership for it. Management should

support subordinates by giving guidance, facilitation of training and provision of

resources (adequate staffing, establishment of infrastructure, availability of drugs,

adequate equipment that is in good working condition etc.) to ensure that quality

care is rendered (Muller, 2002:202-203).

Quality improvement culture: It is important to promote ownership for the programme

among all nursing practitioners. Quality improvement programme should form part of

every practitioner’s daily, weekly and monthly duties, tasks and responsibilities

(Muller, 2002:203).

Quality improvement is a process where standards are set, work performance is

monitored and evaluated against the set standards, remedial steps are taken to

solve the problems. Standards are continually revised with the evaluation of work

performance and the correction of the errors. The process of quality improvement

requires a team effort (Muller, 2002:203).

23

2.8 Written guidelines

Written protocols of care facilitate the training of staff at all levels of health care

systems and improves their performance. The indicator could be the proportion of

staff properly using the protocols for various components of maternal care services

(WHO, UNICEF and UNFPA, 1999:12). Achievement and performance indicators

were recommended. Achievement indicators monitor maternity services for

compliance with technical guidelines measuring inputs, processes and outputs and

with their expectations whereas performance indicators measure utilisation of

prenatal care, hospital mortality and proportion of rooming-in (WHO, UNICEF and

UNFPA, 1999:12). (Hulton, et al (2000) concur with WHO, UNICEF and UNFPA,

(1999), Hulton, et al designed a framework to function into two ways: firstly as a tool

by which to help structure a situational analysis review of quality of care as provided

at a facility and as experienced and perceived by its clients, actual and potential.

Secondly, as a tool by which to improve the quality of care through the continuing

critical examination of activities compared with an agreed standard. This framework

provides an instrument by which to guide and structure the measurement and

monitoring quality in maternal health care (Hulton, et al 2000:47).

Maternal health services can be in place with all good indicators of good quality care

but the main challenge is, why women do not access services at all, access them

later or suffer from an avoidable adverse outcome due to poor quality (Hulton, et al

2000:47).

Quality of care both in terms of technical and human quality of care appears to be a

severe problem in maternal care services in South Africa (Kekana and Blaauw,

2002:21). There are many attempts made to improve the situation. There is both

political and attempts at the National Department to improve maternal health

services. The Confidential Enquiry into Maternal Deaths and Prenatal Care Survey

are also important effort to understand the problems and improve the quality care

(Kekana and Blaauw, 2002:21).

Pattison, 2005 concur with Quality Assurance, Policy that there are institutions in

South Africa both within the public and private sector which are providing excellent

technical quality of care, there is also evidence that at many institutions the technical

quality of care is extremely poor.

24

There are numerous studies looking at different aspects of maternal care that

demonstrate problems with quality of care. According to the study conducted in the

PWV region by Women’s Health Project in 1994, the teenager reported that she

preferred to deliver at home than in clinic or hospital due to maltreatment by

midwives who hit and insult them. Other women reported that midwives influence

each other to scold and insult them (Kekana and Blaauw, 2002:23). A qualitative

study conducted in a number of Midwife Obstetric Units (MOU) in Western Cape

interviewing both nurses and patients. Another woman reported that the midwife told

her to fetch a plastic sheet to deliver on. By the time the midwife came with the

plastic sheet the mother was about to deliver the baby and after delivery she was

ordered to clean up her mess (Jewkes et al, 1998:1786). Women perceived that they

(clients) were neglected by midwives yet the maternity ward was not busy. Clients

further explained that the midwives were having personal conversations, watching

television and sleeping on duty (Jewkes et al, 1998:1787). Brown, Hofmeyr,

Nikodem, Smith and Garner, (2007) agreed with Jewkes et al, (2002) , that the

quality of care in South Africa should be improved, women are often left alone for

long periods of time during childbirth and in some instance women are shouted at

and hit. According to findings in the studies conducted at ten maternity wards in

Gauteng Province it was found that women attending maternity services in public

institutions were subjected to humiliating procedures (Kekana and Blaauw, 2002:21).

Moran (2002) conducted a study in Durban looking at failure to diagnose intra-

Uterine Growth Restriction as a major cause of peri-natal deaths. It was found that

out of (18) eighteen cases occurred (13) thirteen were deaths that could have been

avoided. Midwives failed to act promptly when they discovered that fundal

measurement did not correlate with gestational age according to dates. Midwives

overlooked women’s accounts to their last menstrual period (LMP) even if the

women were sure of their LMP leading to incorrect diagnosis of gestational age of

the fetus.

Fawcus, Rode, Ibach and Dyer (2002) conducted a study to audit the provision of

pain relief in the labour ward in Mowbray Hospital in the Western Cape. 35.4% of

women did not receive pain relief, not ask any pain relief and 34.5% did ask for pain

relief and were not given. The environment was explained having high percentage of

women with complicated deliveries and extra analgesic requirements. The study also

25

found that 60.2% had no birth companion in spite of this practice was officially

encouraged in the institution. Brown, et al (2007) concurs with Fawcus; et al (2002)

that birth companionship improves birth experiences. They further explained the

benefits of birth companion, continuous support of women in labour are less likely to

need intrapartum analgesia or to report dissatisfaction with childbirth experiences.

Health professionals have been slow to implement companion policies and

programs. In South Africa companions during birth are not commonly encouraged by

state maternity services (Brown, et al 2007:5). Hofmeyr, Nikodem, Wolman,

Chalmers, and Kramer, 1991 concur with the above statement and further argued

that the women supported by a doula during labour required fewer caesarean or

forceps deliveries and less oxytocin augmentation and less likely to develop fever

during labour.

The findings support the study conducted in Runic district, Tanzania. The aim was

to assess quality of antenatal care in respect to providers’ counseling of pregnancy

danger signs. 42% clients were not informed of any pregnancy danger signs. The

most common pregnancy danger signs were informed about were vaginal bleeding

50% followed by severe headache blurred vision 45%. The client recalled less than

half of the pregnancy danger signs they had been informed during the interaction.

Nurse auxiliaries were three times more likely to inform a client of a danger sign than

registered/enrolled nurses (http:// www.biomedcentral.com/1471-2393/10/35.

According to the study conducted by Vera, (1993) examining the meaning of quality

of care for women who received reproductive health services (family planning and

mother and child health care) at a non-governmental clinic at Santiago quality of care

was perceived differently by clients. The women interviewed perceived the

cleanliness of the clinic as a sign of respect for client and its hygienic conditions

relieved fears of infection. Women also referred to the quality of time and attention

they received as an important element of overall quality. They described waiting long

period of time as the characteristic of government health services. Women

interviewed regarded high quality of service as treatment that included the following

elements: a clean, hygienic place, prompt service, accurate information, an

opportunity to learn and enough time for consultation by a health professional and

receive advice (Vera, 1993:2).

26

2.9 Implementation of Batho Pele Principles

Government adopted the White paper on Transforming Public Service Delivery in

1997, which is known as Batho Pele-People first, to provide a policy framework and

practical implementation strategy for more efficient, effective and equitable provision

of public services. Batho Pele aimed at introducing a new approach to service

delivery, which puts people at the centre of planning, decision making processes and

when delivering services. This was achieved by active participation of members of

the community (formation of clinic committee) to foster new attitudes such as

increased commitment, sacrifice, dedication by both public servants and the clinic

committee or members of the community (Department of Public Services and

Administration, 2003:10).

2.9.1 Batho Pele Principles: Consultation

Midwives should consult members of the community to participate in patient

satisfaction survey to evaluate the quality of care they (patients) receive and make

choices (Department of Public Services and Administration, 2003: 10).

2.9.2 Service Standards

The services rendered in the Primary Health Care should be written in all languages

so that the members of the community are aware of what to expect (Department of

Public Service and Administration, 2003:11).

2.9.3 Access

Community health Centres should be functional accessible should operate in

accordance with the expectations of the specific community being served

(Department of Public Service and Administration, 2003:13).

2.9.4 Courtesy

Officers working in the public institutions should treat members of the community

with courtesy and consideration by using local language to promote smooth

interaction with the citizens (Department of Public Services and Administration,

2003:14).

27

2.9.5 Information

The participants in a study should be informed by the researcher about her or his

rights and the objectives of the study (Department of Public Service and

Administration, 2003:16).

2.9.6 Transparency

Questions asked by citizens should be answered to build trust between health

professionals and the service users (Department of Public Service and

Administration, (2003:17).

2.9.7 Redress

Health professional should be capacitated to handle complaints, if the promised

standard of service is not rendered, the operational manager should offer an apology

(Department of Public Service and Administration, 2003:18).

2.9.8 Value for money

Punctuality should be maintained by staff members because they are being paid for

hours worked (Department of Public Service and Administration, 2003:18).

2.10 The four main categories of Human Rights relevant to maternal health care

are:

WHO, UNICEF and UNFPA (1999) advocated four main categories of Human Rights

relevant to maternal care namely:

1. The right to life and security.

2. The right to foundation of family and of family life.

3. The right to highest standard of health and benefits of scientific progress.

4. The right to equality and non-discrimination on grounds such as sex, marital

status, race, age and class.

Maternal mortality must be considered as violation of women’s human rights; the

right to live necessitating changes in the legal, political health and education systems

to provide more equitable women centred health services through strong partnership

28

between governments and communities (WHO, UNICEF and UNFPA, 1999:11).

The provision of good-quality care is one of the most effective ways of ensuring that

maternal health services are used and that women’s lives are saved at all times, by

assuring respect of standards of care, decreasing barriers to care, ensuring the

empowerment and satisfaction of users and motivation of providers by involving

them in decision-making processes and improving provider awareness to cultural

and social norms (WHO, UNICEF and UNFPA, 1999:10).

Health professionals fail to treat women with respect and dignity they have right to

expect. This includes the observance of her privacy and dignity during physical

examinations, late stage labour and delivery. All women’s privacy in the birthing

environment should be respect (WHO/UNICEF1996b:29).

2.11 Intersectoral collaboration

In urban areas, the lack of communication between the providers and the complexity

of the system (for example ambulance delay) tend to increase delays to care-

seeking and timely treatment. In rural areas maternal care tends to be inadequate

where one midwife has to attend to all health needs of the population. Women with

obstetrical complications should be complimented with a proper referral system that

builds continuity of care provided at the community level to care at the hospital level

(WHO, UNICEF and UNFPA, 1999:4).

It is found that free or subsidised services in facilities are perceived as offering low

quality services (Uzochukwu, Onwujekwe and Akpala, 1999:294). Most of the

studies that are conducted it is found that nurses or midwives working in government

maternity services are abusive to vulnerable patients, and the private hospitals are

rated as rendering high quality care Eastern Cape Department of Health, Quality

Assurance, 2007:18).

2.11 Community involvement and participation

The patient perception about the quality of care they received is measured in order

to involve patients more in decisions that concern them and to better meet their

expectations or the need to evaluate the effect of budget restrictions on accessibility

and quality (WHO, 2003:18). This could be achieved by formation of clinic committee

29

and each clinic should have suggestion box wherein the clients should write

complaints or compliment the quality of care they have received.

Yaglunayie and Mahfoozpour (2006) argued that client satisfaction reflects the

quality of services rendered and its assessment as an important indicator in

evaluating outcomes is a method in determining clients’ views about the condition of

services. Lafferie (1996) concurs with the above statement that assessing,

identifying client satisfaction is a basis to develop service delivery which in turn can

reinforce their satisfaction.

According to Yaglunayie and Mahfoozpour (2006) In order for an organisation to be

able to solve health problems and finally lead to client satisfaction service delivery

should be based on the needs and demands of each population. They further argued

that promoting service delivery without people’s opinion would be inappropriate and

sometimes impossible. Dissatisfaction results from lack of attention to clients’ needs

and inappropriate response to clients’ needs. This could lead to frustration, anger

permanent anxiety abnormal and ill behaviour in the client

2.12 SUMMARY

Evaluation of maternity services by the clients assist in quality improvement efforts

and facilitate the identification of poor quality care for further investigation and

interventions among health care workers and help to optimise health budget through

client guided planning and evaluation. Satisfied clients are likely to comply with

treatment, take an active role in their own health care, utilise maternity services and

recommend service to other members of the community (Changole et al, 2010:6).

30

CHAPTER 3

RESEARCH METHODOLOGY

3.1 INTRODUCTION

The study aimed to investigate whether patients attending midwifery services were

satisfied with services rendered at Empilweni/ Gompo and Nontyatyambo

Community Health Centres in East London, Amathole District, Eastern Cape in

South Africa.

3.2 OBJECTIVES OF THE STUDY

The objectives of the study were to:

Identify the positive and negative perceptions of women in relation to the maternal

health care services rendered at Empilweni and Gompo Community Health Centres

during antenatal, intra -partum and postnatal period.

Determine the level of satisfaction of women attending antenatal and delivered at

these facilities in relation to the quality of care variables cited above.

3.3 RESEARCH DESIGN

Research design is defined as the structured approach followed by researchers

when conducting a study to obtain answers to a particular research question

(Joubert and Ehrlich, 2007:77). The researcher employed quantitative descriptive

research to achieve the objectives and to address the research problem in question.

3.3.1 Quantitative research

According to Burns and Grove (2009:717) quantitative research is a formal,

objective, systematic study process to describe and test relationships and to

examine cause-and-effect interactions among variables. The rationale for the

researcher to choose quantitative approach was to determine the extent of the

problem and occurrence by quantifying the variations. In the current study the

researcher intended to know how many participants had positive or negative

perceptions about midwifery services rendered in both community health centres.

31

3.3.2 Descriptive Research

Descriptive research provides an accurate portrayal or account of the characteristics

of a particular individual, event, or group in real-life situations for the purpose of

discovering new meaning, describing what exists, determining the frequency with

which something occurs, and categorizing information (Burns and Grove 2009: 696).

In the current study the researcher brought questionnaires to pregnant women who

attended antenatal care in the antenatal clinic as well as post natal mothers in a lying

in to evaluate how they (pregnant women and post natal mothers) perceived the

quality of care rendered to them. The researcher wanted to determine the level of

satisfaction of pregnant women and postnatal mothers with midwifery services

rendered to them.

3.4 RESEARCH METHODOLOGY

3.4.1 Study Population

A population is the entire aggregation of cases that meets a specified set of criteria

(Polit, Beck, and Hunger, 2001:233). The population for the study was all pregnant

women who attended antenatal care from each health centre and mothers who had

delivered during data collecting period. The total number of pregnant women who

attended antenatal care at Nontyatyambo were one hundred and ninety six (196)

whereas at Empilweni Gompo were one hundred and fourty eight (148). The total

number of women delivered at Nontyatyambo were seventy seven (77) whereas

Empilweni Gompo were one hundred and sixty eight (168). See table below.

The following table shows the population for the study

Table 3.1. Population for the study

Name of

institution

Pregnant Women Delivered women

Nontyatyambo 196 (57%) 77(31%)

Gompo/Empilweni 148 (43%) 168 (69%)

Total 344 (100%) 245(100%)

32

3.4.2 Sampling method

Sampling is the process of choosing a part of the population to represent the entire

population (Polit et al, 2001:234). Random sampling was not appropriate in the

current study as random sampling provide equal probability for each individual in the

population of being selected to participate in the study (Creswell, 2003:156). In the

current study the researcher selected non-probability sample. Participants were

chosen based on their convenience and availability (Creswell, 2003:156). The

researcher requested pregnant women who met selecting criteria who attended

antenatal care in the antenatal clinic and women who delivered in the lying in.

The sample of the study was hundred participants, thirty pregnant women who

attended antenatal care two or more subsequent visits from each health centre and

twenty mothers who had delivered after six hours if there were no complications. The

total number of pregnant women during the period of data gathering was 344 and 60

pregnant women participated in the study n= (17%) and the total number of women

delivered during data gathering period were 245 and there were 40 women who

participated in the study postnatal n= (16%). See table below.

The following table shows the sample for the study.

Table 3.2. Sample for the study.

Name of

institution

Pregnant Women Delivered woman

Nontyatyambo 30(50%) 20 (50%)

Gompo

Empilweni

30(50%) 20 (50%)

Total 60(100%) 40(100%)

33

3.4.2.1 Inclusion criteria

Inclusion criteria are the specification of the characteristics of the population that

determines whether a person qualifies as a member of the study population (Polit et

al 2001:233). Women who met inclusion criterion were pregnant women who

attended antenatal care two or more subsequent visits from each health centre and

mothers who had delivered (postnatal) six hours after delivery if there were no

complications.

3.4.2.2 Exclusion criteria

Exclusion criteria are the specification of characteristics of the population that delimit

a person to qualify as the member of the study population (Polit et al, 2001:233).

Pregnant women who came for first visit (first booking), pregnant women who

attended antenatal care at the clinics or hospitals, mothers who delivered at the

clinics or hospitals and had complications were excluded from the study.

3.5 Study setting

The study was conducted at Empilweni Gompo and Nontyatyambo Community

Health Centres in East London, Amathole District, Eastern Cape Province.

3.6 Measurement

The researcher used a questionnaire as data collecting tool. The antenatal card was

used to determine the number of antenatal visit, as the inclusion criteria stated that

women who qualified to participate in the study should have two or more subsequent

visits. Maternity chart was used as a measurement to check time of delivery,

mothers were to answer questionnaire after six hours if there were no complications.

3.6.1 QUESTIONNAIRES

A questionnaire is defined as a method of collecting self report information from

participants through administration of questions in a paper-and-pencil format (Polit et

al, 2001:469). Questionnaires were developed from information gathered in literature

reviewed.

34

The questionnaires were developed by the researcher. In structuring the

questionnaires for pregnant women during antenatal care the following variables

were used: accessibility to the health centre, equitable access during antenatal care,

efficiency of health facility staff, community involvement and participation, sharing of

pleasant and negative perceptions were advocated by; The constitution of the

Republic of South Africa,1996, Dennil et al, 1999, World Health Organisation report,

2000, Kekana and Blaauw, 2002, Quality Assurance Policy, 2007, and Negotiated

Service Delivery Agreement ( NSDA) period 2010-2014. The researcher developed

two questionnaires, one was developed to be answered by pregnant women another

one by women after delivery (postnatally). The questionnaire presented below was

developed to be answered by pregnant women and questions were formulated in

relation to satisfaction with the following quality of care variables:

Section A: Demographic data and geographical accessibility to the health centre.

Section B: Equitable access during antenatal care.

Section C: Efficiency of health facility staff (midwives) in relation to health education

given to pregnant women during antenatal care.

Section D: Obstetric competence of midwives when rendering antenatal care.

Section E: Community participation.

Section F: Open-ended questions to determine positive and negative perceptions in

accordance with quality of care the clients received during antenatal care

(annexure).

The questionnaire presented below was developed to be answered by women during

postnatal period.

Section A: Demographic data and birthing environment.

Section B: Technical factors: Availability of equipments that were in good working

condition.

Section C: The human quality of care: The quality of care rendered by midwives

during intra-partum and postnatal periods.

35

Section D: Pain relief was given or not during labour.

Section E: Companionship during labour.

Section F: Communication and personal skills showed by midwives.

Section G: Fetal outcome.

Section H: Maternal outcome.

Section I: Open-ended questions on client perception in relation to quality of care

rendered during intra-partum and postnatal periods.

The researcher used both closed and open ended questionnaire. In open-ended

questions respondents used their own words to answer a question, whereas in

closed questions prewritten response categories were provided. The closed

response was in Likert type format where the respondents chose from among:

strongly agree-5, moderately agree-4, agree-3, disagree-2, no response-1. The

questions were constructed simple, clear and precise manner in order to avoid

vagueness. Language used in constructing the questions was English.

3.7 Pilot study

The researcher conducted a pilot study before collection of data. The researcher

conducted a pilot study to test if the questionnaire obtained the results

required.There were ten participants, five pregnant women with two or more

subsequent antenatal visits at Nontyatyambo Community Health Centre, five women

who had no complications delivered at Empilweni Community Health Centre. The

researcher observed that there were more pregnant women attending ANC and

fewer deliveries at Nontyatyambo than Empilweni Gompo Community Health Centre.

Participants participated in a pilot study were excluded from the sample of the study.

The purpose of the pilot study was to determine whether the participants understand

the questions, the quality of time spent to administer the questionnaires as

answering of questions should not be tiring to participants should not exceed twenty

five minutes. The researcher and the supervisor agreed that the tool used was

relevant to the study in question and the researcher pursued with data gathering.

36

3.8 Data gathering

According to Burns and Grove (2009) data gathering is a systematic gathering of

relevant information to achieve the specific objectives and address the research in

question. The measurement used by the researcher for data gathering was a

structured questionnaire. According to the researcher’s observation antenatal care

was rendered on daily basis at Nontyatyambo (throughout the week). There were

many women attending antenatal care and few deliveries, whereas at Empilweni

Gompo there were more deliveries and few pregnant women who attended antenatal

care due to the fact that there are many clinics nearby Empilweni Gompo and the

pregnant women utilised the clinics.

The researcher managed to complete data gathering to pregnant women within two

weeks at Nontyatyambo health centre. Antenatal care was rendered two days per

week in the morning session at Empilweni/ Gompo. Sometimes the researcher

managed to get one, in some instances two or three per visit. The researcher

requested her supervisor to select more pregnant women and fewer deliveries at

Nontyatyambo vice versa at Empilweni Gompo. The supervisor disagreed stated that

the researcher should stand firm of what the researcher wrote in the research

proposal. This led to the extension of period for data gathering from February 2009

to June 2010.

Privacy was maintained, the operational manager allowed the researcher to use her

office for data gathering in pregnant women, the operational manager at Empilweni

Gompo was on leave during data gathering to mothers post delivery and the

researcher screened for privacy. The researcher did not put on uniform, was on

leave. At Nontyatyambo the researcher was provided with admission room, the

researcher used the admission room when pregnant women were up and about, not

in established labour to collect data from them. Sometimes there were no women in

labour and the researcher got as much participants as she could. When collecting

data from mothers the researcher screened for privacy. The researcher took twenty

minutes to administer both questionnaires.

37

3.9 Validity

Validity refers to an extent at which an instrument measures what it is supposed to

measure and the difference of the yielding scores reflect the true differences of the

variable being measured (De Vos, Strydom, Fouche, Poggenpoel and Schrink

(1998:166). In the current study the instrument used was valid in that the researcher

selected (100) hundred participants to participate in the study. Sixty of the

participants were pregnant women who were attending antenatal care for (2) or more

subsequent visit which means that the participants who answered the questionnaires

were knowledgeable about the research topic in question. The response rate to

questionnaires was (100) hundred percent. The participants who participated

postnatally were forty in number and were women who delivered in both community

health centres and also response rate was hundred percent.

3.9.1 Content validity

Content validity refers to the instrument that provides sufficient sample of items

representing the concept (De Vos et al, 1998:167).

In the current study the researcher developed the questionnaires in accordance with

the literature reviewed on client satisfaction with midwifery services. The researcher

conducted pilot study prior data gathering to ensure that the instrument used

achieved the objectives of the study and addressed the research question. Content

validity was maintained.

3.9.3 Reliability

Reliability is defined as degree to which independent administration of the same

instrument time to time yield same or similar results (De Vos et al, 1998:168). The

questionnaire was given to experts in midwifery to check for relevance, clarity and

ambiguity.

3.10 Data analysis

Data analysis is the process of categorizing, ordering, manipulating and summarizing

of data to obtain answers to research questions (De Vos et al, 1998: 203). De Vos

et al, (1998) further argued that the purpose of analysis is to reduce data to an

38

understandable and interpretable form so that the recessions of research problems

can be studied, tested and conclusions drawn.

In the current study the researcher employed both descriptive statistics and content

analysis to analyse data collected in the study. Descriptive analysis was employed to

analyse closed-ended questions and content analysis to open-ended questions.

Content analysis: The researcher worked systematically through each transcript

assigned numbers to specific characteristics within the text. The researcher had a list

of categories and the answers were quantified (Dawson 2002:118). Microsoft Excel

data capturing was used. Data was presented in graphs and tables.

3.11 Ethical consideration

The proposed study was submitted to the University of Fort Hare Academic

Research Committee for ethical approval before commencing the study. After

approval by the committee of the University, the proposal was submitted to the

Eastern Cape Department of Health Provincial Research Committee for approval to

conduct the study in the province. To access data from selected sites, permission

was obtained from the District Manager and both Middle Manager Nursing from

these Community Health Centres.

3.11.1 Informed consent

The researcher developed an informed consent form to be answered by participants

before they were engaged in the study to ensure participants’ rights were protected

during data gathering ( annexure G and H). The researcher complied with the

National Health Act 61 of 2003 stating that research participants should be legally

and mentally sound to participate in the proposed study (Joubert et al, 2007:35).The

researcher disclosed to the participants the purpose, significance, potential risk, the

procedures of the study and the rights of the participants so that the participants

could comprehend the information given by the researcher and to know what to

expect and anticipate in the research (Creswell, 2003:64). The researcher explained

that the participants had rights to participate voluntarily without being forced or forfeit

what was due to them because (they) participants refused to participate in the study

(Joubert et al, 2007:35). The participants were given opportunity to ask questions

39

regarding the research process. Signatures of both parties were obtained to ensure

agreement between the researcher and the participant see Annexure G and H).

3.11.2 Anonymity

The researcher ensured the participants that the information given could not be

traced back to them (participants) when the final report was produced. The

information was kept under lock and key to ensure no one had access to information

given. Participants were informed that the information given could not be used

against them (participants) in the future. The researcher used coding instead of

names to ensure anonymity.

3.11.3 Confidentiality

The researcher complied with Data Protection Act 1998 as revised 01 March 2000

stating that the researcher should act fairly and lawfully, data should be accurate and

kept secured. This was achieved by keeping information given by participants

confidentially and was not disclosed to the third parties.

Limitations of the study

The researcher focused on pregnant women attending midwifery services at

Empilweni/ Gompo and Nontyatyambo community health centres. Not all the

community health centres in Eastern Cape were under study. The findings cannot be

generalized.

3.13 Summary

In this chapter the researcher explored the research design used, tools used to collect

data, who participated in the study? Where was the study conducted? How the data was

analysed? The next chapter would be the interpretation of research findings.

40

CHAPTER 4

DATA PRESENTATION AND ANALYSIS

4.1 Introduction

In this chapter, the researcher focused on the presentation and analysis of data.

Following the data collection stage, the researcher followed through with the analysis

of data. In the current study the researcher employed both descriptive statistics and

content analysis to analyse data collected in the study. Descriptive analysis was

employed to analyse closed-ended questions and content analysis to open-ended

questions. Content analysis: The researcher worked systematically through each

transcript assigned numbers to specific characteristics within the text. Microsoft

Excel data capturing was used. Data was presented in graphs and tables.

4.2 Findings

4.2.1 Antenatal services

The distribution of clients by age is presented in the form of the following graph:

Figure 4.1: Distribution of Antenatal (ANC) Clients by age group.

Out of sixty (60) participants interviewed, there was fair age distribution of

participants in the study. The majority were of child bearing age hence the above

3

20

26

8

3

0

5

10

15

20

25

30

<18 19-24 25-30 31-34 >35

Age groups

41

graph was clustered around those ages. In figure 4.2 the distribution of clients is

presented by gravidity.

Figure 4.2: Distribution of ANC clients by gravidity

The majority of the clients in this study were primiparous women who constituted

about n= 23(38%) of the women. The second lot of participants n= 23(38%)

consisted of gravida 2 women. A third group of antenatal participants n=11(18%)

were women who had delivered 3 babies. A small group of participants n=2 (3%)

were multiparous and had just delivered their 4th babies. The smallest group of

women n=1 (2%) had had their 5th delivery. Collectively, these participants had a

wide range of experiences pertaining to delivery.

Grav 1 39%

Grav2 38%

Grav 3 18%

Grav 4 3%

Grav 5 2%

Distribution of clients by gravidity

42

Figure 4.3 Distribution of antenatal (ANC) clients by weeks of gestationOf the

sixty (60) participants n=25 (42%) of them were about 27-32 weeks, n=20 (33%) of

them were 33-39 weeks pregnant, and n=15 (25%) were 20-26 weeks pregnant.

These figures represent a varied range of pregnancies. This denotes that the

participants in the study met the criterion that the participants selected should have

two or more subsequent visits.

The following Table shows the mode of transport and hours travelled by the clients to

the clinic:

Table 4.1: Table showing mode of transport and hours travelled to clinic.

15

25

20

0

5

10

15

20

25

30

20-26 wks 27-32 wks 33-39 wks

Nu

mb

er

of

clie

nts

Gestation weeks

Distribution of clients by gestation weeks

Time

travelled

MODE OF TRANSPORT

Private

Transport

% Travel

on foot

% Public

transport

%

10 – 30

minutes

n=2 3% n=12 20% n=40 67%

30 min – 1 hr 0 0% n=1 2% n=5 8%

Total n=2 3% n=13 22% n=45 75%

43

Participants used different modes of transportation to reach the facility. All the

participants did not take more than an hour to reach the facility. According to Kekana

and Blaauw (2002), transport should take 1hour to Essential Obstetric Care.

According to the findings public transport did not take more than an hour, this

indicated that Community Health Centres were accessible to participants.

Figure 4.4 Geographical access of clients to health services

Out of sixty (60) participants interviewed n=49 (82%) of clients agreed that both

health centres were accessible to them. The literature says that the distance

between the health facility and clients’ residential areas should be 5-10kilometres

(Dennil et al, 1999:6). The criterion was met in this study.

37

5 7

11

0

5

10

15

20

25

30

35

40

Strongly agree Moderately agree

Agree Disagree

Nu

mb

er

of

clie

nts

Graph showing geographical access to health facility

44

Figure 4.5 Equitable access during ANC

Out of sixty (60) participants interviewed n=48 (80%) agreed that they felt welcomed.

n=56 (93%) agreed that they were attended to in accordance with the queue. This

denotes that pregnant women had equal access to the ANC. The findings of the this

study concur with the principle of equity pioneered by World Health Report, 2003:18.

N=51 (85%) agreed that they were treated with dignity and respect and n=9 (15%)

disagreed. This indicates that the midwives were considerate of patients’ rights. The

findings of this study differ with the Quality Assurance Policy, 2007:18 stating that

one of the quality problems identified was disregard of human dignity.

31 42

49

37

11

10 4

7 6

4 1

7

12 4 6 9

0

10

20

30

40

50

60

70

Feel welcomed

Queue in order

Fairly treated

Treated with

dignity and respect

Graph showing equitable access during ANC

DISAGREE

AGREE

MODERATELY AGREE

STRONGLY AGREE

45

Figure 4.6 Experiences of clients during ANC visits

The above figure shows diverse opinions of participants in accordance with their

perceptions during antenatal period, which bordered on the areas of trust between

pregnant women and midwives, the convenience of health centres and the quality of

maternity services rendered to them (pregnant women).Out of sixty (60) participants

interviewed n=28(47%) were well looked after during ANC n=7 (12%) were not well

looked after. This indicates that maternity services in these two facilities are

marginally user-friendly. Trust between midwives and the pregnant women was not

built, n=7 (12%) of women did not trust midwives whereas n=6 (10%) trusted

midwives. The research findings of this study differ with the work of Association of

Ontario Midwives, (May 2007) which argued that midwives should build relationship

with their clients, work with them to make informed choices with their care.

6

2

28

6

1 1

7 7

0 2

0 0 0

5

10

15

20

25

30

Health Centre convinience

Like staff Well looked after during

ANC

Trust nurses

Convenience during ANC

Yes

No

Unsure

46

Table 4.2: Table showing perceived efficiency of health care staff on patient

education

Strongly

Agree

Moderately

Agree

Agree Disagree Unsure

Individual counseling n=52 (87%) n=3 (5%) n=5 (8%) 0 0

Informed of day

&time for ANC

n=49(82%) n=2(3%) n=4(7%) n=5(8%) 0

Focused ANC visits

explained

n=4(7%) n=1(2%) 0 n=53(88

%)

n=2(3%)

Danger signs

explained

n=21(35%) n=3 (5%) 0 n=35(58

%)

n=1(2%)

Told what to do when

danger sign occur

n=20 (34%) n=3 (5%) n=3 (5%) n=32(53

%)

n=2(3%)

Importance of HIV

testing explained

n=56(93%) n=1(2%) n=3 (5%) 0 0

Informed choice

regarding HIV testing

n=50(83%) n=7(12%) n=2(3%) n=1(2%) 0

Information on choice

of infant feeding

n=6(10%) n=1(2%) 0 n=52(86

%)

n=1(2%)

Effective

communication made

me to remember the

advice

n=41(68%) n=10(17%) n=4(7%) n=5(8%) 0

Importance of taking

well balance diet

explained

n=37(62%) n=4(7%) n=2(3%) n=16(26

%)

n=1(2%)

47

Out of sixty (60) participants interviewed, n=60(100%) agreed that individual

counseling and importance of HIV testing was explained. This indicates that

Prevention of Mother to Child Transmission (PMTCT) Program is implemented by

both facilities. Testing rate high, Dual therapy / HAART is given to pregnant women

who are tested HIV positive depending to their CD4 count and stage to prevent fetus

to contract HIV/ AIDS from mother.

Out of sixty (60) participants interviewed n=55 (92%) agreed that they were informed

about day and time for ANC. This indicates that pregnant women did not stay long

period without being attended to. This could result to less defaulting rate and greater

patient satisfaction.

The majority of participants n=53(88%) disagreed that they were explained about

focused ANC visits. This indicates that both facilities implemented Basic Antenatal

Care (BANC) wrongly or did not implement BANC at all.

Out of sixty (60) participants interviewed n= 35 (58%) disagreed that danger signs

were explained and n=32(53%) disagreed that they were told what to do if the

danger signs occurred.These findings indicate that there is lack of health education.

The findings of this study support the study conducted by Mxoli (2007) who wanted

to establish women perceptions and experiences on antenatal care rendered by

midwives and argued that pregnant women complained of lack of health education in

relation to pregnancy.

The majority of the participants interviewed n=52(87%) disagreed that they were

given information on factors to be considered when choosing infant feeding. Out of

60 participants interviewed n=60 (100%) agreed that they made informed choices

regarding HIV/AIDS testing. Out of 60 participants interviewed n=55 (92%) agreed

that effective communication of midwives made them to remember advices given.

This denotes that midwives apply their teaching role and communication skills.

Out of sixty (60) participants interviewed n =43(72%) agreed that they were given

information on well balanced diet and n=16(28%) disagreed. Health education on the

importance of taking well balanced diet is lacking in both facilities.

48

Figure 4.7 Obstetric competences during ANC visits

Out of sixty (60) participants interviewed n=41(68%) agreed that delivery plan formed

part of their ANC visits and n=18 (30%) disagreed. Midwives should put more

emphasis on delivery plan if pregnant woman was conducted caesarean section in

her previous pregnancy. The woman should deliver in hospital to avoid delay. The

woman could then be financially prepared for transportation to hospital and be able

to arrange with the person who would look after other children during hospitalisation

Of the sixty (60) participants interviewed n= 11(18%) agreed that they were told that

they had right to choose labour companion and n=48 (80%) disagreed. The research

findings of this study concur with Brown et al, 2007 argued that in South Africa

companions during childbirth are not encouraged by state maternity services.

Out of sixty (60) participants interviewed n=38 (63%) disagreed that they were

educated on true signs of labour and n=22 (37%) agreed. This denotes that there is

health education deficiency. This could lead to home delivery. Midwives should put

more emphasis on health education.

40 49

32

8 19

7

4

4

2

2

4 2

5

1

1

6 3

18

48

38

3 2 1 1 0

0

10

20

30

40

50

60

70

Obstetric competence

contributed to my welfare

High risk factors detected

Delivery plan formed part of my

ANC visits

Right to select labour companion

Advised on true signs of labour

Obstetric competence of midwives during ANC

Strongly Agree Moderately Agree Agree Disagree Unsure

49

10

25

13

8

23 25

0

5

10

15

20

25

30

Delivery plan part of ANC

selection of labour companion

Advise on labour signs

Nu

mb

er

of

clie

nts

Comparison between two facilities in relation with obstetric competence

Empilweni Nontyatyambo

Figure 4.8 Competency skills of midwives at different facilities during ANC visits

Comparison between the two facilities showed that education on delivery plan at

Empilweni Gompo was N=10 (17%) whereas at Nontyatyambo was N=8(13%). The

difference is not significant. Both facilities should put more emphasis on education

on the delivery plan. If a pregnant woman was conducted caesarean section in the

previous pregnancy, she should be sent to hospital at her first visit and should be

prepared that at 36 weeks she would be referred to hospital for elective Caesar and

delivery would take place in hospital. A pregnant woman can be then prepared to

save money for transport to hospital to avoid delays.

Out of sixty (60) participants interviewed n=25 (42%) of clients from Empilweni

Gompo n=23 (38%) from Nontyatyambo agreed that they were given opportunity to

select labour companion. Both facilities were not doing well as far as education on

selection of labour companion. The findings of this study support the study

conducted by Brown, et al 2007stating that in South Africa companions during birth

are not encouraged by state maternity services. They further argued that the health

professionals have been slow to implement companion policies and programs to

ensure appropriate companionship during childbirth.

Out of sixty (60) clients interviewed n=13 (22) from Empilweni Gompo and n=25

(42%) from Nontyatyambo Community Health Centres agreed that they were told

about true signs of labour. Both facilities were not doing well as far as education on

true signs of labour.

50

Figure 4.9 Community participation

Out of sixty (60) participants interviewed n=9 (15%) agreed that suggestion box was

available in each facility and n=7(12%) agreed that they were able to make

decisions, n= 50(83%) disagreed that the suggestion box was available in each

facility and n= 53(88%) disagreed that they were able to make decisions.

8

0 1

50

1 1 4 2

53

0 0

10

20

30

40

50

60

Strongly agree Moderately agree

Agree Disagree Unsure

Nu

mb

er

of

clie

nts

Graph showing community participation

Suggestion box available Able to make suggestion

51

Postnatal Services

Figure 4.1.1 Distribution of postnatal clients by ethnical group

Out of forty (40) clients interviewed there were n=35(88%) blacks and n=5 (13%)

were coloureds. This denotes that there were two diverse groups.

Figure 4.1.2 Distribution of postnatal clients by age group.

5

35

0

5

10

15

20

25

30

35

40

Coloureds Blacks

Etnical group

Nu

mb

er

of

Clie

nts

Distribution of clients by ethnical group

Age group 0%

<18 yrs 7%

19-24 yrs 32%

25-30 yrs 35%

31-34 yrs 13%

Above 35 yrs 13%

Distribution of clients by age-group

52

Out of forty (40) clients interviewed their ages were as follow: n=13(32%) 19-24, n=

14 (35%) were 25-30 years, n= 5 (13%) 31-34, n=5 (13%) above 35 and n= 3 (7%)

below 18 years. This denotes that there is health education deficiency as far as

family planning is concerned.

Figure 4.1.3: Distribution of postnatal clients by gravidity

Out of forty (40) participants interviewed n=15(37%) were gravida 2, n=13(32%)

gravida 1, n=11(28%) gravida3 and n=1(3%) gravid 4. Gravida 4 was less.

Figure 4.1.4: Expression of birthing environment

35

27

34 35 36 33

4 9

2 0 2 1 0 2 4 3 2 2 1 1 0 2 0 4

0 5

10 15 20 25 30 35 40

Physical Environment

Temp of the room

Warm & welcoming

atmosphere

Privacy provided

Linen clean & appealing

Given water on request

Birthing Environment

Strongly agree Moderate agree Agree Disagree Unsure

53

Out of forty (40) participants interviewed n=39 (98%) agreed that physical

environment of the labor wards were inviting n=38 (95%) agreed that temperature of

the rooms were made comfortable. N= 40 (100%) of clients agreed that atmosphere

was warm and welcoming in both facilities. n=38 (95%) agreed that privacy was

provided. N= 40 (100%) agreed that linen was clean and appealing. n= 35 (88%)

agreed that they were given water on request. Women were satisfied with birthing

environment.

Figure 4.1.5: Human quality of obstetric care

Out of forty (40) clients interviewed n= 39 (98%) agreed that the midwives

encouraged and supported them during labour. n= 38 (95%) agreed that when they

had urged to bear down were given clear guidance. n=36 (90%) agreed that

midwives complemented them on their bearing down efforts,n=4 (10%) disagreed.

N= 40 (100%) disagreed that pain relief was given. The findings of this study support

the study conducted at Mowbray Hospital that audited pain relief provided in the

labour ward.

34 34 28

36 39

36

3 3

6

3 1

1 2 1

2

1 0

2 1 2 4

0 0 1

40

0

5

10

15

20

25

30

35

40

45

Human quality of obstetric care

Unsure

Disagree

Agree

Moderately Agree

Strongly Agree

54

Figure 4.1.6: Technical factors

Out of forty (40) participants interviewed n=39 (98%) of clients agreed that the

equipment appeared to be working good and adequate. This indicates that the

clients were satisfied with the equipments used to them in both facilities.

Figure 4.1.7: Companionship given to clients

5

5

4

30

5

0

1

0

30

35

35

10

0 5 10 15 20 25 30 35 40

Opted to/not to have companion

Companion given guidance

Companion welcomed

Would like to have companion for future delivery

Companionship

Disagree

Agree

Strongly agree

37

1 1 1

37

2 0 1

0

5

10

15

20

25

30

35

40

Strongly agree Moderate agree Agree Disagree

Technical factors

Equipment appear to be working Equipment appear to be adequate

55

Out of forty (40) clients interviewed n=30(75%) of clients stated that they were not

given opportunity to choose whether they want to have labour companions. Only

n=10 (25%) were given opportunity to choose and n=5 (13%) agreed that their

labour companions were welcomed and given guidance. n=35(87.5%) their labour

companions were not welcomed nor given guidance. n=30 (75%) of clients would

like to have labour companion for future deliveries. This indicates that policies on

labour companionship are not implemented in government health facilities.

Figure 4.1.8: Communication and interpersonal skills.

Out of forty (40) clients interviewed n=36 (90%) agreed that they were treated with

courtesy and respect. N= 29(73%) agreed that midwives discussed issues of their

HIV status and related preventive measures (PMTCT) privately.

34

2 0

4

25

2 2

11

0

5

10

15

20

25

30

35

40

Strongly agree Moderate agree Agree Disagree

Communication and interpersonal skills

Treated with courtesy and respect Issue of HIV status and prevention discussed

56

Table 3: Table showing Fetal Outcomes

Fetal Outcomes

Strongly

agree

Moderately

agree Agree Disagree

Delivered a healthy baby n=38(95%) n=2(5%) 0 0

Informed about health status of my

baby n=37(93%) n=3(8%) 0 0

Informed about the sex of my baby n=35(88%) n=1(3%) n=1(3%) n=3(8%)

Fostering of bonding encouraged n=33(83%) n=2(5%) n=1(3%) n=4(10%)

Out of forty (40) participants interviewed N=40 (100%) of women delivered healthy

babies and they were informed about health status of their babies. Midwives

reflected good practice. Midwives should be encouraged to keep up good work.

Mothers were satisfied due to delivery of healthy babies. N=36(90%) agreed that

bonding between the mothers and their babies was encouraged.

Figure 4.1.9 Maternal outcomes

36

1 1 2

38

1 0 1

0

5

10

15

20

25

30

35

40

Strongly agree Moderate agree Agree Disagree

Maternal outcomes

Satisfied the way labour was managed

Recommendation of a friend/relative to deliver at this facility

57

Out of forty (40) clients interviewed n= 38 (95%) agreed that they were satisfied

about the way their labour was managed and n=39 (97%) agreed that they would

recommend a friend or relative to deliver in both facilities. These high percentages

are indicative of effective and efficient service delivery. These findings support

Millenium Development Goals aimed at reducing infant and maternal deaths and

combat HIV from 2010-2014 (Dussault and Franceschini, 2006).

4.3 Positive and negative perceptions of women in relation to care rendered during

antenatal and postnatal period

The researcher gathered information from postnatal women regarding their individual

experiences during intra-partum and postnatal period.

Figure 4.2.1: Positive perception during postnatal care

Out of forty (40) postnatal clients interviewed, n=18(45%) were treated with respect.

n=13 (32.5%) stated that the physical environment was clean. n=5 (12.5%) staff was

supportive and n=4 (10%) argued that observations were done. This indicates that

the midwives are capacitated to render quality care by putting into consideration the

National priorities and service delivery charter against which the achievements are

4

2

1

18

3

5

13

1

2

1

0 2 4 6 8 10 12 14 16 18 20

Observation done

Procedures explained

Adressed by name

Treated with respect

Managed very well

Staff supportive

Environment clean

Desired needs met

Approach was good

Privancy maintained

Positive perception during postnatal care

58

measured in relation with the standards set (clean environment) (Quality Assurance

Policy, 2007:5).Many South Africans receive good quality care as much as many

patients receive substandard care. One of quality problems identified was disregard

of human dignity and the findings of this study differ with the evidence of quality

problem (Quality Assurance Policy, 2007:11).

Figure 4.2.2: Positive perceptions for antenatal care clients

There are similarities between positive perception experienced by women during

ANC and postnatal period clean environment and treated with respect. n=11 (28%)

pregnant women stated that they were treated with respect and good nursing care

was rendered to them. n=9 (23%) stated that the physical environment was clean. n=

5 (13%) were well informed on HIV and n = 4 (10%) advised on appropriate

treatment and management of minor illness of pregnancy.

2

11

1

11

5

4

1

9

1

0 2 4 6 8 10 12

Good communication

Good nursng care

Health Education given

Treated with respect

Well informed on HIV

Nurses supportive

Advised on appropiate treatment and …

Midwives friendly

Environment clean

Observation done

Positive perceptions of ANC clients

59

Figure 4.2.3: Negative perceptions of antenatal care clients

Out of sixty (60) clients interviewed n=23 (38%) stated that they waited long period of

time. In comparison of the two facilities the researcher observed that catchment area

of Nontyatyambo was wide, pregnant women came from Resteen, Mbekweni,

Khayelitsha, and Zinkomeni and all over Mdantsane leaving their nearest clinics.

That is why they waited long period of time and others complained that midwives

could not finish them and were asked to come on the following day. The clients were

dissatisfied because they pointed out when they came in the following day some of

them were referred to Cecilia Makiwane Hospital due to obstetric indications. This

involved money for transportation.

There were few pregnant women attending antenatal care at EmpilweniGompo due

to utilization of nearest clinics. The findings of this study support the study conducted

to evaluate the meaning of quality of care received at non-governmental family

planning, maternal and infant care in Santiago. They described having to wait for

hours and hours as a characteristic of government health services (Vera, 1993). N=

7(12%) of clients complained of being expelled due to late coming and n=3 (5%) due

1 1

7

1

6

3 4 4

3

23

2

0

5

10

15

20

25

Negative Perception of ANC clients

60

to nurses were busy. The findings of this study support the study conducted by

Mxoli, 2007 who argued that pregnant women stayed long at the antenatal clinic and

felt frustrated and angry when turned back home for being late. The researcher

observed that there were no midwives allocated specifically for ANC, ANC was not

done for the whole day same midwives were conducting deliveries at Empilweni

Gompo Health Centre. N= 6 (10%) of women complained of cramped ANC room at

EmpilweniGompo. N=4 (7%) of women experienced bad manner of approach and

were not treated with respect by health care workers. The findings support the study

conducted by (Jewkes, et al 1998) who argued that many patients reported clinical

neglect, verbal and physical abuse by midwives in the maternity services.

N=3 (5%) of women complained of dirty environment. The researcher observed that

postnatal women and pregnant women were using same toilets and there were

drops of blood in the floor and toilet seat and the pregnant women were dissatisfied

about this when they asked the general assistants to clean, they received negative

response.

N=2 (3.3%) of women were dissatisfied with being palpated by inexperienced

student nurses.

61

Figure 4.2.4: Negative perception of postnatal care clients

Out of forty (40) participants interviewed n=15 (38%) stated that they did not have

any negative perception during postnatal n=4(10%) stated that privacy was not

maintained n=3 (8%) stated that there was no food served and recommended meals

to be served because when they were in labour they could not take anything due to

pains but after delivery they were in need of food.

N=2 (5%) stated they showered with cold water. One patient was saying "Slept on a

delivery bed throughout the night as the bed was occupied by a nurse on duty"

1

4

1 1 1

2

3

1 1 1

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Negative perceptions of postnatal clients

62

CHAPTER 5

DISCUSSION OF FINDINGS AND RECOMMENDATIONS

5.1 Introduction

In this chapter the researcher focused on the discussion of findings, implications,

limitations, recommendations and summary. The discussion process included the

examination of evidence, formation of conclusions, exploration of the significance of

the findings, generalisation of the findings, consideration of implications and

suggestions for further studies.

5.1.2 PURPOSE OF THE STUDY

The purpose of the study was to investigate whether the clients that received

midwifery services at Empilweni Gompo and Nontyatyambo were satisfied with the

quality of care rendered at these maternity health care centres.

5.1.3 RESEARCH QUESTION

The key research question that was investigated was: “Are the clients attending

midwifery services at Empilweni Gompo and Nontyatyambo Community Health

Centres satisfied with the quality of care rendered to them?

5.1.4 OBJECTIVES OF THE STUDY

The objectives of the study were to:

Identify positive and negative perceptions of women in relation to the maternal

health services rendered at EmpilweniGompo and Nontyatyambo during

antenatal, intrapartum and postnatal periods.

Determine the level of satisfaction of women attending antenatal care and delivery

at these facilities in relation to the quality care variables cited above.

5.2 Discussion

The study responded to the objectives outlined in the research in that it has dealt

extensively with positive and negative perceptions of the participants in the study

and their level of satisfaction during antenatal, intrapartum and postnatal care. In

response to the perceptions and experiences that the participants had during their

63

visits to the Health Centres, they were confident to deliver at these health care

centres for the following reasons: Out of sixty participants interviewed n=28 (47%)

agreed that they were well looked after, n=6 (10%) trusted the nurses and n=6(10%)

found the health centres convenient. This means that a number of pregnant women

were eager to deliver in these health centres. Various complaints that were brought

up about the services rendered at these health centres included the n=7(12%) of

participants that was not well looked after, n=7(12%) that did not trust nurses,

n=1(2%) that said the health centres were inconvenient, then n=1(2%) that did not

like the staff and the n=2(3%) of the participants were not sure whether they wanted

to give birth in these Health Centres.

5.2.1 Positive perceptions during Antenatal Care

Out of sixty participants interviewed during antenatal care n=11(18%) of the

participants were treated with respect and good nursing care was rendered. Physical

environment was clean and the participants were well informed about HIV&AIDS.

Some participants were satisfied about the management of minor ailments of

pregnancy. Looking at the results achieved throughout the study, positive

perceptions experienced by the pregnant women are outshined by the negative

perceptions.

5.2.2 Negative perceptions during Antenatal Care

The antenatal clinic was charactarised with a high rate of infuriated pregnant women

due to waiting for a long period of time without being attended to by midwives. The

participants further argued that nurses were not attending to them timeously;

secondly midwives elongate their tea and lunch breaks and went for breaks

simultaneously. Out of sixty participants interviewed, n=6(10%) of pregnant women

complained of cramped ANC rooms at Empilweni Gompo Health Centre. At

Empilweni Gompo Health Centre both pregnant and postnatal women were using the

same toilets and there were drops of blood on the floor and toilet seats and the

pregnant women were not comfortable with that. When the pregnant women

requested general assistants to clean they got negative responses. Pregnant

women were turned back home due to late coming. Pregnant women were

dissatisfied with that because they had spent money for transportation to the health

centres. There were also participants that were turned back home without being

64

attended to due to busy midwives. There was one participant who claimed that her

blood pressure was not measured yet it was elevated and this resulted to a

miscarriage in a previous pregnancy and she became angry when she looked at that

midwife who was working at one of these health centres. The implication of all the

above is that effective service delivery is compromised and this reflects badly on the

health care workers as well as the Department of Health. Few of the participants

stated that they had no negative perceptions. Generally, the pregnant women were

dissatisfied with the antenatal care rendered at both health centres.

5.2.3 Positive perceptions during Postnatal Care

Labour wards were charactarised by highly satisfied and enthusiastic postnatal

mothers who claimed that they were treated with respect and dignity. They further

stated that the physical environment was clean and they even commented that

Nontyatyambo Health Centre was at the same standard as St Dominics Private

Hospital. Midwives were supportive and approachable and spent more time with the

participants when they were in labour. Observations were done. Mothers were

satisfied because they delivered normal and healthy infants. Postnatal mothers were

satisfied with services rendered at both health centres.

5.2.4 Negative perceptions during Postnatal Care

The majority of participants stated that they had no negative perceptions. Few of

them complained that privacy was not maintained and no meals were served. One

participant stated that she slept on a delivery bed due to the fact that blankets and

beds were occupied by night shift staff.The implication is that there is no effective

supervision at night and this has to be rectified with immediate effect.

5.2.5 Level of Satisfaction during Antenatal Care

Out of sixty participants interviewed n= 49 (82%) of the pregnant women interviewed

agreed that the Health centres were geographically accessible to their residential

areas. Efficiency of health facility staff regarding patient education n=60(100%) of

pregnant women agreed that individual counseling was done to them and also

agreed that they made informed choices regarding HIV & AIDS, n=55 (92%) agreed

that they were informed about the days and times when ANC was offered n=5 (8%)

disagreed. Out of sixty participants interviewed during antenatal care n=53(88%)

65

disagreed that midwives explained the importance of the four focused antenatal

visits, n=35(58%) disagreed that danger signs were explained by midwives and n=32

(53%) disagreed that they were told what to do if danger signs occurred. Out of sixty

participants interviewed n=52(87%) disagreed that they were given information on

factors to be considered when choosing infant feeding. Out of sixty participants n=55

(92%) agreed that effective communication of midwives made them to remember

advice that was given, n=43 (72%) agreed that they were given information on taking

a well-balanced diet. Midwives did tremendous work as far as HCT is concerned. In

regards to PMTCT they did well but there are areas that need more emphasis, such

as factors to be considered when choosing infant feeding to ensure sustainability the

mother has opted to. There is also education deficiency on health education in some

areas such as not being taught about danger signs and what to do when they

occurred. Out of sixty participants interviewed n=58(98%) agreed that equipment

appeared in good working condition and were adequate.

In comparison between the two health centres regarding delivery plan n=10 (17%) at

Empilweni Gompo Health Centre, n=8 ( 13%) from Nontyatyambo Health Centre

agreed that delivery plan was part of ANC visits, n=25(42%) from Empilweni Gompo,

n=23(38%) from Nontyatyambo agreed that they had the right to select a labour

companion. 22% from Empilweni Gompo and 42% from Nontyatyambo were told

about the true signs of labour. 83% disagreed that suggestion boxes were available

and they were able to make decisions.

5.2.6 Level of Satisfaction during Postnatal Care

Ninety eight percent n=39 (98%) of postnatal women interviewed agreed that

physical environment was clean. Postnatal women were satisfied with the birthing

environment. Ninety eight percent n=39 (98%) agreed that the equipments were in

good working condition and adequate.

5.2.7 Human quality of obstetric care

Out of forty (40) participants interviewed during postnatal care n= 39 (97.5%) agreed

that midwives encouraged and supported them during labour. N= 40 (100%)

disagreed that pain relief was given to them during labour. Seventy five percent n =

30 (75%) had no labour companions and twenty five percent n= 10 (25%) had labour

66

companions. All of them had normal vertex delivery but midwives were supporting

them continuously.

5.3 Implications

5.3.1 Implications for nursing practice

Accessibility to health centres should be increased to ensure utilization. To increase

utilization of the clinics, health centres and hospitals, consideration of six National

Priorities is necessary namely: positive staff attitude, improve cleanliness, improve

patient safety, infection control, availability of medicines and reduce waiting times

are reported of having impact on patient experiences and outcomes (National Core

Standards for Health Establishments in South Africa, 2011:15 ).Long waiting periods

of time is the characteristic of a public institution (Vera, 1993). If the clients are

waiting for a long period of time will make them to be dissatisfied with maternity

services rendered.The clinics as the first contact of care should have pregnosticon

test so that all women of bearing age presenting with minor ailments of pregnancy

should be screened to exclude pregnancy complications and those tested positive

should be health educated to attend ANC below twenty weeks. Early booking helps

the midwives to screen conditions, early detection and management of conditions

that could be detrimental to the lives of both mother and the child (Pattison, 2005: 7).

The findings of the current research identified health education deficiency on the part

of the midwives. Health education is the development of individual, group,

institutional, community and systemic strategies to improve health knowledge,

attitudes, skills and behaviour. Health education enhances the quality of life and

reduces premature deaths. According to Burke, Rafferty and Sperle (2010) obstetric

complications that occur during pregnancy greatly add to maternal deaths worldwide,

these complications are avoidable by proper education.

The researcher found that BANC was wrongly implemented or poorly implemented.

Pregnant women could not recall the importance of the four focused visits during

pregnancy. Antenatal care model provides the detailed instructions on how to

conduct the four focused visits. BANC includes a classifying form for easy

assessment of a woman’s eligibility for the basic component and provides checklist

of activities that should be performed throughout the four visit schedule (WHO, 2011

67

as accessed 15.03.2011).The goal of focused antenatal care is the provision of high

quality, basic antenatal care safe, simple, cost effective interventions that all women

should receive- helps to maintain normal pregnancies, prevent complications and

facilitate early detection and treatment of complications and existing diseases

conditions (www.Accesstohealth.org /toolres/ pdfs/ Accesstechbrief FANC.pdf as

accessed on 15.03.2011).Poor implementation of BANC could lead to poor quality

antenatal care as BANC was pioneered as the tool to reduce infant and maternal

mortality (Pattison, 2005:5).

Midwives health educated pregnant women poorly in relation to danger signs and

what to do when the danger signs occurred during pregnancy. To mention any three

danger signs: If the woman was not empowered with the necessary information, the

pregnant woman could stay at home even if she experienced severe headache

which is a sign of pre-eclampsia. If the woman can stay at home yet she presented

with vaginal bleeding that could lead to ante-partum haemorrhage. If the woman can

stay at home in spite of membranes have ruptured for 12 hours the woman can stay

at home without seeking medical help promptly. This could lead to puerperal sepsis.

Out of the five, three of the danger signs that have been mentioned are found to be

major causes of maternal deaths in South Africa (Confidential Enquiries into

Maternal Deaths in South Africa, 2002-2004:7). Enrolled Nursing Assistants were

three times more likely to inform a client of a danger sign than enrolled and

registered nurses (http://www.biomedcentral.com/1471-2393/10/35) as retrieved on

15.03.2011.

Differences in content and quality of antenatal education appear to be another

significant factor in how women understand and seek care for danger signs. Burke,

et al 2010 recommended that district officials should ensure that health education

during antenatal care should be standardized such that all women receive same

information on danger signs during pregnancy in order to decrease maternal

mortality.

Failure of midwives to empower pregnant women with danger signs in pregnancy

could lead to home delivery and complicated delivery due to failure to seek help

promptly. The results of the current study support the study conducted in the

Kassena-Nankana West districts of the upper East region Ghana to assess ability of

68

pregnant women to recognise and understand act upon six severe danger signs.

Results indicated that antenatal clinics within the two districts varied in what maternal

health topics and what danger signs they supposed to cover.

Midwives had done commended work in relation to HIV counseling and testing to

prevent unborn baby to contract HIV from the mother. There are some areas that

need midwives to put some more emphasis in Prevention of Mother to Child

Transmission. Failure to empower women about factors to be considered when

choosing infant feeding if the choice is not sustainable due to unavailability of milk

supply in the clinic the HIV positive mother would end up breastfeeding her baby.

Mix feeding will result in predisposing the child to HIV transmission from the mother.

Diarrhea has been found in babies who are on mixed feeding as the cause of death

to HIV positive children. Midwives should shift from educating mothers on exclusive

formula to exclusive breast feeding (Eastern Cape Department of Health Policy and

for the implementation of the Prevention of Mother to Child Transmission 2008:81).

If women were not advised to select labour companion when they experience pain,

they would call midwife more often and in some instances there is staff shortage.

Funds would be exhausted buying some more sedatives. It has been found that

support and companionship reduce the need for pain relief during labour (Guidelines

for Maternity Care in South Africa, 2007:37). All the pregnant women who were in

labour were not given pain relief at both health centres.

The majority of women was unaware of the availability of a suggestion box and had

a right to make decisions. Patient-centred approach improves patients’ satisfaction.

Patient-centred approach involves shared control of consultations, decisions about

interventions or management of the conditions with the woman. The woman is not

treated as an entity but as a whole person who has individual preferences (Changole

et al, 2010).

The current study concurs with the study conducted by Mxoli (2007), who

investigated women perceptions and experiences of antenatal care rendered by

midwives. Pregnant women were dissatisfied due to long stay at the health centres.

Women felt frustrated and angry when turned back home without being attended to

due to late coming and lack of health education in relation to pregnancy.

69

The midwives were disrespectful of patients’ rights and above all in some instances

the woman might have, for example, raised blood pressure complicate to eclampsia.

This condition could have been avoided if the midwife had attended to the pregnant

woman. Such occurrence should be regarded as misconduct. Midwives should

account for their acts and omissions (Muller, 2002:53).

5.3.2 Implication for the System

According to the findings of the current study antenatal care at Nontyatyambo was

charactarised by furious pregnant women due to long waiting time. The occurrence

of this nature should have been sorted out by proactive managers before it surfaced.

The researcher observed that the midwives working at antenatal were of the same

age. The nurse with midwifery specialty was a. The midwife who qualified via

bridging course was allocated to do drug management. The researcher observed

that there were poor managerial skills.

Pregnant women were given health education by means of pamphlets, not all of

them can read and this resulted in health education deficiency. Staff shortage was a

problem and there were duties initially done by technicians done by midwives like

RPR (Rapid Plasma Reagin) and RH (Rhesus factor). Mentoring and evaluation was

also lacking.

The antenatal room was cramped. The ante natal clinic should be extended.

Empilweni Gompo Community Health Centre was busy as far as deliveries were

concerned; the pregnant women complained that floors and toilets were not clean.

General Assistants needed supervision and needed to be conscientised in relation to

infection control.

Accompaniment of students was poor if there was any. Tutors should accompany

students when allocated at the clinics and health centres for correlation of theory and

practice. The nursing education institutions should ensure that transport is made

available to transport both the students and their tutors.

Turning back home of pregnant women was associated with disrespect of patients’

rights and Batho Pele principles stating that pregnant women should have equal

access to maternity service. This indicated that there was lack of mentoring and

70

evaluation that should have started at lower level, by operational manager at the

antenatal clinics (Eastern Cape Department of Health Service Delivery Charter,

2007:6-7). Turning back of pregnant women due to busy midwives was associated

with staff shortage. The system should employ more midwives to render effective

and efficient maternity services.

Birth companionship programs and policies are not implemented at government

facilities in South Africa (Brown, et al 2007). The researcher observed that the

private sectors render quality midwifery services as compared with government

institutions. The system should benchmark and find out what make them to render

effective and efficient midwifery services. Mentoring and evaluation help the system

to identify the gaps. In-service training, workshops, on-site training and relevant

courses should be arranged to improve the performance of the midwives to improve

patient satisfaction.

5.3.3 Implications for Research

Many South Africans do receive good-quality maternity services (Women who afford

to have medical aids). Too many women receive sub-standard care (women who are

not affording) (Eastern Cape Department of Health Quality Assurance Policy

2007:11). According to the findings of the Confidential Enquiries into Maternal

Deaths in South Africa, (1999-2001:15) sub-standard care by health care providers

is associated with maternal deaths in more than half the cases and is most prevalent

in the primary level of care.

The findings of the current study make the researcher to appeal to other researchers

to investigate the rationale for private sectors to render quality midwifery services

comparatively with the government health facilities.

71

5.4 Recommendations

5.4.1 Recommendations: nursing practice

Primary Health Care Services as the first contact should ensure increased access to

health facilities. Physical environment should be clean, this can be achieved by

training of all general assistants on infection control in accordance to their level of

understanding and should attend cleaning course as well, proper disposal of sharps

and waste to ensure safe environment.

Competent midwives in detecting early and management of diseases that could be

detrimental to the lives of both mother and child, to prevent complications and

promote patient satisfaction. This could be achieved by setting of standards. The

performance of the midwives could be evaluated in accordance with set standards to

identify gaps in rendering of midwifery services and on-site training, workshop and

in-service training should be organised.

Availability of resources human and material: sociable behaviour of midwives,

qualified and experienced midwives to render quality midwifery services, adequate

equipments that are in good working condition and availability of drugs can facilitate

utilisation of health services.

Waiting long period of time without being attended to by midwives can impede

utilisation of the health facilities or can cause pregnant women not to seek medical

help early and complication could occur resulting to patient dissatisfaction. Midwives

should not all break for tea or lunch simultaneously to ensure continuity of services.

The researcher observed that catchment area of Nontyatyambo Community Health

Centre is wide, pregnant women should attend antenatal care in their nearest clinics

hence Empilweni Gompo there were few pregnant women attending antenatal care.

Awareness Campaign amongst members of the community should be done to

ensure utilisation of nearest clinics.

All women should have access to reproductive health care. Family planning should

be encouraged to girls below eighteen to prevent teenage pregnancy, women above

thirty five years and older, women in their first pregnancy or who had five or more

pregnancies are (gravida five or more) should be discouraged to give birth because it

72

has been found that they are prone to maternal deaths (Saving Mothers and Saving

Babies. Enquiries into maternal deaths in South Africa (1999-2001:5).

All midwives rendering midwifery services should be trained in Basic Antenatal Care

to be able to detect early and management of diseases or conditions that could lead

to maternal deaths (www.Accesstohealth.org/toolres/pdf/pdfs/Accesstechbrief

FANC.pdf as accessed15.03.2011.

It has been discovered that Enrolled Nursing Assistants (ENA) were three times

more likely to inform a pregnant woman on danger signs that can occur during

pregnancy than enrolled and registered idwives(http:www.biomedcentral.com/1471-

2393/10/35 as retrieved on 15.03. 2011). Enrolled Nursing Assistants should be

trained on HIV Counseling and Testing, should be empowered with health education

skills on the following: Family planning, true signs of labour, delivery plan, danger

signs that can occur during pregnancy and steps to be taken when danger signs

occur, factors to be considered when choosing infant feeding, importance of taking

well balanced diet.

Midwives also have a teaching function, health education of pregnant women should

be done throughout pregnancy and midwives should mentor the nursing assistants in

the provision of relevant information.

Implementation of labour companionship should be encouraged. Birth

companionship programs and policies should be in place in all institutions rendering

midwifery services.

All midwives working in maternity wards are encouraged to attend course on

integration of HIV/AIDS, sexual transmitted infections and tuberculosis, it has been

found that HIV/AIDS is one of the causes of maternal deaths (Saving Mothers.

Confidential Enquiries into Maternal Deaths 2002-2004:15). All pregnant women

should be offered HCT, if tested HIV positive blood for CD4 Count should be

withdrawn. If CD4 Count is above three hundred and fifty DualTherapy is

implemented and if CD4 Count is below three hundred and fifty HAART is

implemented (Eastern Cape Department of Health Policy and for the implementation

of Mother to Child Transmission 2008:52).

73

5.4.2 Recommendations to the System

Infra-structure: Cramped antenatal rooms should be extended. Generators should be

in place in case of load shedding of electricity, postnatal women complained of

showering with cold water.

Braking for tea and lunch of midwives simultaneously is associated with lack of

supervision. Operational managers should be encouraged to attend supervisory

courses which will equip them on the skills and information on how to ensure efficient

and effective services. They should increase staff members for them to be able to

delegate them according to the needs of the health centre. They should ensure the

availability of human and material resources to reduce waiting time.

Turning back home of pregnant women due to busy midwives is associated with staff

shortage. More midwives should be employed.

Operational managers are encouraged to attend Mentoring and Evaluation course to

be able to monitor performance of the subordinates and identify weaknesses or gaps

and arrange relevant in-service training or workshop.

The researcher recommends serving of meals because some of pregnant women

delivering at Empilweni/ Gompo and Nontyatyambo community health centres are

staying in rural areas they were in labour throughout the night, after delivery women

want something to eat and in some cases relatives do not have money to visit them

(women).

Student accompaniment by their tutors is encouraged for correlation of theory and

practica. Transport system should be made available.

Effective transport system is encouraged to prevent delay that could cause

complication to both mother and baby. More ambulance should be hired. Stand-by

ambulances are encouraged. Midwives should be trained in Advanced Midwifery to

be able to manage complicated deliveries.

Midwives who violate patients’ rights should undergo disciplinary actions. More

budget should be allocated in maternity wards to ensure equipments are available

and in good working order, drugs for example cyntocinon, materials, ensure that

disposable napkins, toilet papers, gloves are made available.

74

5. 4.3 Recommendations for research

The findings of the current study make the researcher to appeal to other researchers

to investigate the rationale for private sectors to render quality midwifery services

comparatively with government health facilities.

All clinics should have pregnosticon test so that all women of child bearing age

presenting with minor ailments of pregnancy to be screened to exclude pregnancy.

Women with positive pregnancy test should be health educated for early booking

before twenty weeks (20) (Pattison, 2005:7).

All midwives should be trained on BANC. Pattison (2005:1) pioneered training of

trainers.

All midwives should undergo Nurse Initiation Management of Anti-Retroviral Training

(NIMART) so that HIV positive pregnant women with Cluster Differentiation Four

Count (CD4Count) below three hundred and fifty to be commenced on HAART to

prevent delay that could lead to transmission of HIV from mother to baby.

Midwives should attend courses on integration of HIV Counseling and Testing

(HCT), Sexually Transmitted Infections and Tuberculosis.

Labour companion policy should be in place in all maternity wards and should be

implemented.

General Assistants should attend a cleaning course.

The researcher recommends that there should be laboratory services in health

centres to improve turn- around of results and to alleviate work load to midwives as

they are supposed to take blood rapid test for Wassermann Reaction (WR), Rhesus

Factor (RH). This could be done by laboratory technicians and midwives should

ensure that they (midwives) render maternity services effectively and efficiently.

All midwives allocated in mother and child program at the clinics, community health

centres and maternity wards in tertiary hospital should attend peri-natal reviews to

address identified deficiencies during antenatal, peri-natal and postnatal period.

In–service and onsite training and workshop should be conducted to improve the

performance of the midwives to ensure quality of care is rendered.

75

Promotion of employing monitoring and evaluation officer in both health care centres

to identify gaps and assess performance of midwives in rendering midwifery services

is in accordance with set standards to ensure desired outcomes are achieved.

(Compliance with maternity guidelines, protocols and policies).

Refresher courses are encouraged. Midwives should be trained in advanced

midwifery. Health education should be encouraged. Supportive supervision should

be made to enhance health education.

Health education as the preventive role of the nursing assistants should be trained in

HCT, PMTCT, topics in relation to pregnancy: importance of breast feeding and

taking well balanced diet, family planning, signs of true labour, danger signs and

steps to be taken when the danger signs occur, etc. This should take place during

the presence of the midwife to ensure proficiency of the enrolled nursing assistants

and to answer questions asked by pregnant women that are above the scope of the

enrolled nursing assistants.

Accompaniment of student nurses by their tutors when allocated in the clinics and

health centres to ensure correlation of theory and practica (The institution should

ensure that transport is made available).

Infrastructure: Cramped antenatal clinic at Empilweni and Gompo should be

extended and should be re-structured in such a way that pregnant women and

postnatal women do not use same toilets and sluice room.

Continuity of care should be encouraged. Midwives should not break for tea or lunch

simultaneously. More staff should be employed to ensure quality care is rendered.

Patient satisfaction survey should be conducted to elicit areas of satisfaction and

dissatisfaction.

5.5 Summary

In comparison between the midwifery services (that is antenatal, intrapartum and

postnatal care) rendered in both health care centres, pregnant women are

dissatisfied with antenatal care and satisfied with postnatal care to such an extent

they commented that Nontyatyambo is like St Dominics Private Hospital and they

were impressed with panic buttons (bell) and the support they got from midwives.

76

The most important thing that made them to be enthusiastic was the outcome of

delivering live and normal infants.

77

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83

ANNEXURE A

Ikamva eliqaqambileyo!

Eastern Cape Department of Health

Enquiries: ZonwabeleMerile Tel No: 0833781202

Date: 30'* December 2008 Fax No: 0406081177

e-mail

Address:

zonwabele.merile@impilo.ecprov.gov.za

Dear Mrs. P Mfundisi

R»: Client satisfaction with midwifery services rendered by two Community Health Centers in the Eastern

Cape Province, South Africa

The department of Health would like to inform you that your application for conducting a research on the above

mentioned topic has been approved based on the following conditions:

1 During your study, you will follow the submitted protocol with ethical approval and can only deviate from it

afterhaving a written approval from the Department of Health in writing.

2. You are advised to ensure you observe and respect try rights and culture of your research participants and

maintain confidentiality of their identities and shall remove or not collect any information which can be used to

link the participants. You will not impose or force individuals or possible research participants to participate in

your study. Research participants have a right to withdraw anytime they want to.

3 The Department of Health expects you to provide a progress on your study every 3 months (from date you

received this letter) in writing.

4. At the end of your study, you will be expected to send a full written report with your findings and

implementablerecommendations to the Epidemiological Research & Surveillance Management. You may be

invited to the department to come and present your research findings with your implementable

recommendations.

5. Your results on the Eastern Cape will not be presented anywhere unless you have shared them with

the

Department of Health as indicated above.

84

Your compliance in this regard will be highly appreciated.

DEPUTY DIRECTOR: EPIDEMIOLOGICAL RESEARCH & SURVEILLANCE MANAGEMENT

85

ANNEXURE B

Ikamvaeltgaqambileyo!

Eastern Cape Department of Health

Enquiries: ZonwabeleMerile Tel No: 0833781202

Date: 30'* December 2008 Fax No: 0406081177

e-mail

Address:

zonwabele.merile@impilo.ecprov.gov.za

Dear Mrs. P Mfundisi

Re: Client satisfaction with midwifery services rendered by two Community Health Centers in the Eastern

Cape Province, South Africa

The Department of Health would like to inform you that your application for conducting a research on the

abovementioned topic has been approved based on the following conditions:

1. During your study, you will follow the submitted protocol with ethical approval and can only

deviate from it afterhaving a written approval from the Department of Health in writing.

2. You are advised to ensure you observe and respect the rights and culture of your research

participants andmaintain confidentiality of their identities and shall remove or not collect any information

which can be used to link the participants. You will not impose or force individuals or possible research

participants to participate in your study. Research participants have a right to withdraw anytime they want

to.

3. The Department of Health expects you to provide a progress on your study every 3 months

(from date youreceived this letter) in writing.

4. At the end of your study, you will be expected to send a full written report with your findings and

implementablerecommendations to the E:pidemiological Research & Surveillance Management. You may

be invited to the department to come and present your research findings with your implementable

recommendations.

5. Your results on the Eastern Cape will not be presented anywhere unless you have shared

them with the

86

Department of Health as indicated above.

DEPUTY DIRECTOR: EPIDEMIOLOGICAL RESEARCH & MANAGEMENT

87

ANNEXURE C

NO 16NU13 MDANTSANE 5219

06 02 2009

THE NURSING SERVICE MANAGER EMPILWENI COMMUNITY HEALTH

CENTRE EAST LONDON

RE- REQUEST TO CONDUCT THE RESEARCH STUDY

Dear Madam

I, Nokwamkela Pearl Mfundisi, doing Master Program in Advanced Midwifery at

the University of Fort Hare, hereby request to conduct a study in your institution.

The title of the study is: Patient satisfaction with midwifery services that are

rendered at Empilweni and Nontyatyambo Community Health Centres.

I hope my request will receive your favourable attention.

Thank you Your's faithfully

N.P Mfundisi

88

ANNEXURE D

89

ANNEXURE E

NO 16NU13 MDANTSANE 5219

06 02 2009

THE NURSING SERVICE MANAGER NONTYATYAMBO COMMUNITY

HEALTH CENTRE MDANTSANE

RE- REQUEST TO CONDUCT THE RESEARCH STUDY

Dear Madam

I, Nokwamkela Pearl Mfundisi, doing Master Program in Advanced Midwifery at

the University of Fort Hare, hereby request to conduct a study in your institution.

The title of the study is: Patient satisfaction with midwifery services that are

rendered at Empilweni and Nontyatyambo Community Health Centres.

I hope my request will receive your favourable attention.

Thank you Yours faithfully

N.P Mfundisi

90

ANNEXURE F

IsebeLeZempilo - Department of Health

NONTYATYAMBO COMMUNITY

HEALTH CENTRE

P.O BO X 363 Mdantsane5219 2009/02/06

Enquiries: Ms B.G TsengiweTel: 043 7600420 Fax: 043)7600646

BUFFALO CITY SUB-DISTRICT

This serves to confirm that Nokwamkela Pearl Mfundisi has been granted permission to

conduct her study at Nontyatyambo Health Centre from February 2009 to June 2010.

Yours faithfully

A CTING MIDDLE MAN AGER HEAL TH

1

2009-06- 0

91

ANNEXURE G

IPHEPHA MVUME PHAKATHI KOMPHANDI NOMPHANDWA Uyacelwa mama

uthabathe inxaxheba kuphando

ISIHLOKO SOPHANDO: Ukwaneliseka kwabaguli abahamba iinkonzo zokubelekisa

eGompo naseNontyatyambo, eMonti, eMpumakoloni.

INJONGO ZOPHANDO

Kukuphanda ukuba abantu abahamba kumaziko okubelekisa bayaneliseka zinkonzo

abazifumanayo eGompo nase Nontyatyambo.

ABANTU ABALINDELEKE BAXHAMLE KOLU PHANDO

Abahlali baseMdantsane naseMonti: Ukuba abahlali bayoneliseka, imfuno zabo

neminqweno yabo iyaphunyezwa izakubanceda ababelekisi noogqirha baqwalasele

ngakumbi imeko ezibenza abaguli baneliseke ,izakubabangela bangafuni ukuphangela

kwezinye inkonzo bafune ukubelekisa babengamachule okubelekisa ngakumbi ,yehlise

izinga lokusweleka kukamama ebeleka nomntwana osanda kubelekwa.

Abomthetho kwiqumrhu lokonga:

Abaqulunqibomthethobazakuncedakalabazakuqwalaselazonkeimekoezenzauluntulonelis

eke nemithetho izakulungiswa ibeke abantu kuqala nemfuno zabo

Oluphando luzakunceda ekongezelekeni kulwazi olukhona, Iwazi olo

lungasetyenziswa nangabanye abaphandi.

INXAXHEBA EZAKUDLALWA NGUMPHANDWA: Okulindelekileyo kumphandwa

kukuphendula imibuzo eyakuthatha imizuzu engamashumi amabini. Umphandi ucela

nemvume yokuvulela unomathotholo xenikweni uphendula imibuzo.

INXAXHEBA YOMPHANDI:

Kukumhloniphaumphandwangokuthiafikengethubaxabenezigqibozokuhlangana,

nokuphendulaimibuzoengaqonnwayongumphandwa.

INKCUKACHA MALUNGA NOPHANDO

Umphandwa unelungelo lokuthatha inxaxheba ngokuqhutywa yintliziyo, yaye

unelungelo lokungawuphenduli umbuzo angaziva efuna ukuwuphendula .Oko

akuzumenza angalifumanii lungelo ebemele ukulifumana ngenxa yokurhoxa ukuthatha

inxaxheba.

92

Ukuba umphandwa unemibuzo malunga nophando angabuza kumphathi womphandi

Mary Hodkinson

University of Fort Hare East London cell no: 0834150775

Uphandingu Nokwamkela Mfundisi no!6 nu!3 Mdantsane 5219 home phone no 043

7631841 cell no

0761115743

Umphandwaasayine:

Umphandiasayine:

93

ANNEXURE H

INFORMED CONSENT FORM

TITLE OF THE STUDY: PATIENT SATISFACTION WITH MIDWIFERY SERVICES

THAT ARE RENDERED AT GOMPO AND NONTYATYAMBO COMMUNITY HEALTH

CENTRES

PURPOSE OF THE STUDY: The purpose of the study is to establish whether the

patients are satisfied with midwifery services rendered at Gompo and Nontyantyambo

Community Health Centres.

POTENTIAL BENEFITS OF THE STUDY

MEMBERS OF COMMUNITY: Evaluation of midwifery services by clients, families and

members of the community will help health professionals to improve their performance

and there will be decreased infant and maternal death rate.

POLICY MAKERS: The study will elicit areas of satisfaction/ and dissatisfaction. This

will help the policy makers to modify the existing policies in order to enhance patient

satisfaction.

HEALTH PRACTITIONERS: The study will be useful to health practitioners, if the

clients are satisfied with care rendered the morale will be elevated and will be more

considerate to patients' needs.

RISKS AND DISCOMFORTS: There will be no risks and physical discomforts; there

could be psychological discomfort if the patient has negative perceptions during

antenatal/ intrapartum period.

INFORMATION

The participant has a right to participate in the study or not. A participant has a right to

withdraw from the study at any time without consequences of any kind or loss of

benefits to which they may be entitled. A participant has a right to refuse to answer any

question that she or he chooses not to answer. There will be no penalties for

withdrawal from the study.

94

CONFIDENTIALITY

The information obtained from the participants will be kept confidentially and there will

be no one who will have access to the information given except the researcher. The

results will be disclosed with the subject's approval,or as required by law.

ANONIMITY

The researcher will use coding instead of names.

PARTICIPANTS' RIGHT TO KNOW

The participants have right to ask questions about the study and the participants'

rights, have right to know the researcher's supervisor contact number:082003551. The

researcher's home address N0.16 NU13 Mdantsane. Home no.043 7631841, cell

no.0761115743. University Research Board has reviewed and approved this project.

PARTICIPANT'S SIGNATURE: DATE:

RESEARCHER'S SIGNATURE:

95

ANNEXURE I

NAME OF HEALTH CENTRE

Kindly answer the following questions which should not take more than 10 minutes of your time.

Date Patient code

DEMOGRAPHIC DATA

Kindly provide the following demographic information about yourself.

Ethnic group

Black Indian Coloured White

Age

Below 18 19-24 25-30 31-34 Above 35

Obstetric data

Gravidity Parity Number of current

ANC visits

Period of

gestation

Kindly provide the following demographic information about yourself. Make an X against the

block that represents your answer.

DISTANCE FROM HEALTH CARE CENTRE

PATIENT

EXPERI

0-2 km 2-3 km 4-5 km 6-10 km More than 10 km Mode of

transport during

ANC

Foot Public

transport

Private transport Hired transport

Mode of

transport used

during labour

Foot Public

transport

Private transport Hired transport

ambulance

Time it takes to

reach facility

15-30 min 30 min to 1

hour

More than Ihour More than 2hours

96

ENCES AT THE ANTENATAL CLINIC

Rating scale: 5= strongly Agree, 4= Moderately Agree, 3= Agree, 2= Disagree, 1= Unsure

Accessibility to the health centre 5 4 3 2 1 No

response

1. The health care centre is geographical accessible to me. 2. The maternity care is accessible to pregnant women as

the service is free

B. Equitable access during Antenatal Care (ANC)

3 The midwives made me feel welcome at this clinic on

every antenatal visit.

4. Midwives provided all women with numbers which

indicated the order in which they would be attended

5. Women were fairly treated whoever they were.

6. 1 felt that 1 was being treated with dignity and respect

throughout the antenatal period.

7. My experience during the antenatal period gave me the

confidence to deliver at this health centre for the following

reasons: Tick the most appropriate answer or answers

below:

7.1 It is most convenient for me.

7.21 like the staff here.

7.3 1 have been well looked after during the ANC visits.

7.4 1 trust the nurses to deliver my baby

8. My experience during the antenatal period made me to

decide NOT to deliver at this health centre for the following

reasons:

8.1 The health centre is not convenient for me.

8.2 1 do not like the staff here.

8.3 1 have not been well looked after during ANC visits.

8.4 1 do not trust the nurses to deliver my baby.

If there is any other reason explain below:

C. Efficiency of health facility staff: patient education

9 Both group and individual counseling was offered to

pregnant mothers.

11. The midwives explained the importance of the four

focused antenatal visits during pregnancy and my

responsibilities in relation to each visit

12.The midwives explained the danger signs that could

occur during pregnancy such as early rupture of

membranes

97

13. The midwives explained the steps that the woman

should take should the danger signs appear, such as noting

the time the membranes ruptured, the color and odor of the

liquor and the need to come to the health centre.

14. The midwives explained the importance of HIV testing

during pregnancy as a measure of protecting the inborn

baby.

15. 1 made informed choices regarding HIV testing due to

health education given by midwives.

16. I was educated about the factors to consider when

making a choice on infant feeding.

17 The effective communication skills of midwives made

me to remember the advice given and to act accordingly.

18. During information sharing the midwives explained the

importance of taking a well balanced diet.

D. Efficiency of health facility: obstetric competence of

midwives during antenatal care

19. 1 believe that the obstetric skill of midwives contributed

to my welfare and that of my unborn baby

20. The midwives demonstrated competence by detecting

a high risk factor, high blood pressure in my pregnancy.

21. Delivery planning formed part of my regular pregnancy

visits in the last trimester of my pregnancy.

22. The midwives explained that 1 have a right to select a

labour companion of my choice.

23. The midwives advised me on the true signs of labour.

E. Community participation

24 1 have seen the suggestion box which enables the

community to express their views regarding the midwifery

services rendered at this facility

25 Community members are able to make suggestions of

services through the community health committee

F. Open- ended responses 26. Did you have any positive perceptions that you would

you like to share with me regarding your antenatal care?

27. Did you have any negative perceptions that you would

like to share with me regarding your antenatal care?

Thank you for responding to this questionnaire. Your responses will contribute to the

improvement of maternity care services offered at this health centre.

98

ANNEXURE J

NAME OF HEALTH CENTRE

You are requested to participate in this study by answering the following questions as honestly

as possible. There is no right or wrong answer.

Date Patient code

DEMOGRAPHIC DATA Kindly provide the following demographic information about yourself

Ethnic group:

Black Indian Coloured White

Age:

Below 18 19-24 25-30 31-34 Above 35

Obstetric data:

Gravidity Parity

PATIENT SATISFACTION WITH HEALTH SERVICES DURING LABOUR Rating scale: 5= Strongly agree; 4= Moderately agree; 3= Agree; 2= Disagree; 1= Unsure

A. The birthing environment 5 4 3 2 1 No

response

1. The physical environment of the labour ward

was inviting.

2. The temperature in the labour ward made the

room comfortable.

3. The midwives created a warm welcoming

atmosphere.

4. Midwives used screens to provide privacy.

5. Linen was clean and appealing.

99

6. Water was given to me by midwives on

request.

B. Technical factors

7. The equipment such as blood pressure

machines used on me appeared to be in good

working order.

8. There appeared to be adequate equipment for

all patients.

The human quality of obstetric care

9. The midwife supported and encouraged me

during labour.

10. When I had the urge to bear down, the midwife

gave me clear guidance on how to do so.

11. The midwife complemented me on my bearing

down efforts.

12. The midwife conducted my delivery in a manner

that satisfied me.

13. My labour ended in the safe delivery of my baby.

14. When I developed problems they were managed

satisfactorily.

D. Pain and relief during labour

15. I was given pain relief during labour as the need

arose.

E. Companionship in labour

16. I opted to have/ not have a labour companion

(encircle the statement showing the patients

response)

100

17. My labour companion was given guidance on

how best to assist me (Giving me emotional support,

providing me with basic needs etc.)

18. My labour companion was made welcome

during labour and delivery process, and was well

looked after

19. Would you have a labour companion for future

deliveries?

Explain why/ why not

F. Communication and interpersonal skills

20. The midwives treated me with courtesy and

respect.

21. The midwives discussed the issue of my HIV

status and related preventive measures (PMTCT) in

private.

G. Foetal outcomes

22. I delivered a normal healthy infant in this facility.

23. I was informed about the health status of my

baby immediately after delivery.

25. My baby was placed on my chest soon after

delivery to foster bonding.

H. Maternal outcomes of labour

26. I am satisfied with the way my labour was

managed at this Health Centre.

27. Would you recommend a friend or a close

relative to deliver at this facility?

Please explain why you said yes/ no.

101

OPEN-ENDED RESPONSES

Did you have any positive perceptions that you would like to share regarding your delivery?

Did you have any negative perceptions that you would like to share regarding your delivery?

102

OFFICE OF THE DEPUTY VICE-CHANCELLOR: ACADEMIC AFFAIRS AND RESEARCH

Private Bag X1314, Alice 5700 Tel: 0406022403 Fax: 0866282944 tsnyders@ufh .ac.za

University of Fort Hare

Ms. N.

Dyeli200605055

An evaluation of effectiveness of the

implementation of the Basic

Antenatal Care (BANG) programme

in selected clinics in Mdantsane,

Eastern Cape Province, South

Africa.

Approved with

corrections. Supervisor

to oversee.

Mrs. P. Mfundisi

9517359

Client satisfaction with midwifery

services rendered by two

Community Health Care Centres in

the Eastern Cape Province, South

Africa.

Approved with

corrections. Supervisor

to oversee. Mrs. F. Jakeni-

Gomba 200605054

Post delivery auditing of adherence

to the dual therapy (AZT and NVP)

intake during labour at Cecilia

Makiwane Hospital, Eastern Cape

Province, South Africa.

Approved with

corrections. Supervisor

to oversee. Ms. T. Dondashe-

Mtise2000421891

An exploratory study of the attitudes

of nurse managers towards quality

improvement programmes in the

East London Hospital Complex,

Eastern Cape Province, South

Africa.

Approved with

corrections. Supervisor

to oversee.

Ms. N.

Rululu8920093

Job satisfaction among professional

nurse working in Antiretroviral clinics

in the Eastern Cape Province, South

Africa.

Approved with

corrections. Supervisor

to oversee. Ms. L Hlosana-

Lunyawo200605059

Experiences of newly qualified

professional nurses working in

primary health care facilities in the

Eastern Cape Province, South

Africa.

Approved with

corrections. Supervisor

to oversee. Mrs. N. Hlaula

200605075

Challenges faced by the families of

chronically ill persons in the

Amathole District in the Eastern

Cape, South Africa.

Approved with

corrections. Supervisor

to oversee.

103

Professor J R Midgley

Deputy Vice-Chancellor

Chairperson of the interim Ethics Committee

4 December 2008

104

OFFICE OF THE DEPUTY VICE-CHANCELLOR: ACADEMIC AFFAIRS

AND RESEARCH Private Bag X1314, Alice 5700 Tel: 0406022403 Fax:

0866282944 tsnvders@ufh .ac.za

University of Fort Hare

Application for clearance from the University of Fort Hare's Ethics Committee

Project Title: Various applications in the Department of Nursing Sciences as

detailed below:

Date of application: 1 December 2008

Having consulted the Dean of Research, I hereby grant permission to conduct

the research as set out in the schedule below.

Name of student Proposal tide Comments Dr. EM. Yako

200605058

Adherence to pre-selected infant

feeding practices among mothers on

the prevention of mother-to-child

transmission (PMTCT) of HIV/AIDS

programme in the AmathdeRegion,

Eastern Cape, South Africa.

Approved.

Mrs. N.

Mkhencele20060506

6

An evaluation of the role of support

groups on the lives of HIV positive

people at two Community Health

Centres in East London, Eastern

Cape.

Approved with

corrections. Supervisor

to oversee. Mrs. B. Bell

200605056

A comparative study of selection

criteria and academic outcomes for

students in undergraduate nursing

programmes in two nursing

institutions in East London 2004-

2008.

Approved.

Mrs. R. Durrtieim

200605060

The study of self-esteem among

patients diagnosed with

schizophrenia in the East London

Hospital Complex, Eastern Cape

province, South Africa.

Approved with

corrections. Supervisor

to oversee. Mrs. N. Qomfo

200605064

Community Based Education: The

perception of the 2008 first year B.

Cur students of the University of

Fort Hare.

Approved with

corrections. Supervisor

to oversee.

105

Ms. N. Jora 8421725 Perceptions of final year nursing

students of the University of Fort

Hare in the Eastern Cape towards

the Objective Structured Clinical

Examination during the year 2008.

Approved.

Mrs. N. Mangi

2004421891

The impact of HIV/AIDS on the

delivery of maternal and child

services of selected primary health

care dinics in the Eastern Cape

Province, South Africa.

Approved with

corrections. Supervisor

to oversee.

106