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
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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.
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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
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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
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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
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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
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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
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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
Address:
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
Address:
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
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