Quality of Maternal Healthcare in Four Districts in Northern Region, Ghana

Abstract

Background: The quality of maternal healthcare women receive during pregnancy and delivery has attracted global attention. However, tools and empirical studies on quality of maternal healthcare women receive are lacking in many low-income settings including Ghana. Available literature shows that many of the current assessment tools are provider driven, focusing mainly on clinical care aspect of quality without considering clients' perspectives. This study aimed to fill these knowledge gaps by developing and validating an assessment tool and using same tool to assess the quality of maternal healthcare in selected districts in Northern Region of Ghana. Methods: An exploratory sequential mixed methods study design was used. This design was operationalised in three phases. The first phase was a qualitative exploration of clients' and providers' perspectives on quality of maternal healthcare. It comprised 6 focus group discussion sessions with 46 postnatal women and 39 in-depth interviews with postnatal women and 7 healthcare workers. The second phase of the design built on the first. This involved the development and validation of a quality of care assessment tool. Fifty-five (55) maternal and child health experts were purposively selected to assess quality of care domains that was proposed. The aim was to determine item's clarity and relevance on a 5-point Likert scale. The final phase involved administering the maternal healthcare quality assessment tool to a total of 520 randomly sampled postnatal women in a survey in four districts in the northern region (Tamale metropolis, Savelugu-Nanton municipality, Kumbungu and Sagnerigu districts) to assess quality of maternal healthcare they received during their most recent pregnancy. Thematic content analysis techniques were used to analyse qualitative data. Content Validity index (CVI), polychoric correlation co-efficient, and Item Response Theory (lRT) model were used, to assess suitability, correlation between items in each construct and reliability of the tool. Descriptive statistical analysis was done to describe important demographic and maternal health characteristics of survey respondents. To assess quality of maternal healthcare women received, mean quality of care scores were obtained for each domain by adding the mean scores for individual items and dividing the results by the number of items in each domain. Based on this mean score for each domain, the quality of care under each domain was then recategorized into three scales, where a mean score of 1.0 - 2.0 meant low quality; mean score of 2.1- 3.9 meant moderate quality; and mean score of 4-5 meant high quality. Percentage distribution tables were then constructed to show the proportion of respondents who rated the quality of care they received as either low, moderate or high. Findings: Results from the qualitative interviews identified a total of 13 domains of care and 57 indicators of maternal healthcare quality. These domains included proximity of health facilities to clients, availability of infrastructure and other amenities, availability of logistics including equipment and medicines and good environmental sanitation, quality of the human resource/workforce. non-discriminatory provision of maternal healthcare services, interpersonal relationship, privacy of clients, pain management, Safety, outcome of pregnancy and client's satisfaction with the care processes and outcomes. Results from the experts' evaluation of the appropriateness and validity of the 57- indicators identified from the qualitative research showed that all the items of the construct were rated above a content validity index (CVI) of 0.6, where 0.6 was the benchmark below which items would be rated as irrelevant/inappropriate. However, following modification and pretesting of the tool and further reliability testing of the items in the tool using item discrimination indices, only 47 indicators had acceptable item discrimination indices. These were, therefore, included in the final tool. Findings from the survey showed that overall, 72% of the respondents rated the quality of maternal healthcare they received as high, with 27% and 0.6% rating the quality of care as moderate and low respectively. The highest rated domain was the outcome domain with a mean score 4.26 ± 0.57. The proportion of women who rated the outcome domain as high was 91.15% while 8.08% and 0.77% of them rated it as moderate and low respectively. The least rated' domain was pain management, which had an average rating score of 3.14 ± 1.18, with 277(53.27%) of respondents rating it as high, 179(34.42%) rating it as moderate and 64(12.31%) rating as low. Conclusion: For any meaningful quality of maternal healthcare assessment to occur, there is need for including both women's and provider's perspectives. Although majority of women rated the overall quality of care, they received to be high, there is space for further improvement. There is the need for more attention to be paid to aspects of maternity care that were poorly rated by clients. In this regard, good inter-personal relationships with clients. better resourcing of health facilities and sustained collaboration between clients and healthcare providers is needed for enhancing the status of maternal healthcare in the region.