Quality care during child birth: women and health care

provider’s perspectives in Malawi

Dr Florence Mgawadere

26th September, 2017

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Outline

• Background

• Aim

• Methodology

• Results

• Recommendations & Implications for practice

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• MDG strategy was successful in SBA at birth

in LMICs from 62% in 2000 to 73% in 2013

However, 99% of maternal deaths still occur in developing region- 66% in SSA

• Malawi, SBA ↑ from 55% to 91.4% between 2000-2015

MMR remains high- 439 per 100 000 live births in 2015

• Quality of care (QoC) has become paramount

To improve quality of care, it is important to understand what quality means to mothers and

health care providers.

Many studies have shed more light on perception of care from women and providers

However, relatively limited literature is available on how women and providers define QoC during

child birth and no tools to give feedback on care

Background

(WHO global monitoring report 2015, WHO,2004 &

2015, MDHS, 2015),

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Republic of Malawi

• A Landlocked country in southeast Africa

with a population of about 18 million people

• Poor country with GDP per capita , 4,544$ billion

• Poor health indicators

- MMR- 439 deaths per 100,000

- Under-five mortality 63 per 1,000

- HIV prevalence 8.8% ( 10.8, women &

6.4 men)

(World Bank 2016, MDHS, 2015)

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Framework for assessing QOC

Tunçalp et al 2015, WHO Quality of Care Framework for maternal and newborn health

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Aim

• To explore women’s and healthcare provider’s perspectives on quality of care provided during childbirth in rural Malawi?

• Specifically to define

- good care

- poor care

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Rationale

• Low quality has been reported as a major factor in non-utilisation of health services and visa versa

• Results are expected to identify common key focus areas for improving child birth care

• Inform development of a simple, user friendly tool that can be used to give feedback on quality of child birth.

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Methodology

• Qualitative study

• Two districts in Malawi (Kasungu and Thyolo)- (14 facilities- 7 in each district)

• Part of 5 LSTM intervention districts- MoH choice- poor maternal health indicators- different tribes

• Convenient sample

• Data collection

- Semi-structured interviews (27 HCPs)

- FGD- women post-delivery (14 groups)

- Recorded/transcribed

- Saturation principle was used

• District- selected by MOH, have poor maternal health indicators . A large part of Thyolo’s surface area is taken up by tea estates, leaving the remainder of land to local families for small farming and food production

• Thematic analysis

• Thyolo district is comprised of seven Traditional Authorities (TAs;!Nchilamwela,! Kapichi,Changata,Nsabwe,Thomas,Bvumbwe and Chimaliro) and four SubTA Traditional Authorities (Mphuka, Mbawela, Thukuta and Khwethemule) with a total of 456 villages.

• Data management – becoming familiar with the data (reading and re-reading); identifying initial themes/categories; developing a coding matrix; assigning data to the themes and categories in the coding matrix.

• Descriptive accounts – summarising and synthesising the range and diversity of coded data by refining initial themes and categories; identify association between the themes until the ‘whole picture’ emerges; developing more abstract concepts.

• Explanatory accounts – developing associations/patterns within concepts and themes; reflecting on the original data and analytical stages to ensure participant accounts are accurately presented and to reduce the possibility of misinterpretation; interpreting/finding meaning and explaining the concepts and themes; seeking wider application of concepts and themes

1. Doctors

2. Midwives

3. Clinical officers

4. Medical assistants (directly involved in maternity

care)

Women who had

delivered within 7-

42 days prior to

interview and had

live births

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Methodology

• Thematic content analysis :Framework approach (Ritchie and Lewis 2003)

• Ethical approval LSTM and NHSRC- Malawi

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Results: GOOD QUALITY by women and HCP

Midwife available

Examined often

Greeting

Warm welcome

Rapport

Provision of care

Good referral system

Pain Medication

Human resources

God infrastructure

Information giving

Self-introduction

Prompt care

Equipment

Consented

care

A clean bed

Competent staff

A smile

Warm water Complete

labour graph

Not sleeping on the floor

Effective communication

Ask questions

Interpersonal relationship

Environment

Figure 1. Aspects of good care by women (white circles), HCP (grey circles) and both women and HCP (Blue)

Monitoring per guidelines Incentives e.g.

risk allowance, appraisal

Salary increment

Woman- “I love

midwives who can

smile and talk to you. It

just makes all the child

experience superb”

HCP- “Quality of care

requires adequate

resources such as

staff, equipment, and

motivated staff”

Woman - “I wish

there was pain

medication for

labour but my

grandmother told

me child birth pain

does not need

any medication”

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Interpersonal relationship Environment

Provision of care

Poor quality of child birth care

Poor interperso

nal relationshi

p

Lack of privacy

Giving birth without SBA

Poor referral system

Inadequate HR

Verbal and physical

abuse

Inadequate room for

companionship

Companionship in labour

Figure 1. Aspects of poor care both women and HCP (white circles), women only (grey circle) and HCP only (Blue)

Woman “I arrived at a health

facility at 6pm and found no one,

a cleaner came after sometime

and took me to a delivery room.

The cleaner went to call a doctor

and she did not come. I stayed

for almost three hours, and I

gave birth on my own

Woman “Those are the

fruits you enjoyed with your

spouse, I was not available

that time, why bother me,

labour is painful, I cannot

not use my hands to extract

the baby from your womb”

HCP “If the woman is not

cooperating and closing

the legs when a baby is

coming out, staff could be

so agitated, thereby, just

slap the woman on the

thigh so that she can

actually deliver the baby. I

have witnessed such

situations. It is not really

mistreatment. It is helping

the woman indirectly

HCP “You are alone in a

labour ward against 6

women who are giving

birth at the same time, I

mean how do you attend to

all of them, women are

often neglected that way”

Results: POOR QUALITY by women and HCP

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Interpretation of results

• Aspects of good quality of care differed substantially

- HCPs concerned with structural aspects of care such availability of material and human resources

- Women valued more on a positive relationship with their caregiver- not aware of most technical aspects of care

• Most aspects of poor quality were similar, such as giving birth without SBA, non-consented care, neglect/abandonment physical and verbal abuse, lack of privacy

• Like other studies in Malawi and other countries in LMC, HCPs linked poor quality of care provided to lack of resources, staff de-motivation and frustration

• Surprisingly, companionship during childbirth was described as example of poor care. HCPs were happy with companionships but the environment was not conducive.

• Women not knowledgeable about use of pain medication during child birth

.

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Limitations of the study

• Findings reflect opinions of who interacted with the health system

but provide useful information about quality of childbirth care

• Most women were from rural area and illiterate

• Women who had still births were not included- may have different

views

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Recommendations and implication to practice

• The context factors identified are relevant in designing quality improvement interventions and policies to improve child birth care

• A renewed focus needed –improve on communication, strengthen patient rights and respecting women’s autonomy in decisions is important

• HCP motivation and providing enabling environment for comprehensive and inclusive quality of care.

• Educating women about evidence based quality of childbirth including technical care to address the gap between perceived and actual care is necessary

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Acknowledgements

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Thank you!