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SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
QUALITY OF MATERNAL HEAL THCARE 
IN FOUR DISTRICTS IN NORTHERN REGION, GHANA 
BY 
VICTORIA SHARON-LISA MUMUNI 
(10191732) 
THIS THESIS IS SUBMITTED TO UNIVERSITY OF GHANA, 
LEG ON, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR 
THE AWARD OF DOCTOR OF PHILOSOPHY DEGREE IN 
PUBLIC HEALTH 
JULY 2019 
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DECLARATION 
I, Victoria Sharon-Lisa Mumuni, hereby declare that this thesis was written by me in the 
School of Public Health of University of Ghana under the supervision of Professor 
Augustine Ankomah. Dr. Amos Laar and Dr. John K. Ganle. All references cited in this 
document have been duly acknowledged. 
W.('!3/.2.61u 
Date 
(Student) 
.... ~ 
Professor Augustine Ankomah Date 
(Primmy Supervisor) 
,~/ 
~~f$~:~:;··~ \>...1:o..~~?;p 
_~AmosLaar Date 
(Secondary Supervisor) 
~ .. 
Dr John Kuumuori Ganle 
Date 
(Secondary Supervisor) 
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ACKNOWLEDGEMENTS 
First of all. I would like to extend my deepest appreciation to my supervisors, Professor 
Augustine Akomah, Dr Amos Laar and Dr John Kuumuori Ganle for their guidance 
throughout this academic exercise. I am very grateful, and I remain indebted to them. To 
Professor Philip Baba Adongo, I remain grateful for your unconditional love and support 
always. To Dr Patricia Akweongo for her encouragement, I am grateful. 
I wish to express my gratitude to my mother for her prayers and to all my brothers and 
sisters for their support in diverse ways in making this research work a success. To my 
good friend, Christiana and her family, I am forever grateful. My acknowledgement will 
be incomplete without a very special thanks to my husband and my beautiful kids for 
making this academic work possible. 
My sincere gratitude goes to all those who have in one way or another contributed and 
supported this work. My special thanks to Dr Philip Teg-Nefaah Tabong for his brotherly 
support and guidance throughout the process of this academic exercise. To my only sweet 
friend and sister, Dr Sodey Zakariah-Akoto, I remain indebted to you and the entire Akoto 
family - I am humbled and grateful for accepting me into your home and your great 
contribution that has made the completion of this thesis possible. Many thanks to Prof. 
Moses Deyegbe Kuvoame at the University of South East Norway for his support. 
I am grateful to you Dr Hannah Benedicta Taylor-Abdulai and the entire Abdulai family 
for your support throughout this academic work. To Dr Yvette Otto and the entire Otto 
family, I am extremely grateful for always accepting me as part of your family. Mr. 
BerUamin Aiddo, a very big thank you for your encouragement. 
To all my friends that have made my stay in Ghana a success, many thanks. To Mr. 
Victor Addo and family, I say a big thank you for all your support and words of 
encouragement. To you my friend and partner, Mr. Philip Bleboo, thanks for your advice, 
support and encouragement that has made the completion of this thesis very possible. 
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Thanks to all of the visibility group, and staff of School of Public Health, Legon, for their 
encouragement and support. 
I am very thankful to all the women from the four districts in the northern region for their 
commitment that made it possible for me to conduct this research. My appreciation goes to 
all my research assistants and all the study participants. 
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DEDICATIONS 
This thesis is dedicated to my beloved late father, husband and children, for their support 
and understanding as well as all mothers from Northern Region of Ghana. 
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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 
....... .,.;~"' __I  •.••. -_.- done to describe important demographic and maternal health 
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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 (eVI) of 0.6, where 0.6 was the benchmark below which items 
would be rated as irrelevant/inappropriate. However, following modification and pre-
testing 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 
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0.71% 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. 
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TABLE OF CONTENTS 
DECLARATION ................................•........................................................•••........................ ~ 
ACKNOWLEDGEMENTS................................................... ..............................................  11 
DEDICATIONS .................................................................................................................. IV 
~~:;:~~:.:. ... ::::::::::::::::::::::.:: ....: ... ... :.: ... :.:: ... :.:::::::::::::::::::: ..•. ::~ 
LIST OF FIGURES ............................................................................................................ xv 
LIST OF ABBREVIATIONS .......................................................................................... . xvi 
OPERA TIONALIZAT ION OF KEY CONCEPTS ......................................................... xvii 
CHAPTER ONE ................................................................................................................... 1 
INTRODUCTION ................................................................................, . ............................... 1 
1.1 Background ..................... , ........................................................................................... 1 
1.2 Problem Statement............... .. ................................................................................... 6 
1.3 Objectives of the Study ............................................................................................... 9 
1.3.1 General Objective ................................................................................................. 9 
1.3.2 Specific Objectives ............................................................................................... 9 
1.4 Research Questions ................................................................................................... 10 
1.5 Justification of the Study ........................................................................................... 10 
1.6 Chapter summary and thesis outline ......................................................................... II 
CHAPTER TWO ................................................................................................................ 12 
LITERATURE REVIEW ................................................................................................... 12 
2.1 Introduction ............................................................................................................... 12 
2.2 Quality of maternal healthcare: concepts and definitions ......................................... 12 
2.3 Quality of Matemal Healthcare: Evidence across the World ................................... 13 
2.3.1 Quality of ANC Services in sub-Saharan Africa (SSA) ..................................... 19 
2.3.2 Quality of matem al healthcare in Ghana ............................................................ 29 
2.4 Improving Quality of Matemal healthcare: global policy responses ........................ 32 
2.5 Policies/programmes for ensuring Quality of Matemal Healthcare in Ghana .......... 37 
2.6 Maternal healthcare quality assessment.. .................................................................. 39 
2.6.1 Health workers' perspective on maternal healthcare quality assessment.. ......... 40 
2.6.2 Women's perspective on maternal healthcare quality assessment. .................... 41 
2.6.3 Indicators and Tools for Quality of Maternal Healthcare Assessment .............. 42 
2.6.4 Existing tools for maternal healthcare quality assessment ................................. 44 
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2.7 Theoretical Framework ............................................................................................. S2 
2.8 Conceptual Framework ............................................................................................. S6 
2.8.1 Factors that influence quality of care ................................................................. S8 
2.8.2 Structure, process and outcome domains ........................................................... S9 
2.8.3 Outcome ............................................................................................................. 60 
2.9 Chapter summary and gaps in literature ................................................................... 61 
CHAPTER THREE ............................................................................................................ 62 
METHODS ......................................................................................................................... 62 
3.1 Introduction ............................................................................................................... 62 
3.2 Study Design: mixed methods and its philosophical underpinnings ........................ 62 
3.3 Study Location .......................................................................................................... 66 
3.4 Description of selected study districts ...................................................................... 72 
3.4.1 Profile of Tamale Metropolis ............................................................................. 73 
3.4.2 Profile ofSagnerigu District. .............................................................................. 74 
3.4.3 Kumbungu District Profile ................................................................................. 75 
3.4.4 Profile ofSavelugu-Nanton Municipality .......................................................... 76 
3.5 Study Population ....................................................................................................... 76 
3.5.1 Inclusion and exclusion criteria .......................................................................... 77 
3.6 The Qualitative study ................................................................................................ 77 
3.6. I Sample Size for the qualitative research ............................................................ 78 
3.6.2 Sampling and recruitment procedures into the qualitative study ....................... 79 
3.6.3 Qualitative Data Collection methods and tools .................................................. 80 
3.6.4 Data Quality Assurance ...................................................................................... 84 
3.6.5 Qualitative Data Analysis ................................................................................... 85 
3.7 The Quantitative Study ............................................................................................. 86 
3.7.1 Development of Quantitative Tool for Quality of Care Assessment ................. 87 
3.7.2 The quantitative survey design and data collection ............................................ 90 
3.8 Ethical considerations ............................................................................................... 99 
3.8.1 Ethical approval .................................................................................................. 99 
3.8.2 Administrative Approval .................................................................................... 99 
3.8.3 Informed consent ................................................................................................ 99 
3.8.4 Confidentiality and Privacy .............................................................................. tOO 
3.8.S Right of withdraWal .......................................................................................... 100 
3.8.6 Risks and Benefits ............................................................................................ 100 
'10., n...._ ... - - :l Use ....................................................................................... tOI 
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3.9 Same gender- interviewing: ethics and reflexivity ................................................. 101 
3.10 Chapter summary .................................................................................................. 102 
CHAPTER FOUR ............................................................................................................ 103 
RESULTS: PERSPECTIVES ON QUALITY OF MATERNAL HEALTHCARE ........ I03 
4.1 Introduction ............................................................................................................. 103 
4.2 Participants' socio-demographic characteristics ..................................................... 103 
4.3 What Constitutes Quality Maternal Healthcare: Women and Maternal Healthcare 
Providers' Perspectives ...................................................................................... '" ........ 105 
4.3.1 Good Antenatal Care (ANC) services .............................................................. 105 
4.3.2 Good quality care during labour and delivery .................................................. 111 
4.3.3 Good postnatal care services ............................................................................ 112 
4.4 Measuring/Assessing Quality of Maternal Healthcare: Women and Healthcare 
Providers' perspectives ................................................................................................. 114 
4.4.1 Proximity of health facilities to clients ............................................................. 114 
4.4.2 Availability of infrastructure and other amenities ............................................ 116 
4.4.3 Availability oflogistics including equipment and medicines .......................... 118 
4.4.4 Good environmental sanitation ........................................................................ 119 
4.4.5 Human resource/workforce .............................................................................. 120 
4.4.6 Discriminatory provision of maternal healthcare services ............................... 122 
4.4.7 Range of services .............................................................................................. 123 
4.4.8 Inter-personal relationship ................................................................................ 124 
4.4.9 Privacy of clients .............................................................................................. 125 
4.4.10 Clients' involvement in the care decision-making process ............................ 126 
4.4.11 Mother and baby's safety ............................................................................... 126 
4.4.12 Outcome of pregnancy ................................................................................... 127 
4.4.13 Clients' satisfaction ........................................................................................ 128 
4.5 Chapter summary .................................................................................................... 129 
CHAPTER FIVE .............................................................................................................. 130 
RESULTS: MATERNAL CARE QUALITY ASSESSMENT TOOL ............................ 130 
5.1 Introduction ............................................................................................................. 130 
5.2 Selected characteristics of the experts .................................................................... 130 
5.3 Domains of assessment ........................................................................................... 131 
5.3.1 Health facility domain ..................................................................................... 131 
5"'.13 .2 Amenities in health facility domain ................................................................. 132 '1 U_kl. 1':' __ !t!~..... do 
.nVU'Onment main ............................................................... 133 
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5.3.4 Privacy in health facility domain ...................................•••••.............................. 133 
5.3.5 Inter-personal relationship domain ................................................................... 134 
5.3.6 Human resource domain ................................................................................... 134 
5.3.7 Safety in health facility domain ........................................................................ 136 
5.3.8 Range of Services domain .............................................................................. . 136 
5.3.9 Health insurance domain .................................................................................. 137 
5.3.10 Logistics and supplies domain ....................................................................... 137 
5.3.11 Pain management domain .............................................................................. 138 
5.3.12 Clients' satisfaction domain ........................................................................... 138 
5.3.13 Overall outcome ............................................................................................. 139 
5.4 Additional items suggested by experts and final tool ............................................. 139 
5.5 Item reduction and validity analysis ....................................................................... 140 
5.6 Chapter summary .................................................................................................... 144 
CHAPTER SIX ................................................................................................................. 145 
RESULTS: QUALITY OF MATERNAL CARE IN NORTHERN REGION ................ 145 
6.1 Introduction ............................................................................................................. 145 
6.2 Respondents' socio-demographic characteristics ................................................... 145 
6.3 Respondents' maternal characteristics .................................................................... 147 
6.4 Women's rating of the quality of maternal care domains ....................................... 147 
6.5 Women's rating of the quality of care domains ...................................................... 155 
6.6 Rating of quality of maternal care by respondents' background characteristics .... 156 
6.7 Chapter summary .................................................................................................... 159 
CHAPTER SEVEN .......................................................................................................... 161 
DISCUSSION ................................................................................................................... 161 
7.1 Introduction ............................................................................................................. 161 
7.2 Summary and discussion offmdings on women's and healthcare providers' 
perspectives on quality of maternal care ....................................................................... 161 
7.3 Summary and discussion of findings on the Development and Validation of Quality 
Maternal Care assessment tooL ..................................................................................... 168 
7.4 Sumrnary and discussion of Findings on quality of maternal care in Northern Region 
....................................................................................................................................... 169 
7.5 Strengths and contribution of the Study to knowledge ........................................... 173 
7.6 Limitations of the study .......................................................................................... 174 
7.7 Chapter sununary .................................................................................................... 175 
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CHAPTER EIGHT ........................................................................................................... 176 
CONCLUSION ................................................................................................................. 176 
8.1 Conclusion .............................................................................................................. 176 
8.2 Recommendations ................................................................................................... 178 
8.2.1 Recommendations policy and practice ............................................................. 178 
8.2.2 Recommendations for further research ............................................................ 179 
REFERENCES ................................................................................................................. 181 
APPENDICES .................................................................................................................. 214 
Appendix A: Consent Form Information Sheet for Participants ................................... 214 
Appendix B: Content Validity of Tool for Measuring Quality of Maternal Health Care 
....................................................................................................................................... 217 
Appendix C: Interview Guide for Midwives and Doctors ............................................ 220 
Appendix D: Focus Discussion Guide for Women ....................................................... 221 
Appendix E: Tool for experts in maternal healthcare provision ................................... 222 
Appendix F: Survey questionnaire for women ............................................................. 226 
Appendix G: Quality of Maternal HealthCare (Final Tool) ......................................... 227 
Appendix H: Ghana Health Service Ethical Clearance Form ....................................... 230 
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LIST OF TABLES 
Table I: Consensus Health Care Service Quality indicators .............................................. 48 
Table 2: Dimensions of quality of care according to the Donabedian model .................... 53 
Table 3: Distribution of IDI Participants by district.. ......................................................... 81 
Table 4: Distribution of Focus Group Discussants by Age group and district.. ................. 83 
Table 5: Districts and selected health facilities ................................................................. 92 
Table 6: Independent variables and their measurements .................................................... 97 
Table 7: Participants' socio-demographic characteristics(N=85) ..................................... 104 
Table 8: Experts background characteristics .................................................................... 131 
Table 9: Indicators for assessing health facility domain .................................................. 132 
Table 10: Indicators for assessing amenities in health facility domain ............................ 133 
Table 11: Indicators for assessing health facility environment domain ........................... 133 
Table 12: Indicators for assessing privacy in health facilities .......................................... 134 
Table 13: Indicators for assessing quality of inter-personal relationship ......................... 134 
Table 14: Indicators for assessing quality of human resources in health facility ............. 135 
Table IS: Indicators for assessing safety in health facilities ............................................ 136 
Table 16: Indicators to assess range of services in health facilities ................................. 136 
Table 17: Indicators for assessing health insurance domain ............................................ 137 
Table 18: Indicators for assessing logistics and supplies in health facilities .................... 137 
Table 19: Indicators for assessing quality of pain management in health facilities ......... 138 
Table 20: Indicators for assessing clients' satisfaction with care received ...................... 138 
Table 21: Indicators for assessing overall outcome of care .............................................. 139 
Table 22: Suggestions from experts ................................................................................. 140 
Table 23: Item discrimination indices of construct items ................................................. 141 
Table 24: Final tool for assessing quality of maternal care .............................................. 142 
Table 25: Respondents' socio-<iemographic characteristics ............................................. 146 
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Table 26: Respondents' maternal characteristics ............................................................ 147 
Table 27a: Women's assessment of quality of maternal care they received during their 
most recent pregnancy ...................................................................................... 149 
Table 28: Best and Worst-rated indicators under domains of quality of matem al care ... 153 
Table 29: Overall six best-rated and six worst-rated indicators of quality of maternal care 
women received ............................................................................................... 155 
Table 30: Percentage distribution of women's rating of the quality of care domains ...... 156 
Table 31a: Level of quality of maternal care by respondents' background characteristics 
.......................................................................................................................... 158 
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LIST OF FIGURES 
Figure 1: Conceptual Framework of Quality of Matemal Healthcare ................................ 57 
Figure 2: Stages of the Study .............................................................................................. 64 
Figure 3: Map ofNorthem Region Showing Study Districts ............................................. 67 
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LIST OF ABBREVIATIONS 
AOI Adverse Outcome Index 
CFI Comparative Fit Index 
CHP Community-based Health Planning and Services 
EmNC Emergency Neonatal Care 
EmONC Emergency Obstetric and Newborn Care 
FGDs Focus Group Discussions 
GDHS Ghana Demographic and Health Survey 
GFI Goodness-of-Fit Index 
GHS Ghana Health Service 
GSS Ghana Statistical Service 
HIRD High Impact Rapid Deli very 
IDIs In-depth Interviews 
IFI Incremental Fit Index 
IPT Intermittent Preventive Treatment 
LMIC Lower- and Middle-Income Country 
MDGs Millennium Development Goals 
MICS Multiple Indicator Cluster Survey 
MMR Maternal Mortality Ratio 
MOH Ministry of Health 
NIPH Norwegian Institute of Public Health 
NTSV Nulliparous Term Singleton Vertex Caesarean birth 
NTSV Nulliparous term singleton vertex caesarean birth 
PMMP Prevention of Maternal Mortality Programme 
QA Quality Assurance 
QOC Quality of Care 
QUALMAT Quality of Maternal and Prenatal Care' 
RMSEA Root Mean Square Error Approximation 
SARA Service Availability and Readiness Assessment 
SDGs Sustainable Development Goals 
UNFPA United Nations Population Fund 
UNICEF United Nations Children's Fund 
VAST Vitamin A Supplement Trials 
WHO World Health Organization 
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OPERATIONALIZATION OF KEY CONCEPTS 
Antenatal care- Care received during pregnancy 
Health care providers- Personnel who provide maternal health care services 
Labour care- Care received during delivery or labour 
Maternal care- Care received during pregnancy, delivery and postnatal periods. 
Maternal care c1ients- Women who receive maternal health care services 
Postnatal care- Care received post-delivery 
Quality of maternal care- Nature of care received by women during pregnancy through 
to childbirth at the health facility level. 
Women of reproductive age- Women aged 15-49 years of age 
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CHAPTER ONE 
INTRODUCTION 
1.1 Background 
Globally, much progress has been made to reduce maternal mortality and promote 
maternal health (United Nations, 2010). This progress has been made possible through the 
commitment engendered by Goal 5 of the Millennium Development Goals, which 
intended to reduce maternal mortality ratio by 75% between 1990 and 2015. This progress 
has also been enhanced by the new Sustainable Development Goals (SDGs) (WHO, 
2018). Despite this progress, 303,000 women still die every year from pregnancy and 
childbirth-related causes globally (WHO. 2018). The majority (99%) of these deaths occur 
in low and middle-income countries (LMICs) with close to 65% of all maternal deaths 
occurring in the WHO African Region (WHO, 2018). 
As suggested by World Health Organisation, women's access to quality care before, 
during and after childbirth is one of the central ways of reducing maternal mortality. The 
WHO therefore, recommends that, antenatal care in the first trimester of pregnancy should 
be a top priority to pregnant women (WHO, 2018). Although early antenatal care enables 
early management of conditions and could avert adverse potential risk of complications, 
global estimates show that about 40% of pregnant women do not receive antenatal care 
(WHO, 2018). Current estimates show that almost 50% of births in LMICS are assisted by 
skilled health professionals (trained midwives, doctors and nurses) as against 90% in the 
high-income and upper-middle-income countries (WHO, 2018). 
Studies have shown an increasing proportion of safe births over the past decade due to the 
assistance by skilled health personnel. Global statistics indicate that about 80% of live 
births occurred with the assistance of skilled health personnel in the period 2012-2017 
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WHO, 2019). These studies further point out the coverage and the rate of progress across 
the regions. Central and Southern Asia, for instance, had the highest rate of skilled birth 
coverage - 40% in the period 2000-2005. The rate increased to 77% in the period 2012-
2017 (Yaya et al., 2018; WHO, 2019). Sub-Saharan Africa also showed progress with over 
50% of births attended by skilled health personnel over the period 2012-2017. This pattern 
of progress is attributed to enhancements in the coverage of the proportion of births 
attended by skilled health personnel (WHO, 2019). Despite these successes, there are 
inequalities in the coverage of skilled birth attendance during the period 2012-2017 within 
the WHO regions (WHO, 2019). Estimated coverage shows that 50% of births in the sub-
Saharan African Region, where maternal mortality is highest, are attended by skilled 
health personnel as against 68% to 99010 in the other WHO regions (Yaya et aI., 2018; 
WHO. 2019). 
The maternal health literature has suggested that sustained commitment to improving 
maternal health should be central to the post-20lS development agenda in all countries 
with low levels of skilled birth (Kendall & Langer, 2015). The importance of skilled 
attendance at birth lies in the fact that access to and use of maternal care facilities and 
skilled personnel, particularly skilled attendance at birth, is often associated with 
substantial reduction in mortality and morbidity for the mother over home births (Cham et 
aI., 2005 Smith & Sulzbach, 2008; Babalola & Fatusi, 2009; Aseweh et aI., 2011; Tsawe 
& Susuman, 2014). Despite this recognition, not all women seek skilled care during 
pregnancy or childbirth. 
In Ghana, for example, while the percentage of women meeting the WHO's recommended 
minimum of 8 antenatal care visits is 81.3%, skilled attendance at birth is 56.5% (WHO, 
2016; Nsiah-Asare, 2017)' thus so 43SO/C f . 
• ,me . 0 0 women m Ghana still do not receive any 
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fonn of skilled care during delivery. This situation, therefore, calls for an urgent need to 
develop innovative strategies that will improve access to and use of maternal health 
services by women in Ghana (Aseweh et al., 201l). 
Globally, several factors have been identified as barriers to access to skilled maternal 
healthcare. Studies have shown that delivering in a health facility may be hampered by 
distance to facilities (Moyer et al., 2013;Yanagis8wa et al., 2013; Ganle et al., 2014a; 
Miteniece et al., 2018). Other studies indicate that structural factors, including lack of 
financial or economic resources, transportation, delivery supplies and lack of coordination 
of referrals between Traditional Birth Attendants (TBAs) at the community level and 
facilities prevent women from using facility-based services (Seljeskog et aI., 2006; Hoope-
Bender et ai, 2006; Mills et aI., 2008; GSS et al., 2009; Okafor & Rizzuto, 2015; 
Miteniece et aI, 2018). Some studies show that barriers to access, especially financial 
barriers, rather than traditional beliefs are the main obstacles to delivery at health care 
facilities (Griffiths & Stephenson, 2001; Mills et aI., 2008; Miteniece et al, 2018). Other 
studies also indicate that clients' negative perceptions of health care staff, including reports 
of unfriendliness at delivery, serve as barriers to obtaining skilled care (Griffiths & 
Stephenson, 2001; Seljeskog et aI., 2006; Okafor & Rizzuto, 2015). 
These barriers are often confounded by delays in the care-seeking process. According to 
Thaddeus and Maine (1994), delays can occur at three different levels: decision to seek 
care, reaching the appropriate facility and receiving adequate care at the facility. The 
reasons for the first level of delay, decision to seek care may be late recognition of the 
problem, fear of the hospital or the costs or lack of an available decision maker (Gabrysch 
& Campbell, 2009). The second level of delay, reaching the appropriate facility has been 
reported to be caused by difficulty in transport while the third level, receiving adequate 
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care at the facility, is often due to is often due to difficulty in getting supplies of blood. 
equipment and operation theatres (Shah et aI., 2009). 
More recently, one factor that has emerged as a major inhibiting factor for mothers who 
patronize facility-based maternal healthcare is the increasing evidence of maltreatment and 
abuse of women at health facilities (Bohren et aI., 2015). In north-eastern Tanzania, for 
example, one study reported that between 19% and 28% of women at eight facilities 
experienced disrespectful and! or abusive treatment from healthcare providers during 
childbirth (Kruk et aI., 2014). Similarly, a study in northern Ghana has shown that women 
refused to patronize facility-based delivery because of poor quality of care and 
maltreatment during labour (Moyer et aI, 2014). Similar cases of maltreatment have been 
reported in both northern and southern Ghana, especially during delivery at health 
facilities (Moyer et aI, 2014; Yakubu et ai, 2014; Ganle and Krarnpah, 2018). 
Maltreatment affects the quality of maternal healthcare though it has often been 
overlooked because quality of care has often focused on the perspective of the service 
providers and health outcomes with little attention given to the perspective of clients 
(Tripathi, Stanton, Strobino, & Bartlett, 2015). In studies across Africa, however, poor 
quality of maternal healthcare - through abuse and maltreatment - has been reported as one 
of the reasons why women may fail to seek healthcare at health facilities (Kruk et aI., 
2014; Moyer et aI., 2014; Yakubu et aI., 2014; Ganle and Krarnpah, 2018 ). Indeed, the 
quality of maternal healthcare provided at healthcare facilities has started to receive global 
attention and many researchers in maternal and child health have joined in the debate on 
quality of care (powell-Jackson et aI., 2009; Baral 2012; Souza et aI., 2014; Tripathi et aI., 
2015; Bohren et aI., 2015). The WHO's (2015) vision on quality of care for mothers and 
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new-borns illustrates how important the debate on the quality of maternal healthcare has 
become. 
Quality of care has been defined as the difference between how medical care can 
optimally be delivered and how it is actually delivered (Salinas et al., 1997; WHO, 2006). 
Several studies have demonstrated the role of quality care in producing enhanced maternal 
health outcomes (Salinas et al., 1997; Kendall, 2015; Tripathi et al., 2015). To this end, 
evidence from diverse settings has suggested that increasing facility delivery may not 
reduce mortality if quality of care is poor ( Miller et aI., 2003; Barber & Gertler. 2009; 
Lim et al., 2010; Randive et aI., 2013). For instance, a 2013 analysis of WHO multi-
country survey data suggests that coverage with life-saving interventions may be 
insufficient to reduce maternal deaths without overall improvements in the quality of 
maternal healthcare (Souza et al., 2013). Miller et al. (2003), using record reviews, 
provider and patient interviews and care observations, showed that poor quality of 
emergency obstetric and newborn care (EmONC) may underlie the persistence of high 
maternal mortality in the Dominican Republic despite high institutional delivery rates. 
Other research suggests that inadequate quality of care is implicated in low demand for 
facility-based maternal healthcare and bypassing of closer facilities in favour of those that 
are more distant (Kruk et aI., 2009; Parkhurst & Ssengooba, 2009; Mselle et al, 2013). 
There are also concerns about quality of care in facilities facing increasing demand due to 
incentives for institutional delivery such as the free maternal healthcare policy in Ghana 
(Witter et al., 2007; Witter et al., 2009; Ganle et al., 2014b). An increased focus on quality 
of care at the time of birth bas quadrupled returns on investment through the reduction of 
maternal and neonatal deaths, prevention of stillbirths and future disability (Lawn et aI., 
2009). 
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Recent estimates indicate that closure of the quality gap through the provision of effective 
care for all women and new-born babies could prevent an estimated 113,000 maternal 
deaths, 531,000 stillbirths and 1· 325 million neonatal deaths annually by 2020 (Bhutta et 
aI., 2014). All these estimates clearly emphasize a need to pay attention to the quality of 
care women receive during pregnancy or childbirth not only in policy and practice but also 
in research. 
1.2 Problem Statement 
Scholarly evidence from previous studies suggests that maternal healthcare in recent times 
is a topical concern in both clinical care and health services research (Kendall & Langer, 
2015). However, there has been overt focus on quality of care from the perspective of 
healthcare providers rather than that of pregnant women and lactating mothers (Maxwell, 
1992; Donabedian. 1997; Raven et al., 2015). The importance of quality maternal 
healthcare has therefore resulted in a global drive to develop measurement tools with high 
levels of precision and reliability using locally available knowledge from various 
stakeholders. 
While quality of care (real or perceived) is now widely recognised to influence utilization 
of maternal healthcare services, limited research has been conducted to explore and 
measure it (Kambala et aJ., 2015). The few studies conducted in this area are more 
clinical-based with less attention paid to the beneficiaries of the care services (Kendall & 
Langer, 2015; Tripathi et al., 2015). Key areas are health outcomes such as number of 
stillbirths, near misses, complications, case fatality rates, context (time of day, day of the 
week, number of births compared to staffing levels) and process targets such as the use of 
the partograph (Kendall & Langer, 2015). Quality of care studies in sub-Saharan Africa 
have also assessed facility readiness to provide delivery services (structural quality) or 
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evaluated outcomes using case fatality rates and similar indicators (Tunt;alp, Hindin, Adu-
Bonsaffoh, & Adanu, 2012). 
Some research has also evaluated quality in terms of women's satisfaction with health 
services, identified by Donabedian (1997) as a care outcome, without assessing technical 
quality of care (Baltussen et aI., 2002; Anwar et al., 2009). Similarly, many studies have 
been limited to documenting whether or not EmONC interventions are available or were 
recently provided without assessing the quality of these services (Bailey et aI., 2006; 
Admasu et ai, 2011). 
Although these previous quality of care-related studies have contributed to a better 
understanding of how quality of care may be assessed and the quality of care women 
receive at health facilities during pregnancy, labour and childbirth, the perspectives of 
women have received relatively little attention in both clinical practice and research 
(Tripathi et al.. 2015). One recent study decried this phenomenon and argued that it is 
inadequate to base quality of care assessment solely on provider knowledge or facility 
capacity to provide care (Granja, Machungo, & Bergstrom, 2000). 
In the context of Ghana and specifically in northern Ghana, there are few studies that have 
examined the quality of maternal healthcare offered at health facilities (Moyer et aI., 
2014). The few studies that have attempted to assess quality of maternal healthcare have 
not explored the views of maternal healthcare service providers and women on what 
constitutes quality maternal healthcare and how quality of maternal healthcare oUght to be 
assessed (O'Neil et aI., 2017; Yaya et ai, 2018; Miteniece et alo, 2018). Also, while some 
studies have evaluated the technical aspects of care processes, for example through 
criterion-based audits they have ge rail l°ed . 0. 
, ne y re 1 on retrospective analYSIS of mcomplete 
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sources of data that were not intended to measure quality such as maternity registers 
(Tripathi et al .. 2015). 
Numerous studies have documented poor quality and limited sensitivity of obstetric 
facility records and databases for assessing the performance of care processes in both low-
and high-resource settings and how these are not reliable sources of data for measuring 
quality (Hermida et al., 1999; Duffy & Crangle, 2009; Flood & Small 2009; Chiba et al., 
2012; Lain et al., 2012; Broughton et al., 2013). Also, while measurement of quality of 
routine intrapartum and immediate postpartum services is essential in ensuring the 
delivery of appropriate interventions to reduce maternal and new-born morbidity and 
mortality (Tripathi et aI., 2015), the majority of available measurement tools have been 
developed in Western or other high-income countries. For instance, there is currently no 
validated quality of care assessment tool in Ghana. However, the cultural diversity of the 
Western and African contexts may pose a challenge in using such western-based 
assessment tools. For example, whereas women in a Western country may perceive any 
harsh word from a maternal healthcare service provider as abusive (Kendall, 2015; 
Tripathi et al., 2015), a Ghanaian woman who has been maltreated during labour may 
perceive that as good price to pay to have a baby (Yakubu et aI., 2014). To this end, 
several researchers have recently emphasized a need for the development of contextually-
relevant tools to measure quality of care and promote on-going quality improvement at the 
facility, district and national levels (Kendall & Langer, 2015). 
As efforts to improve maternal bealthcare under the sustainable development goals 
continue, measurement of the quality of routine maternal healthcare services is essential in 
ensuring the delivery of appropriate interventions to reduce maternal and newborn 
mortality and morbidity (Tripathi et al., 2015). In view oftbe knowledge gaps identified 
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above as well as the recent calls for more empirical research on the development of 
contextually-relevant tools to measure quality of care, this study was conducted to develop 
and validate a maternal healthcare quality assessment tool and to use this tool to assess the 
quality of maternal healthcare women receive during pregnancy, labour and childbirth in 
northern Ghana. 
1.3 Objectives ofthe Study 
1.3.1 General Objective 
The general objective of the study was to assess the quality of maternal healthcare women 
received during their most recent pregnancy in four districts in Northern Region of Ghana. 
1.3.2 Specific Objectives 
The specific objectives of the study were to: 
1. Assess the perspectives of women and maternal healthcare providers on what 
constitutes quality maternal healthcare; 
2. Assess women's and maternal healthcare providers' views about how quality of 
maternal healthcare should be assessed from the perspectives of women; 
3. Develop and validate a tool for measuring quality of maternal healthcare in Ghana 
from the perspectives of women and healthcare providers; and 
4. Use the developed and validated tool to assess the quality of maternal healthcare 
women received during their most recent pregnancy in the four districts in 
Northern Region of Ghana. 
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1.4 Research Questions 
To achieve the objectives above, the following research questions guided the study: 
I. What do women and maternal healthcare providers understand to constitute quality 
maternal healthcare? 
2. How should maternal healthcare qUality be assessed in Ghana from the 
perspectives of women and healthcare service providers? 
3. What tool will be suitable for measuring quality of maternal healthcare in Ghana 
from the perspectives of healthc are providers and women? 
4. What was the quality of maternal healthcare women received during their most 
recent pregnancy in Northern Region of Ghana? 
1.5 Justification of the Study 
This research was conducted in response to the inadequate attention paid to the views of 
pregnant women and nursing mothers in maternal healthcare quality assessment studies. 
This gap in literature is as a result of the excessive reliance on care provider-driven tools 
for the measurement of quality of maternal healthcare in most parts of the world. The 
findings of the current research could, therefore, contribute to the maternal healthcare 
literature in two ways. First, it has developed a measurement tool that could be used to 
assess the quality of maternal heaIthcare from the perspectives of women who are the end-
users of maternal healthcare services. This tool could potentially be adopted by other 
researchers to measure quality of maternal healthcare in other parts of the world. 
Second. the study also provides knowledge on the lived experiences of pregnant women 
and nursing mothers on quality of maternal healthcare services they receive in Northern 
Region of Ghana. This knowledge could potentially be used to influence future maternal 
healthcare policies and programmes by including the views of the end-users of maternal 
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healthcare services. focusing on their definition of maternal healthcare quality in Ghana. 
The findings of this study may not only aid in the improvement of services but may also 
be useful for policy-making and implementation in the quest to minimize maternal 
morbidity and mortality in the country. This research would also add to the existing body 
of knowledge on the subject matter and, thus, make contribution to academia. 
1.6 Chapter summary and thesis outline 
This chapter introduced the study, articulated the research problem, set the objectives and 
research questions as well as outlined the significance of the research. The rest of the 
thesis is organized as follows: Chapter Two reviews literature under sub-themes which 
includes definitions of quality of maternal healthcare, maternal healthcare quality across 
the world. perspectives on maternal healthcare quality assessment, health workers' 
perspectives on maternal healthcare quality assessments, women's perspectives on 
maternal healthcare quality assessments, existing tools for maternal healthcare quality 
assessment and the framework that provides the lens under which the study was 
conceptualized. Chapter Three discusses the research methods, focusing on the 
philosophical underpinnings of the study, the research design, methods of data collection 
and analysis as well as ethical issues. Results from the qualitative arm of the study are 
presented in Chapter Four. Chapter Five presents results in relation to the development 
and validation of the quantitative tool for assessing quality of maternal healthcare. Chapter 
Six presents results from women's assessments of the quality of maternal healthcare they 
received during their most recent pregnancy. Chapter Seven discusses the results while 
Chapter Eight concludes the study and makes recommendations for policy and further 
research. 
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CHAPTER TWO 
LITERATURE REVIEW 
2.1 Introduction 
In this chapter. literature is reviewed to contextualize this study. The literature review 
covers global, regional and national issues related to maternal health, quality of maternal 
healthcare, various perspectives on quality of maternal healthcare and how quality of care 
has previously been assessed. The chapter also outlines and discusses a conceptual 
framework for the study. 
2.2 Quality of maternal healtbcare: concepts and definitions 
There are many definitions of 'quality' used both in relation to healthcare and health 
systems and other spheres of activity. Quality of care (QC) has been dermed as 
consistently delighting the patient by providing efficacious, effective and efficient 
heaIthcare services according to the latest clinical guidelines and standards, which meet 
the patient's needs and satisfies providers (Mosadeghrad, 2013). QC comprises provision 
of timely, reliable, equitable, efficient, compassionate, patient-centred care with 
application of evidence-based standards to ensure patient safety and health-worker 
satisfaction (Donabedian, 1978; Hulton et aI., 2000). 
Studies have shown that a health system should seek to make improvements in six areas 
or dimensions of quality (WHO, 2006). The first area is effective delivery of healthcare 
that adheres to an evidence-based data and results from improved health outcomes for 
individuals and communities based on need. The second area is efficient delivery of 
healthcare in a manner that maximizes resource use and avoids waste while the third is 
accessible delivery of healthcare that is timely, geographically reasonable and provided in 
a setting where skills and resources are appropriate to medical need. Acceptable/patient-
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centred delivery of healthcare, which considers the preferences and aspirations of 
individual service users and the cultures of their communities, constitutes the fourth area 
identified by WHO. The fifth area is equitable delivery of healthcare, which does not vary 
in quality because of personal characteristics such as gender, race, ethnicity, geographical 
location or socio-economic status. The last area is safe delivery of healthcare, which 
minimizes risks and harm to service users. 
For the purpose of this study, quality of maternal healthcare encompasses adequate 
provision of amenities that ensure access and fairness to all clients, including the presence 
of enough trained maternal healthcare staff, safe and clean environment and accurate 
provision of a range of services that ensure the privacy of clients. Quality of maternal 
healthcare also involves the inclusion of clients in the healthcare decision-making process, 
good communication and inter-personal relationship between health personnel and the 
clients, which produces satisfaction and ensures satisfactory outcome for both mother and 
baby. 
2.3 Quality of Maternal Healtbcare: Evidence across tbe World 
In recent times, quality of maternal healthcare has emerged as an area of intense interest 
among scholars and healthcare providers. This development has therefore generated 
interest among researchers who have attempted to conduct research in some aspects of 
care quality across the world. One of such studies was conducted in southern India to elicit 
information on the clients' expectations of the quality of maternal healthcare and what was 
received at the facility (Singh et a1., 2014). The results of this study showed that the 
quality of antenatal care received was lower than clients' expectations (Singh et al., 2014). 
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A study in China showed that neither the public nor private sector provided all 16 
standardized services, which included ANC and postnatal services albeit more women in 
the public sector received ANC procedures (Chen et al., 2013). A related study in China 
also found that coverage and quality of postnatal care were low in rural Hebei Province 
and far below the targets set by the Chinese government (Chen et al., 2014). In Canada, 
Harvey et at. (2002) reported that women who were delivered by midwives reported that 
they had received better quality of care than those who were delivered by doctors. 
There is evidence in literature to suggest that there is a plethora of barriers and challenges 
to the delivery of good quality antenatal care (ANC) and facility-based delivery (FBD) 
across the globe (Mpembeni et al., 2007, Pervin et aI., 2012). For instance, in Australia, 
Forster et al. (2006) found that shortage of qualified staff was a major factor impeding the 
provision of quality postnatal care. A study by Pervin et al. (2012) in Bangladesh found 
that good quality ANC was associated with an increase in antenatal care visits and better 
access to FBD leading to lower neonatal and maternal mortality rates. This finding is 
echoed by the National Institute of Health and Care Excellence (NICE) (2012), which 
argue that standards for ANC must be of high quality, cost effective and evidence based. 
Furthermore, a study on quality of antenatal care suggested that it was closely linked with 
compliance, effectiveness and continuity of care and could ensure that people have 
positive experiences of maternal healthcare (NICE, 2012). 
A UK survey that was conducted by Hawkes (2018) to examine women's perceptions of 
maternal healthcare quality found that women reported being satisfied with the quality and 
standards of maternal healthcare. In this survey, women reported not being left alone 
during labour although they reported not being seen by the same midwife during postnatal 
care. Like Pervin et at. (2012), Hawkes (2018) and a UK. study by Petrou et al. (2003) 
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found that women felt that they were treated with kindness and respect. They also found 
that the availability of adequate maternal health information, the screening of risk factors 
and availability of skilled attendants reduced the risk of MMR. This study by Pervin et al. 
(2012) confirmed the findings of other studies that good quality ANC correlates with 
positive healthcare delivery, better neonatal outcomes and better perinatal survival (Bhutta 
et aI.. 2010). Although, Hawkes (2018) also found that women were generally satisfied 
with the quality of care, some women felt their planned method of pain relief during 
labour was not followed due to shortages of staff, which undermined continuity of care -
one of the standards set under the Better Births National Maternity Review 2016 
(Cumberlege. 2016) and the NICE guidelines(2012). Recommendations outlined under 
Better Births National Maternity Review 2016 stemmed from a study by Kirkup (2015), 
which identified evidence of serious failings in the delivery of maternity care within the 
National Health Service (NHS). In this UK study, Kirkup (2015) investigated the quality 
of maternity and neonatal care services at NHS Trust health facilities and found that sub-
optimal ANC significantly led to avoidable harm and unnecessary maternal and neonate 
deaths and this situation was attributed to sub-standard clinical competence, poor record-
keeping and a lack of information-sharing among professionals. These findings contrast 
with those reported in an earlier UK survey which was conducted by the Commission for 
Healthcare Audit and Inspection (2008). This earlier study found that most women rated 
the quality of ANC they received as good or better although the assessments varied among 
the various UK trusts. However, like Kirkup (2015) and Hawkes (2018), the Commission 
for Healthcare Audit and Inspection (2008) found reports of shortages of staff and a lack 
of continuity of care as reported in other studies (McCourt & Stevens, 2006; Rainey et al., 
2015; Hawkes, 2018). 
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Evidence of poor quality of maternal services is also reported in a study conducted by 
Barclay et aI. (2014) in Australia among Aboriginal women. The study found that limited 
resources and poor healthcare workers' attitudes hindered significantly the quality of care. 
In their study, Barclay et aI. (2014) found disparities in the quality of care for women 
residing in southern Australia and advocated closing the quality and equity gap in the 
provision of ANC within this region. In another Australian study among women of 
Aboriginal origins, Waller et al. (2016) found that the quality of ANC was sub-optimal 
and that women reported receiving little support in relation to issues such as nutritional 
supplements, managing weight-gain and oral health. Similar findings have been reported 
by Small et aI. (2014), in which immigrant women of non-English speaking background 
across five high-income countries reported lower satisfaction with the provision of their 
ANC needs. Small et al. (2014) found reports of clients being unhappy with the long 
waiting lists, lack of continuity. shortages of staff and poor access to information. These 
findings resonated with those of Redshaw et al. (2019) in the UK. Again, access to 
adequate information, being treated with respect and having a therapeutic relationship with 
healthcare workers have been reported as critical factors in ensuring high quality ANC by 
other authors in the UK (Healthcare Commission, 2008), Canada (Kingston et al., 2011) 
and America (MacDorman et aI., 2016). 
Another study was conducted in the UK to examine immigrant women's experiences with 
ANC (Phillimore, 2015). It found that immigrant mothers tended to under-value maternal 
healthcare services compared to their British counterparts as reported by Hayes et al. 
(2011) in a study in Ireland. Furthermore, Phillimore (2015) found that health workers did 
not have enough time to communicate with these non-English-speaking women due to 
time constraints. Most women reported that the ANC services were culturally incompetent 
to fully cater for their diversity. Heikkila et al (2010) m' the' 'thin th 
' If survey WI e general 
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UK population, found that women who reported being supported by health workers had 
more choice regarding relief of pain during labour. Again, most women felt that staff 
understood their needs, which contradicted Phillimore's (2015) fmdings. 
Symon et al. (2018) in a qualitative study that was conducted in Scotland, found that 
limited resources, boundary tensions within care teams, access to information and staff 
support for immigrant women were reported to have negative effects on the quality of 
maternal healthcare. Evidence of inadequate resources and limited time within maternity 
care in the UK is also reported by Ham and Alderwick (2015), who argued that this had a 
profound negative effect on the delivery of high-quality care and could undermine the 
ability of professionals to build trusting relationships with women in their care. Symon et 
al. (2018) further found that women reported variations in the referral process similar to 
fmdings by Renfrew et aI. (2014) in the UK. Similar to the findings by Symon et aI. 
(2018), a qualitative study by Dahlberg and Aune (2013) in Norway found that women 
perceived relational continuity a critical factor during childbirth a good quality of care as 
earlier reported in a UK study by Hunter et aI. (2008) and in a USA study by Diamond-
Bro'Wll (2016). 
Diamond-Bro'Wll (2016), in a study in the USA, found that person-centred ANC care was a 
critical element in the doctor-patient relationships and influenced how the quality of 
maternal healthcare was perceived. This finding was supported by Pervin et al. (2012), 
who found that antenatal education improved mothers' understanding of the early 
recognition of danger signs during pregnancy and delivery and enhanced the quality of 
staff-patient relationships, which in tum positively affected new-born care and improved 
Facility-Based Delivery (FBD) rates. Ford & Long (2011) found in China that the number 
of women who underwent FBD was a target indicator of the effectiveness and quality of 
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maternal healthcare services. Similar findings were reported by Gobema-Tricas et al. 
(2011) in Spain, where women associated being treated with compassion, empathy and 
respect with high-quality care. Similarly, Shafiei et aI. (2012) reported that participants in 
Australia felt that how health workers interacted with them influenced their satisfaction or 
dissatisfaction with the quality of care provided. In a very recent qualitative study that was 
conducted in Germany using focus group interviews with midwives, they (discussants) 
reported that many pregnant women were not aware of the scope of their professional 
knowledge and expertise that midwives provided (Mwase et aI., 2018). This study differed 
from other studies in that it considered the views of the health workers and not those of the 
patients themselves who are the actual consumers of ANC services and found that the 
midwives felt unable to meet the quality of care standards expected of them with some of 
them reporting feeling overwhelmed and overworked to the detriment of delivery of high-
quality care. These findings echoed those in other European studies that found that 
midwives reported not having enough time to deliver high-quality women-centred ANC in 
Sweden (Lundgren & Dahlberg, 2002), Ireland (Keating and Fleming, 2009) and Cyprus 
(Hadjigeorgiou & Coxon, 2014). 
In Cyprus, Bammann et al. (2019) found that midwives felt that the prevalence of sub-
optimal ANC was linked to a lack of recognition of their profession and their expertise in 
midwifery education. Furthermore, Bammann et al. (2019) found that midwives were 
failing to deliver high-quality women-centred ANC due to time constraints and the 
adoption of a medicalized approach within maternity care. Similar findings have been 
reported in Belgium (Van Kelst et aI., 2013). 
Sharma (2017) conducted a study in India that examined the quality of maternity care at 
the time of delivery and found that women were being cared for by unqualified attendants 
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and that infonnal payments influenced the quality of care they received. However, a study 
within urban areas in India revealed that the quality of ANC was highly rated (over 90%) 
although health education was reported to be poor (Singh et al., 2014). 
In summary, working relationships, availability of resources, adequate staff and access to 
adequate infonnation are themes that have emerged as determinants of how the quality of 
maternity care is perceived across the globe. It can be concluded that the quality of 
maternity care globally continues to be variable and inconsistent and evidence from 
literature continues to suggest a need to improve the standards and quality of maternity 
care if the Sustainable Development Goals are to be achieved (O'Neil et aI., 2017). 
2.3.1 Quality of ANC Senrices in sub-Saharan Africa (SSA) 
There is evidence to suggest a paucity of research that focuses on the quality of maternal 
healthcare in low-income settings including sub-Saharan Africa (SSA) (Pervin et aI., 
2012). The existing studies show differences in what women feel is quality care. For 
instance, some studies suggest empathy, respect and healthcare providers' attitudes as 
indicators of high-quality care (Shafiei et aI, 2012; Goberna-Tricas et aI., 2011) while 
others have shown that normal deliveries or complications being successfully handled 
overrode complaints and were indicators of good-quality care (Filippi et aI., 2002, Bazant 
& Koenig, 2009). 
Differences in women's perceptions of what constitutes quality care, therefore, raise 
questions about whether women within the African region have a clear understanding of 
the standards of care they expect. Furthermore, Edwards & Saha (2011), Tran et al. (2012) 
and Joshi et aI. (2014) argue that few quantitative studies have explored the determinants 
of quality of ANC in SSA and this paucity bas been linked to a paucity of data (Afulani, 
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2015). According to Afulani (2015), quality of care is a concept that is hard to measure 
and studies which have investigated the quality of ANC within the African context and 
even across the globe have mainly been qualitative in nature, which makes fmdings 
susceptible to social desirability bias because research participants may either be afraid of 
speaking against their governments or professionals as a result of cultural constraints to 
open discussions with male researchers as reported in some studies (Guzha et al., 2018, 
Benova et aI., 2018, Adewuyi et aI., 2018). 
Another limitation in literature is the lack of a universally- agreed defmition of quality of 
care (QoC). Guzha et al. (2018), in their study, therefore, argued that disparities in the 
definition and perception of QOC had led to significant variations in obstetric outcomes 
like caesarean sections, instrumental deliveries and induction of labour rates among 
different health institutions or even within the same healthcare setting. Indeed, in a 
qualitative study that used focus groups discussions in Malawi, it was found that the 
quality of antenatal care varied due to disparities in the provision of medical resources and 
unethical practices by health workers (Machira and Palamuleni, 2018). Machira and 
Palamuleni (2018) particularly found that some women reported being impressed by the 
health care workers' conduct, knowledge and expertise. This finding conflicted with 
reports by some women of inadequate levels of attention from medical personnel and 
antagonistic attitudes of healthcare workers, which consequently undermined quality of 
care (Machira & Palamuleni, 2018). 
Similar findings are reported in an earlier study in Malawi, where inadequate staff levels, 
erratic availability of medical resources and inadequacy of critical equipment and drugs 
led to poor care quality (Kambala et al., 2015). In another Malawian study, Kumbani et al. 
(2012) explored women's views about the quality of perinatal care. They found that 
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although most women reported being satisfied with the quality of care provided, they did 
not know the quality of care to expect. Kumbani et aI. (2012) found that women reported 
that they were not provided with adequate information during pregnancy. Similar fmdings 
were reported by Lungu et aJ. (20 II). Creel, Sass and Yinger (2009) argue that being 
satisfied might not necessarily correlate with high quality care and might just be an 
indication of low or no expectations. This view suggests a need for women and their 
families to be informed of the quality of care to expect from maternal healthcare service 
providers. 
Machira and Palamuleni (2018) and Kumbani et al. (2012) found that being treated with 
respect, not being shouted at and being given medicines were associated with high quality 
care. Using Demographic and Health Surveys of 10 selected low-income countries to 
analyse ANC related to women's most recent live births, Benova et aJ. (2018) reported 
that the quality of ANC was poor and did not meet global recommendations in the ten 
countries including Nigeria, Haiti, Nepal and Cambodia. The authors linked these findings 
to poor staffing, poor resources, overcrowding of facilities and poor nurse-patient 
relationships. The findings were also similar to those by Boller et aI. (2003) in Tanzania 
and Owolabi et al. (2018) in West Africa. 
Guzha et aI. (2018), in their study, compared the quality of obstetric care in a variety of 
geographical locations in Zimbabwe and found that the true quality of ANC was difficult 
to ascertain across the different geographical areas because of the existence of 
heterogeneous population characteristics and the prevalence of complications experienced 
by women (see also Fagbamigbe & Idemudia, 2015, Adewuyi et aI., 2018). Guzha et aI. 
(2018) found variations in the quality of ANC care between rural and urban areas and 
attributed this difference to a lack of transport and government funding, skilled birth 
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attendants' unwillingness to work in remote areas and lack of trained personnel to perform 
operations. Similar findings were reported in other studies (Mrisho et aI., 2009; Mangoma 
et a1., 2010; Kyei, Chansa & Gabrysch, 2012; Nyathi et aI., 2016; Yamba, 2018). Other 
qualitative studies have suggested that perceived poor quality of health services has a 
negative effect on women's willingness to use skilled birth attendants (Gabrysch & 
Campbell, 2009; Moyer & Mustafa, 2013); thus, some studies have reported that in 
Nigeria, many women felt that traditional birth attendants provided higher quality care 
especially in terms of inter-personal communication and relationships (ljadunola et ai, 
2003). One study in South Africa found that women reported being yelled at and scolded 
by health workers and indicated that some health workers gave preferential treatment to 
women of higher socio-economic backgrounds (Ngomane & Mulaudzi, 2012). 
Furthermore, in Zimbabwe, women described health workers as hostile and abusive, 
which significantly affected their perception of the quality of care delivered and affected 
their willingness to access ANC (Chaibva, 2009). 
A recent study in Swaziland by Sacks et aI. (2017) found that women's perceived reality of 
and satisfaction with the quality of intra-pactum care practices were poor and below global 
standards. This finding is supported by that of a much earlier study by Mngadi et a1. 
(2002) in the same country, which found that the quality of ANC was affected by a lack of 
verbal communication and interaction between health workers and adolescent mothers. 
Another study in Swaziland reported that health workers did not provide counselling 
services to postnatal women (Paulden et aI., 2009). Another study on quality of postnatal 
care in Malawi reported that all the seven facilities scored 48% on postnatal services 
rendered, which was far below the Score of 80% recommended in the Reproductive Health 
Standards of World Health Organization (Chimtembo et aI., 2013). Many of the facilities 
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were reported to lack infrastructure in all the basic emergency obstetric and neonatal care 
facilities and also midwives had not received refresher training (Chimtembo et aI., 2013). 
In a study by Wandabwa et aI. (2008) in Uganda. the findings confirmed that staff 
shortages, poor infection control practices and insufficiency of critical maternity drugs and 
equipment were associated with poor ANC care quality. Wandabwa et al. (2008) found 
appreciable availability of both diagnostic equipment and physical infrastructure but birth 
preparedness and access to counselling services were poor. In their study, Nwaeze et aI. 
(2013) found conflicting evidence: some women reported that clinical services were good 
whilst others complained of long waiting times and unsatisfactory supplies of water and 
other amenities. An earlier survey in Nigeria by Oladapo et aI. (2008) found that women 
were generally satisfied with the quality of ANC even though there were inconsistencies 
between received care and their expectations of health facilities. Another study by Ejigu, 
Woldie and Kifle (2013) in Tanzania indicated that patient satisfaction was not just 
affected negatively by long waiting times but also by the patients' expectations and 
understanding of the causes of the waiting. Ejigu, Woldie and Kifle (2013), in this study, 
found that poor staff training, and heavy workloads contributed to poor quality of ANC. 
In Tanzania, a study on the quality of maternal healthcare found shortages of staff, 
equipment and supplies as common complaints hindering quality of care (Mrisho et aI., 
2009). In Eritrea, a study on the quality of maternal healthcare showed that there was 
considerable pressure on the infrastructure and health providers at hospitals (Sharan et ai, 
2011). Compliance with clinical care standards and availability of supplies were reported 
to be optimal (Sharan et al, 2011). 
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FurthelIDore, in Zimbabwe, poor access to effective ambulance and emergency transport 
due mainly to poor road infrastructure contributed to poor care quality (Muchabaiwa et al., 
2012). In their study, Kyei et al. (2012) found that only 3% of ANC facilities in Zambia 
were meeting the set criteria for optimum ANC services with only 47% of facilities 
offering adequate services and the remaining providing inadequate services. The same 
study found that only 29% of women reported receiving good quality ANC and concluded 
that such quality gaps showed missed opportunities in the delivery of high-quality ANC. 
Amare (2017) found in Zambia that 54.3% of mothers reported receiving low-level quality 
of ANC and that about 24.7% of such mothers lived in communities with low levels of 
literacy. 
Indeed, evidence from literature suggests a strong correlation between literacy levels and 
the quality of ANC women across SSA received. Accordingly, illiteracy limits women's 
ability to exercise choice and overcome cultural barriers that hinder their utilization of 
maternity services (Babalola & Fatusi, 2009). Arsenault et al. (2018) conducted a study in 
LMICs to explore the quality of ANC and assess geographical and socio-demographic 
factors affecting quality of ANC in these countries. They found that ANC quality in low-
income countries was lagging with funding being higher in middle-income countries, 
where women of higher socio-economic status reported good quality care. Socio-economic 
inequalities is, therefore, a theme that has resonated throughout this literature review as a 
key concept in women's perception of good quality ANC not just in Africa but also across 
the globe. Arsenault et a1. (2018) found that almost one-third of women accessing ANC 
were not receiving a basic package of three services during their pregnancy and also that 
poorer women received lower quality care. These findings were similar to reports from 
other studies elsewhere within the sub-Saharan African Region (Guzha et al., 2018; Nyathi 
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et aI., 2016; Balarajan, Selvaraj, Subramanian, 2011) as well as in Brazil, India, and 
Mexico (Sharma et al., 2017, Rani and Harvey, 2007). 
In summary. it is fair to conclude that the quality of ANC across the SSA region remains 
generally sub-optimal and women across this region continue to have different views 
regarding the quality of ANC they are receiving. Evidence continues to suggest that the set 
global standards for ANC are not being fully achieved across the African region, which 
calls for better funding, better maternity education, better access to skilled birth attendants 
and better staff training. Contradictory evidence continues to emerge in literature about the 
quality of ANC with women from wealthier backgrounds citing better quality ANC, which 
can be attributed to the poor-rich gap in the delivery of ANC across private and public 
facilities. Guzha et aI. (2018), thus, argued that, to improve the quality of maternity 
services, there is a need to monitor the quality of care women receive and that physical 
accessibility and financial affordability to services is a factor that needs to be taken into 
consideration when discussing quality of care. 
2.3.1.1 Quality of delivery and postnatal services in sub-Saharan Africa 
According to WHO (2018), sub-Saharan African region continues to have modest health 
outcomes and continues to be associated with high maternal mortality rates. UNICEF 
(2009) indicated that almost 4.7 million mothers, children and new-borns die each year in 
sub-Saharan Africa due to complications both during and after delivery. Friberg et aI. 
(2010) found that complications during childbirth and after delivery have been linked to 
maternal deaths even though these complications are preventable. According to Friberg et 
aI. (2010), over half of these mortalities OCCur a day after delivery, as also reported in 
some studies elsewhere (Montagu et aI., 2017, Friberg et aI., 2010, Black et aI., 2010, 
Bhutta et al. 2010, UNICEF, 2009). These high mortality rates during and after delivery 
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are attributed to HIV infection, malnutrition, new-born illnesses and childhood infections 
(United Nations, 2009), including maternal anaemia, poor diet and iodine deficiency 
(Black et al, 2008). 
A study by Jordan et al. (2005) conducted in South Africa suggests that more than one-
half of child deaths in the country, including about 38% of maternal deaths, are linked to 
HIV/ AIDS. pneumonia and tuberculosis. However, Black et al. (2010) argued that simple 
interventions such as adequate warmth, adequate nutrition, optimal feeding, better hygiene 
and early treatment of infections have been found to reduce the prevalence of these 
preventable deaths especially when evidence suggests that most child deaths are caused by 
diarrhoea. pneumonia and malaria. 
Studies in Cape Verde, Eritrea, Mauritius, the Seychelles, Botswana and Malawi have 
shown reductions in new-born mortality rates due to improved immunization coverage 
(UNICEF, 2009). This report is echoed by Kruk et al. (2014) that there is growing 
evidence to suggest that educated women have more power and autonomy to make choices 
about the quality of facility-based service and are more likely to bypass community clinics 
in search of first-level healthcare facilities in their search for quality. Graham et al. (2013) 
postulate that the quality of care during delivery must be improved and this is possible 
through better preparedness for emergency obstetric cases, better communication between 
staff and access to medication (Basinga et al., 2011). 
Access to facility-based deliveries has therefore, been found to result in better health 
outcomes as reported in literature (Kohl et al., 2018). For example, in countries like 
Malawi and Rwanda, government regulations in the 2000s have minimised the use of 
assisted home deliveries (Cammack et ai. • 2011, Bucagu et aI., 2012, Chambers and 
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Booth, 2012, Banda, 2013). Kohi et al. (2018), in their qualitative study in Tanzania. 
explored women's access to hospital-based deliveries and who were involved in the 
delivery process. In this study, Kohi et al (2018) found that most women indicated a desire 
for delivery at health facilities but also found the need for these healthcare settings to 
move away from practices that dehumanised the birth process. Furthermore, poor 
infrastructure. lack of trained staff and high caseloads have been found to be contributory 
factors to sub-optimal care during and after delivery across sub- Saharan Africa (Souza et 
al. 2013). 
Gabrysch and Campbell (2009) stated that access to skilled birth attendants is associated 
with lower maternal and neonatal deaths yet women in low- and middle-income countries 
continued to give birth outside health facilities with no skilled assistance. The evidence 
suggested that obstetric complications often happened during delivery. There is thus a 
need to adopt interventions and strategies to reduce maternal and new-born deaths. The 
relevant interventions and strategies include access to skilled maternity care, effective 
management of third-stage labour and timely administration of uterotonics as reported by 
Duysburgh et al. (2013) in their 'Quality of Maternal and Prenatal Care' (QUALMAT) 
project in Burkina Faso, Ghana and Tanzania. In their QUALMAT  project, Duysburgh et 
aI. (2013) focused on detection, prevention and management of complications such as 
haemorrhage, pre-eclampsia and obstructed labour, which had been examined in earlier 
studies by Khan et al (2006) and Ronsmans and Graham (2006). Findings by Duysburgh 
et al. (2013) showed poor quality of history taking, health education, counselling, labour 
investigations and the examination of mothers and the new-born during delivery. 
Additionally, partographs were found to be poorly used. 
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In a very recent qualitative study, Jolly et al. (2019) assessed the quality of antenatal, 
intrapatum and postnatal care in Malawi and found that women felt that attitudes and 
methods of communication from healthcare providers, including education for women 
relating to the stages of pregnancy and labour, were critical in the reduction of 
complications during and after labour. In their study, Jolly et aI. (2019) found that access 
to respectful maternity care was closely associated with women's perceptions of good 
quality care as outlined by WHO (2014). Jolly et aI. (2019) indicated that disrespectful 
maternity care practices continued to be rife in healthcare facilities as reported by Abuya 
et aI. (2015) in Kenya, Asefa and Bekele (2015) in Ethiopia, Okafor et al (2014) and 
Bohren et a. (2016) in Nigeria, Pitter et al.(20 17) in Jamaica, Arnroussia et aI.(20 17) in 
Tunisia. Thet et al. (2016) in India and Kanengoni, Andajani-Sutjahjo and Holroyd 
(2019) in Zimbabwe. 
A study conducted in Ghana by Ganle and Krampah (2018) found that disrespectful and 
abusive maternity care practices during and after labour seriously undermined women's 
willingness to access healthcare facilities. Ishola et al. (2017) found that in Nigeria, 
women reported being slapped or tied down during labour, being pinched or sexually 
abused by healthcare workers during labour. Moreover, McMahon et al. (2014), in a 
qualitative study, made similar findings in Tanzania found Moyer et al. (2014), in another 
qualitative study, found that discrimination, disregard for traditional practices, neglect and 
abuse seriously undermined the quality of antenatal and postnatal care in Ghana. The 
scenario, however, is different in high-income countries like the UK where intrapatum and 
postnatal care is person-centred, respectful and holistic (Vishram et aI., 2018; McConville, 
2014). For instance, Redshaw and Heikkila (2010), in their UK survey, found that most of 
the women reported that staff treated them well and respectfully and that they had access 
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to the NHS Choices website and the NHS Pregnancy Book. Additionally, many caesarian 
sections were planned before labour started. 
2.3.2 Quality of maternal healthcare in Ghana 
Afulani (2015) has examined the impact of maternal risk factors and the quality of 
maternal healthcare services in Ghana. Afulani found that higher quality ANC services 
correlated with a decrease in child mortality and stillbirths by almost a half. Afulani 
(2015) also found that educating women about the risks of pregnancy complications 
influenced the quality of ANC. Afulani (2015) argued that good quality ANC can lead to 
better birth outcomes, similar to conclusions drawn by other studies in Ghana 
(Sabuncuoglu & Basgul., 2016). These findings are confirmed by Kwegyir-Afful et al. 
(2018), who investigated the effects of individual- and community-level factors on the 
delivery of antenatal care, facility-based delivery and postnatal care in Ghana using the 
2014 Ghana Demographic and Health Survey. Kwegyir-Afful et al. (2018) found that 
more affluent and better-educated women were more likely to utilize antenatal services 
and facility-based delivery and were also more likely to be satisfied with the quality of 
care compared to uneducated and socio-economically disadvantaged women. In other 
studies, distance to healthcare facilities has been found to influence women's perception 
about the quality of care (Gething et aI., 2012). Marital status, living in urban 
communities, higher economic status and access to secondary education for both women 
and men were associated with better access to ANC and influenced women's perception of 
the quality of ANC being delivered (Kwegyir-Afful et al., 2018, Chimankar & Sahoo, 
2011, Magoma et aI., 2010, Nair, Ariana & Webster, 2012). 
Similarly, Amoakoh-Coleman et aI. (2015), in their cross-sectional study in Ghana to 
explore the demographic, matemal and community predictors of skilled attendance during 
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labour, found that education, higher economic status and health insurance were 
determinants of women's access to good-quality ANC and delivery and recommended that 
female education be pivotal in the attainment of both the Millennium Development Goal 
(MDG) 5 and the Sustainable Development Goal 3. Some other qualitative studies in 
Ghana suggest that rural women are more likely to be treated less positively when they try 
to access ANC in urban facilities (Andersen, 2016, Moyer et aI., 2014). Tun~alp et al. 
(2012) found that many women reported incurring extra 'hidden' costs on drugs covered 
under the national health insurance scheme or which were not available at the hospital 
pharmacies. Women also expressed concerns about the lack of physical resources like 
water, mosquito-nets and hospital beds, which negatively affected the quality of ANC. 
Another study was conducted in Ghana by Atinga and Baku (2013) to investigate the 
factors that influenced the quality of ANC at public hospitals. This study indicated that 
women aged between 30 and 35 were more likely to be satisfied with the quality of ANC 
and the same passive assessment was made by women with either junior or senior high 
school education. Atinga and Baku (2013) found that distance to health facilities shaped 
women's perception of the quality of ANC including positive interaction with health 
workers, privacy and dignity during consultation and an adequate supply of drugs and 
other pertinent maternity resources. Such evidence points out that women across the world 
not just in Ghana want maternity services that are customer-friendly, well equipped, very 
near to their homes and also offer them quality care regardless of their age, education, 
culture or socio-economic status. 
Bonso (2015) found that most teenage mothers felt that the quality of ANC was good 
although this was attributed to the fact that these mothers perceived service delivery 
differently from older women. Other studies showed that women of low educational status 
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are more satisfied with the quality of ANC than higher educated women who can better 
identify the challenges present in maternal healthcare (Bonso, 2015; Afulani, 2015). 
A study on quality of antenatal care in selected health facilities in Burkina Faso, Ghana 
and Tanzania found that counselling and health education practices were poor while 
laboratory investigations were often not made (Duysburgh et ai., 2013; Duysburgh et ai, 
2014). A comparative study in Ghana showed that there were disparities in the quality of 
ANC care received by clients by place of residence and socio-economic status (SES) 
(Afulani, 2015). Specifically, it was found that being an urban resident and of higher SES 
were positively associated with receiving higher ANC quality (Afulani, 2015). 
A study in Ghana showed that only 3-13% of services received by clients fulfilled the 
requirements for the highest quality category in any dimension (Nesbitt et a1., 2013). 
Quality was lowest in the emergency care dimension with 63% and 58% of facilities 
categorised as "low" or "substandard" for EmOC and EmNC respectively (Nesbitt et aI., 
2013). A study on the quality of care during delivery in Ghana also showed that 
examination and monitoring of mother and the new-born during childbirth were 
inadequate and partographs were often not used (Duysburgh et ai., 2014, 2013). 
Equipment required to provide assisted vaginal deliveries (vacuum extractor or forceps) 
were lacking in all surveyed facilities (Duysburgh et al., 2014,2013). 
In sum, while there is limited research on quality of maternal healthcare services in Ghana, 
the factors that influence women's perceptions of poor quality of maternal healthcare 
services are not different from those in other African countries. The vital factor that runs 
through all the available literature is lack of better communication and inter-personal 
relationships with health service providers. 
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2.4 Improving Quality of Maternal bealtbcare: global policy responses 
The high global burden of maternal mortality has over the years led to the development of 
different policy responses and strategies to promote maternal health and prevent death 
during pregnancy. In this section, these policy responses are briefly summarized along 
three main phases - namely, antenatal care attendance during pregnancy, skilled delivery 
and postnatal care following delivery. 
Antenatal care (ANC) consists of healthcare services provided to women from conception 
to the time they give birth (McKenzie-Mcharg & Rowe, 2014). ANC has a long history. 
The traditional model of ANC was instituted two centuries ago with the aim of educating 
"ignorant" women on child welfare issues (Oakley, 1986). Later on, in the 1950s, ANC 
became a tool for screening women for high risk complications during pregnancy (Villar 
& Bergsjl2J, 1997; WHO, 2003). However, some of the women who are classified as low 
risk do experience complications, especially during delivery (PMNCH, 2006). 
The delivery and the early postpartum periods are periods of the highest risk for a pregnant 
woman and health promotion services offered during ANC contribute to the lowering of 
maternal and neonatal deaths (Finlayson & Downe, 2013). In addition to this, pregnant 
women are presented with the opportunity to contact the healthcare service, where they 
may obtain integrated care, acquire education on healthy home practices and avail 
themselves of existing referral system options. When done properly, ANC has the 
potential to prevent direct deaths as it leads to early detection of warning signs for timely 
interventions (Nishimura et al,2016). The ANC schedule is programmed in such a way 
that a pregnant woman will have to make a minimum of 8 contacts with relevant 
healthcare providers before birth (WHO, 2018). In places where health facilities are not 
located in the communities, it may come with some financial obligations to pregnant 
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women and their families and this challenge has been reported to affect utilization of ANC 
(Austin et al, 2014). Despite knowing the importance of timely ANC, a study in Zambia 
found that some women intentionally initiated ANC late to avoid making several visits to 
the healthcare facilities and to reduce the overall costs of patronizing the facilities (Menon, 
Musonda, & Glazebrook, 2010). 
The poor and vulnerable in society are constantly at the receiving end of poor maternal 
healthcare. In the industrialized countries, there is widespread utilization of ANC by 
pregnant women with the exception of the under-served groups such as migrants, minority 
ethnic groups, unmarried teenagers, the very poor and those living in isolated rural 
communities (Hagey, Rulisa, & Perez-Escamilla, 2014). The dire condition of maternal 
health in urban slums in low-income countries has been documented in several studies that 
highlight poor uptake of ANC services in these resource-deprived urban areas. A Kenyan 
study showed that female slum dwellers started ANC later than other urban dwellers with 
66% of pregnant women in Nairobi slums starting in their second trimester while 20% 
started in their last trimester contrary to WHO recommendations (Kwambai et aI., 2013). 
Studies in India and Nigeria reported that the poor are less likely to initiate ANC early or 
attend any ANC at all during pregnancy (Aniebue & Aniebue, 2011; Singh 2014). 
In order to enhance and maintain good health and safe delivery for pregnant women, 
World Health Organization, in 2016, formulated policy recommendations to guide the 
provision of quality antenatal care services. These recommendations include unitization of 
health system interventions to improve the quality of antenatal care; the need for pregnant 
women to adhere to the stipulated standard, which is a minimum of 8 antenatal contacts 
with health professionals (WHO, 2016); shifting of antennal care services from health 
facilities to the community to meet th iii 
e spec c needs of pregnant women living in hard-
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to-reach or conflict areas and adoption of flexibility and different options for the delivery 
of antenatal care based on varying needs of pregnant women. 
Among the other recommendations are the promotion of health-related behaviours as well 
as the distribution of recommended nutritional supplements and malaria prevention; the 
inclusion of daily oral iron and folic acid supplementation with 30mg to 60mg of 
elemental iron and 400 Ilg (0.4 mg) folic acid for pregnant women to prevent maternal 
anemia, puerperal sepsis, low birth weight. and preterm birth and tetanus toxoid 
vaccination for all pregnant women, depending on previous tetanus vaccination exposure, 
to prevent neonatal mortality from tetanus. Additionally, there should be one ultra-sound 
scan before 2-1 weeks gestation (early ultrasound) for pregnant women to estimate 
gestational age, improve detection of foetal anomalies and multiple pregnancies, reduce 
induction of labour for post-term pregnancy and improve a woman's pregnancy 
experience. It is also recommended that healthcare providers ask all pregnant women 
about their use of alcohol and other substances (past and present) as early as possible in 
the pregnancy and at every antenatal visit WHO, 2016). 
Prior to making the 2016 policy recommendations on antenatal care, World Health 
Organisation made some policy recommendations for quality postnatal care for new 
mothers in 2014. These policies included the provision of mother and her new-born child 
with postnatal care within 24 hours of delivery. In the case of hard-to-reach areas, 
mothers should at least receive postnatal care on the third day after birth, the second week 
after the birth and six weeks after the delivery (WHO, 2014); iron and folic acid 
supplementation should be provided for at least three months; screening for and treatment 
of infection, haemorrhage, thromboembolism, postnatal depression and other conditions 
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and prophylactic antibiotics should be given to women who have a third- or fourth-degree 
perineal tear. 
There should be counselling on early and exclusive breastfeeding, nutrition, birth spacing 
and family planning options - including any available contraception in addition to care of 
the umbilical cord; special care for preterm, low-birth-weight and HIV -infected neonates; 
attention should be paid to screening and treatment of infections and postnatal growth 
restriction; assessment of factors predisposing to infant anaemia and teaching the mother 
to seek additional care for her neonate if she notices danger signs such as convulsions or 
problems with feeding. 
In addition, within WHO's domains of quality of care, several strategies are used to 
improve the quality of maternal and child healthcare. These strategies include those to 
improve the skills and knowledge of health professionals, use of actual data and maternal 
and paediatric case audits (WHO, 201S). For instance, strategies and tools to improve 
children's health in Kenya included a training course on emergency triage developed by 
the Ministry of Health, which was based on WHO's course for continued care of 
critically-ill children during the initial 4S-hour after admission (Mwaniki et al .• 2014). 
A systematic review of strategies to improve the performance of healthcare providers in 
low- and middle-income countries showed the effectiveness of group problem-solving in 
addition to training. supervision of training, the effectiveness of longer training, training 
through lectures, interactive sessions, role play and clinical practice in combination or 
training covering several topics and use of check-lists (Bright et aI., 201S). The check-list 
and the accompanying implementation manual help healthcare workers to deliver essential 
maternal and perinatal care. They were prepared jointly by WHO Patient Safety 
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Programme, the departments of Maternal, New-born, Child and Adolescent Health and 
Reproductive Health Research and the Harvard School of Public Health. The check-list is 
based on published guidelines, evidence-based literature, expert consensus, collaborator 
feedback and reviews of mortality and near-miss audits (WHO, 2017). It comprises 29 
items covering the major causes of maternal death (haemorrhage, infection, obstructed 
labour and hypertensive disorders), intrapartum-related stillbirths (inadequate intrapartum 
care) and neonatal deaths (birth asphyxia. infection and complications related to 
prematurity) (WHO, 2017). 
Furthermore, WHO has developed a Safe Child-birth Checklist to help strengthen the 
practices of the delivery of essential maternal and perinatal care (WHO, 2017). The 
Check-list points to the major issues of maternal mortality. This Checklist was designed 
following a rigorous methodology and was further tested for its usability in ten countries 
in Africa and Asia. A guideline was further formulated to support skilled attendants and 
healthcare professionals to use and ensure the sustainability of the WHO Safe Childbirth 
Checklist (WHO, 2017). 
Although the WHO Safe Childbirth Checklist is comprehensive and holistic in its context, 
the generalized intentions in terms of application do not take the specific cultural issues of 
the different groups of women into consideration. Moreover, it is a provider checklist and 
no consultation with women who are the end-users of this service was included. The 
application of these tools might not work in several cultural settings where religion and 
low levels of education are prominent such as northern Ghana. It is in this light that a tool 
developed in partnership with women who experience maternal healthcare in Ghana could 
be essential. 
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Another strategy by WHO is the maternal death surveillance and response. The system, 
promoted by WHO and its partners and currently implemented in many countries, includes 
maternal death identification, reporting, review and response, which is the essential 
infonnation for stimulating and guiding action to prevent future maternal deaths and 
improve measurement of maternal mortality. It can improve the quality of care and 
prevent maternal deaths (WHO. 2016). 
2.5 Policies/programmes for ensuring Quality of Maternal Healthcare in Ghana 
Ghana has developed few policies to ensure quality of maternal healthcare. Ghana 
launched the Safe Motherhood Programme and developed a policy for its implementation 
in 1987 after it was initially launched by WHO (Okiwelu, et aI., 2007). This initiative led 
to the training and deployment of more midwives to ensure quality ANC and skilled 
delivery (GHS, 2015). The High Impact Rapid Delivery (HIRD) approach has also been 
employed to work in tandem with other maternal and child mortality reduction strategies. 
This approach encapsulated the important principles of vision and data-driven methods to 
attain at least 90 percent coverage of crucial and cost-effective interventions, which are 
known to have a high impact on maternal and child mortality. Among other things, a 
Ministry of Health Report in 2008 indicated that the High-Impact Rapid-Delivery (HIRD) 
approach aimed at ensuring that health services were available and utilized by all women 
who need such services (MOH, 2008). The HIRD planning was then started with four 
most deprived regions that had poor maternal and child health indicators. These regions 
were Upper East Region, Northern Region, Upper West Region and Central Region. 
The eight steps to guide the regions and district to fonnulate their vision for maternal and 
child health (MCH) included statement of the vision of the region and district for maternal 
and child health. comparison of the current coverage levels of MCH interventions with 
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stated targets using the most recent surveys (or routine administrative reports) that were 
available, listing of the interventions with current coverage levels below the set targets and 
identification of bottle-necks that hampered the achievement of set targets and listing the 
underlying causes of the bottle-necks. The other steps included formulation of strategies to 
remove the underlying causes of the bottle-necks, identification of potential resources 
within and outside the health sector, and development of a plan for implementing the 
strategies. The last step was the estimation of the extra cost required to implement the plan 
such as the Vitamin A Supplement Trials (VASn Survival Programme, the Prevention of 
Maternal Mortality Programme (PMMP), Making Pregnancy Safer Initiative, Prevention 
and Management of Safe Abortion Programme, Maternal and Neonatal Health 
Programme, the Roll Back Malaria Programme containing the Intermittent Preventive 
Treatment (lPT) for pregnant women; and Emergency Obstetric and Neonatal Care 
(EmONC) (GHS, 2015; MOH, 2008). 
Ghana has also involved communities in ensuring that basic healthcare, including 
reproductive health services, is accessible to all individuals (pence et ai., 2007). The 
Community-based Health Planning and Services (CHPS) programme is a health 
intervention that was successfully piloted in 1994 in Navrongo, Upper East Region of 
Ghana (Nyonator et al., 2005). The initiative sought to scale up the success story from the 
Navrongo pilot into a national programme in 2000 to ensure that healthcare services made 
accessible, equitable and of good quality (Pence et aI., 2007). This method of healthcare 
delivery entails the posting of a trained nurse/Community Health Officer (CHO) to 
designated communities called CHPS zones to provide door-to-door healthcare services to 
members of the community (Binka et aI., 1995; Nyonator et aI., 2005). The CHOs in the 
CHPS zones serve as community- 1e vel bas'lC  healthc are servI. ce prOV.i ders under the 
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supervision of municipal health directorates. It has proven to lead to an improvement in 
the provision of maternal, reproductive and child health services (Nyonator et aI., 2005). 
Ghana introduced a quality assurance system and customer care, which are aimed at 
orienting service providers on quality issues (Nsiah-Asare, 2017). Quality Assurance (QA) 
has been defined as the planned and systematic activities implemented in a system so that 
quality requirements for a product or service will be fulfilled (Kow, Motohiro, Doe, & Sri 
Heruwati. 2017). Ghana developed the policy and strategic plan in the early 1990s but a 
review conducted in 1998 concluded that while substantial progress had been made in 
setting up QA systems in the country, coverage of quality assurance interventions was low 
and varied approaches were being used where QA programmes were in place (Nsiah-
Asare. 2017). The report observed that structures at all levels had not yet been organised to 
provide direction and guidance for QA in health institutions and recommended the 
mainstreaming ofQA into planning and delivery of health care (GHS, 2007). 
Another quality assurance strategy that has been developed by Ghana is the patient 
charter. Ghana Health Service expects healthcare institutions to adopt the patient's charter 
to ensure that service personnel as well as patients/clients and their families understand 
their rights and responsibilities. This charter is made to protect the rights of the patient in 
Ghana Health Service (GHS, 2003). 
2.6 Maternal health care quality assessment 
Many stakeholders have acknowledged the multi-faceted nature of healthcare quality 
(Rowe 2005; Tripathi et al., 2015; Tun~lp et al., 2012). In the literature, QoC is often 
described from the perspective ofhealtbca re proVi'd e rs, managers and pati"e nts; dimensions 
within the bealthcare system; using elements such as safety, effectiveness, patient-
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centredness. timeliness, equity and efficiency and through the provision of care and 
experience of care (Van Den Broek & Graham 2009; Raven et aI., 2012; Tripatbi et aI., 
2015). This section summaries the various perspectives on maternal healthcare quality 
assessment. 
2.6.1 Health workers' perspective on maternal healthcare quality assessment 
From the perspective of healthcare providers, the main concern is to ensure that the 
services they provide are of the highest possible standard and meet the needs of individual 
service users. their families and communities (WHO, 2006). Obstetric outcome is a major 
measure of the quality of care provided and mostly considered in assessi3ng quality of 
matemal healthcare from the health workers' perspective (Karlstrl>m, Nystedt, & 
Hildingsson, 2015; Tripathi et aI., 2015). In recent years, checklist-based interventions 
have been adopted by WHO (in 2008 and remodified in 2017) to aid management of 
complex or neglected tasks that risk serious human harm. In 2008, World Health 
Organization established a checklist-based childbirth safety programme with the goal of 
determining whether a simple, low-cost, scalable intervention with potential for broader 
testing could be devised (WHO, 2008). The WHO's Safe Childbirth Checklist was 
developed according to previously established methodology and tested for usability in ten 
countries in Africa and Asia (Weiser et aI., 2010). This checklist is mainly tailored toward 
clinical procedures such as monitoring stages of labour by assessing maternal and baby 
physiological processes such as heart-beat, respiration, blood pressures and contractions 
(Duysburgh et aI., 2014; Wall et a1., 2010). Adherence to this checklist is therefore used to 
measure quality of care provided during birth. In a related study, Spector et al. (2012) 
found that the use of such a checklist led to an over 150% increase in adherence to 
accepted clinical practices at any given birth event and that 28 of 29 individual practices 
were delivered with significantly greater frequency. This check-list was, however, 
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developed without consultations with healthcare providers who are supposed to implement 
these policies (Duysburgh et al., 2014). As observed by Lipsky (2010), frontline providers 
who do not make inputs are sometimes reluctant to implement those aspects of the policy 
that conflict with normal practices. 
2.6.2 Women's perspective on maternal healthcare quality assessment 
The experience of giving birth has long-term implications for a woman's health and well-
being (Crompton, 2002). Satisfaction with birth has been associated with several factors 
and the emotional dimensions of care have been shown to influence women's overall 
assessment (Karlstr~m et al., 2015). Individualized emotional support empowers women 
and increases the possibility of a positive birth experience (Moyer at el., 2014); therefore, 
women's views of what constitutes quality of maternity care are important indicators of 
quality service provision (Jackson, Chamberlin, & Kroenke, 2001; Tripathi et a!., 2015). 
In an earlier study, effective behaviour such as frequent and cordial engagement of clients 
during care was found to be the most important factor in determining patients' satisfaction 
(Bensing, 1991). A systematic review identified four key factors essential for women's 
satisfaction with the quality of care regarding birth (Hodnett, 2002). Two of these factors 
were directly related to the woman-caregiver relationship: first, the quality of the 
relationship between the woman and the caregiver, and second, the amount of support the 
woman received from the healthcare provider. The attitude and behaviour of the caregivers 
expressed in the relationship with the woman outweighed the effects of all other variables 
such as age, birth environment and medical interventions (Hodnett, 2002). In a related 
study, continuity of care was reported as very important for women because it contributed 
to their feeling of safety during labour (de Jonge et al., 2014). However, a study in Ghana 
reported that factors such as provision of good information, good communication and 
attitudes and availability of human (that . d . 
IS, more octors) and phYSical resources (that is, 
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more beds and water) at the facility were key element of a woman's views on quality of 
maternal care (Tun~alp et al., 2012). Again, assessment of quality of care from the clients' 
perspective is important but this does not take into consideration the perspectives of the 
healthcare provider and the institutional barriers. It would, therefore, be important to 
develop a tool that incorporates all these dimensions. 
2.6.3 Indicators and Tools for Quality of Maternal Healthcare Assessment 
In most countries. there is no national accreditation system or mechanism to monitor the 
quality of care provided in health facilities despite the availability of evidence-based 
guidelines and tools. A few countries have mechanisms to assess the quality of healthcare 
but they are usually meant for specific population groups, conducted at a limited number 
of sites and address issues of care of national relevance (Austin et aI., 2014). Such 
accreditation systems, hence, do not adequately address the dynamic nature of quality of 
care and the associated problem-solving necessary to improve care (WHO, 2013b). They 
do, however, represent a launching point for a more standardized approach to assessing 
quality of care. A number of quality assessment tools including Service Availability and 
Readiness Assessment (SARA), Consensus Health Care Service Quality indicators and the 
WHO integrated tool are available for assessing and auditing the quality of services 
provided at health facilities. Nevertheless, existing measures should be rationalized to 
obtain a unified framework for measuring results with a limited set of output and impact 
indicators. 
The Norwegian Institute of Public Health (NIPH, 2013), in a study, argued that indicators 
for measuring quality of maternal healthcare should be action-focused, important, 
operational, feasible, simple and valued (NIPH, 2013). To be action focused means that 
the tool and indicator should be c Ie ar on hat should be W done to I. mprove outcomes 
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associated with the indicator (for example, vaccination to reduce neonatal tetanus). It 
should be important in that the indicator and the data generated should make a relevant, 
significant contribution to detennining how to respond to the problem effectively. To be 
operational, the indicator should be quantifiable and the definitions precise while reference 
standards are either available and tested or could be developed (NIPH, 2013). The 
indicator should also be feasible such that it can collect the data required for the indicator 
in the relevant setting. Finally, the indicator must be simple and valued, making it possible 
for the people involved in the service delivery to understand and rate (the indicator) 
(NIPH.2013). 
In their study in Europe on the use of maternal health indicators, Escuriet et al. (2015) 
found that a total of 388 indicators were identified capturing aspects of maternity care. 
Intrapartum care was the most-frequently measured feature through the application of 
process and outcome indicators (Escuriet et aI., 2015). Postnatal and neonatal care of 
mother and baby were the least-appraised areas (Escuriet et aI., 2015); however, these 
indicators are measured using quality tools. It has, thus, been argued that tools for 
measuring quality of care should specifically include process indicators (Gupta, 2008). 
Much of the background literature on tools for measuring healthcare refers to 'quality 
indicators' (also known as performance indicators or quality measures). These indicators 
may be structural, process or outcome in nature so they track significant changes such as 
deterioration and/or improvement within a specific area of care (Sibanda et aI., 2013). The 
monitoring of quality indicators is understood to substantially enhance understanding of 
what is working well or not, where efforts for improvement should be targeted and the 
evaluation of any introduced changes either within a particular unit of analysis (such as a 
hospital, a region and a country) or across units (Gibberd et al., 2004). 
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2.6.4 Existing tools for maternal bealtbcare quality assessment 
Identification and measurement of healthcare service quality attributes and patient 
satisfaction have been examined by several scholars. According to Woolley et al. (1978), 
patients' satisfaction is a product of quality and outcome, continuity of care, patient 
expectations and doctor-patient communication. In line with this thinking, Parasuraman, 
Berry & Zeithaml (1991) devised the SERVQUAL scale containing 5 dimensions, which 
used customer expectations and perceptions to judge the quality of service. These 5 
dimensions are tangibles, reliability responsiveness, assurance and empathy. The 
SERQUAL scale was and has been deemed to cover expectations and perceptions of 
clients and also it met various criteria for reliability and validity (Babakus & Mangold, 
1992). The strength of the SERQVQUAL's Scale lies in its strong reliability and 
consistency with its structures regarding the various dimensions for measuring quality in 
providing support for its validity assessment. The tool is also an accurate scale for 
measuring service reliability and validity to better understand customer expectations. The 
flexible nature of this tool allows it to be applicable across a broad spectrum of services. 
Despite these strengths, its 5 dimensions are not adequate to capture and measure the 
unobservable underlying constructs, which it intends to measure. The major weakness of 
the SERQVQUAL tool is that it was solely developed to measure customer expectations 
in commercial settings and not the expectations of clients who seek health services. 
Anderson (1995) adapted the SERVQUAL scale and designed two sets of tools containing 
15 statements, each for measuring quality at in a health facility. The first set of tools 
measured expectations relating to university health clinics in general while the second set 
measured perceptions relating to University of Houston Health Centre in particular. The 
first five statements on expectations are that health centres should have up-to-date 
equipment; their physical facilities should be visually appealing; their employees should 
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appear neat; they should provide their services at the time they promise to do so and when 
patients have problems, health centre employees should be sympathetic and reassuring. 
The second set of five statements on expectations are that health centres should be 
accurate in their billing; their employees should tell patients exactly when services will be 
performed; it is realistic for patients to expect prompt service from the employees, who 
should always be willing to help the former, and patients should be able to feel safe in 
their interactions with the employees. 
In the last set of five statements, health centre employees are expected to be 
knowledgeable, polite, get adequate support from their employers to do their jobs well and 
give their patients personal attention. Finally, it is realistic to expect health centres to have 
their patients' best interests at hem1. 
Lim & Tang (2000) also adapted the 5-dimensional SERVQUAL tool and used it to 
formulate their 25-item tool for determining healthcare service quality in Singapore 
hospitals. They identified the following items in respect of tangibility: up-to-date and 
well-maintained facilities and equipment; clean and comfortable environment with good 
directional signs; neatness in professional appearance on the part of doctors; informative 
brochures about services and privacy during treatment. 
Reliability was accorded the follOwing five items: provision of services should be 
provided at the appointed time, carrying out services at the right time; professionalism and 
competence among doctors; error-free and fast retrieval of documents and consistency of 
charges. In respect of responsiveness (RS), Lim and Tang (2000) indicated that patients 
should be . . 
given prompt servtces; doctors and other staff should be responsive; attitude of 
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doctors/staff should instil confidence in patients and waiting time should not be more than 
one hour. The four items that fell under assurance (AS) were friendly and courteous 
doctors/staff; doctors' possession of a wide spectrum of knowledge; treating patients with 
dignity and respect and thorough explanation of medical condition to patients. In respect 
of empathy (EM), Lim and Tang (2000) indicated that Singapore hospitals should obtain 
feedback from patients as well as offer 24-hour service. Additionally, doctors and other 
staff should have patients' best interests at heart and also understand the latter's specific 
needs. Accessibility and affordability (AA) required the hospital to have adequate parking 
facilities and accessible locations. They should also have affordable charges for services 
rendered. 
labnoun and Chaker (2003) adapted the measurement dimension of the SERVQUAL 
Scale and developed a 39-item questionnaire to compare the quality of health service 
provision in private and public hospitals in Abu Dhabi, Sharjah and Dubai. The 
dimensions were put under four headings: empathy, tangibility, reliability and supporting 
skills. The items under empathy included concern for family and visitors as well as 
patients' needs. amount of time spent by staff in getting to know and understand patients' 
needs, politeness of physicians, ability of the hospital to treat patients the way the latter 
expect and responsiveness of the nurses to patients' needs. 
Tangibility is related to cleanliness of the hospital, pleasantness and appeal of the hospital 
rooms, availability of information about one's condition and sense of wellbeing one felt at 
the hospital. The items under reliability included availability of visitor parking, 
performance of services the way one was told it would be performed, ability of hospital to 
deliver what was promised in their advertising, skills of physicians attending to a patient, 
competence of staff in filling insurance 1I U. ms and  admini" C stratlve responsI.v eness. Waiting 
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time for tests, speed and ease of admissions as well as discharge, waiting time for 
medication and time between admissions and getting into one's room were the other items 
under reliability. The three items under supporting skills were instructions about billing 
procedure and the nurses who perform the tasks. 
In a study in India, a 70 indicator point healthcare quality measurement instrument was 
identified as relevant to healthcare service in general. The indicators covered various 
aspects of the structural, process and outcome elements of the Donabedian model (Gupta. 
2008). This instrument became known as Consensus Healthcare Service (Table 1). 
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Table 1: CODsensus Health Care Service Quality indicators 
No Quality Dimension No Quality Dimension 
1 Modern state-of-art equipment 23 Providing appointment at a time convenient to patients 
2 Comfortable, clean and visually appealing physical facilities 24 Performing treatment, tests and surgeries at a time 
(stretchers, wheelchairs, waiting rooms, seating, lifts, stairs. convenient to patients 
examination/consultation rooms, wash rooms, directions, 
passages etc.) 
3 Easy to understand, comprehensive and visually attractive 25 A vai lability of doctors at odd hours in case of emergencies 
materials associated with service (eg. information brochures, 
posters, report-cards, pamphlets etc.) 
4 Neatly and appropriately dressed doctors. 26 Doctors accessible on phone 
5 Neatly and appropriately dressed support staff (i.e. nurses, 27 Employees are always sympathetic and helpful 
administrative staff and other employees) 
6 Convenient location of hospitaVdoctor (It can be quickly and 28 Employees are never too busy to respond to requests and 
easily accessed which is important during an emergence) needs of the patients 
7 Good housekeeping and laundry 29 Prompt availability of drugs and other consumables 
required for treatment 
8 Pathology lab, provides correct, quick and reliable results 30 Giving priority to treatment over paperwork 
9 Ambulance 31 Giving priority to treatment over monetary transactions 
20 Informing patients exactly when service will be provided 32 Courteous, polite and friendly doctor 
21 Providing service at the appointed time 33 Courteous, polite and friendly support staff 
22 Providing service without an appointment 34 Doctors make patients feel safe and relaxed 
35 Support staff makes patients feel safe and relaxed 44 Devoting adequate time to carefully listen to the medical 
history and current symptoms of the patients 
36 Medical condition of the patients is thoroughly explained and 45 Patience in responding to queries of the patients 
discussed by the doctor 
37 Confidentiality of information 46 Understanding concerns and needs of the patients 
38 Informing and explaining possible treatments 47 Reassuring the patients about the medical treatment and 
procedures 
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39 Explaining cost of service to the patients 48 In case of need, referring patients to other specialists 
40 Infonning side effects ofmedicinesltreatment 49 Having patients' best interest at heart 
35 Support staffmakes patients feel safe and relaxed 50 Follow up by doctor, whenever required 
36 Medical condition of the patients is thoroughly explained and 51 Total health care system supporting quick patient recovery 
discussed by the doctor 
37 Confidentiality of information 52 Educating patients 
38 Informing and explaining possible treatments 53 Informing patients, at the time of discharge, about 
symptoms and health problems to look out for 
39 Explaining cost of service to the patients 54 No overcharging 
40 Informing side effects of medicinesltreatment 55 No overstay in the hospital 
41 Employees get adequate support from their employers for 56 No discharge from the hospital before time 
helping patients 
42 Providing privacy to patients 57 No unnecessary investigations and tests 
43 Doctors providing personal attention to the patients 58 No unnecessary referrals to other specialists 
S9 No unnecessary procedures (treatments/surgeries) 
60 Refer patients to another doctor in case of doubt or if unsure about diagnosis or treatment 
61 No experimentation with the patient 
62 Qualifications 
63 Experience 
64 Knowledge 
65 Training 
66 Skill 
67 Referral contacts with specialists. hospitals and laboratories 
68 Positive outcomes of the past treatments and procedures 
69 Familiarity with latest advances 
70 Explaining trade-offs between cost and benefit 
Source: Gupta, 2008 
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All these tools developed by Anderson (1995), Lim & Tang (2000) and labnoun and 
Chaker (2003) were adaptations of the SERQVQUAL Tool specifically for the assessment 
of healthcare services. Anderson's (1995) tool, for instance, extended the parameters of 
assessment to include the expectations and perceptions of clients who sought healthcare 
services, which were more specific in measuring quality of healthcare services in the 
health sector. However, a common weakness of these tools is that they assess general 
healthcare services and not specific to maternal healthcare services, which is the focus of 
this study. In addition, concepts and parameters of assessments of quality of healthcare 
applicable to these tools were borne out of ideologies of a developed western environment, 
which might not work in a developing country like Ghana. Besides, these tools measure 
quality of health care from the perspective of the health providers but not that of the client, 
which this study seeks to achieve. Although the Consensus Health Care Service Quality 
indicators are appropriate for the developing world, the tool is limited by the fact that it 
assesses general healthcare services. The limitations of these tools, therefore, called for the 
development of a more suitable tool to achieve the objectives of this study. 
Although new measurements such as Risk-Adjusted Primary Caesarean Rates, the 
Nulliparous term singleton vertex caesarean birth (NTSV) rate and the Adverse Outcomes 
Index (AOI) are more specific to maternal healthcare services (Foglia et aI., 2015; Shields 
et al., 2016), they are all clinical based and not patient-centred. They are only limited to 
caesarean deliveries and are, thus, not applicable to every pregnancy since it is not every 
woman who goes through caesarean delivery. 
The next tool that is used to assess quality of maternal healthcare is WHO's (2013) 
Service Availability and Readiness Assessment (SARA) tool. SARA is a tool for assessing 
and monitoring the availability of services at health facilities and the readiness of the 
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health sector to generate evidence for planning and managing a health system (WHO, 
2013). The objective of the tool is to obtain reliable, regular information on service 
delivery (such as the availability of key human and infrastructural resources), the 
availability of basic equipment, basic amenities, essential medicines and diagnostics and 
the readiness of health facilities to provide basic interventions in family planning, child 
health services, basic and comprehensive emergency obstetric care and treatment and care 
for HIV, tuberculosis, malaria and non-communicable diseases (WHO, 2013). According 
to WHO (2013), the SARA tool is designed as a systematic survey to assess health facility 
service delivery. It aims at generating reliable and systematic data on health service 
delivery and service availability (such as the availability of key human and infrastructure 
resources) and the readiness of health facilities to provide fundamental healthcare 
interventions. 
The main SARA indicators include scope of availability of basic packages of essential 
health services offered by public and private health facilities, adequacy of qualified staff, 
resources and support systems available to assure a certain quality of services and level of 
preparedness of facilities to provide high-priority services such as reproductive health 
services, maternal and child health services, and infectious disease diagnosis and treatment 
(for example, HIV, sexually- transmitted infections, tuberculosis and malaria). The other 
indicators are the levels of readiness of facilities to respond to the increasing burden of 
non-communicable diseases and the strengths and weaknesses in the delivery of key 
services at hea1th-care facilities. 
SARA has aided in filling critical data gaps in measuring and tracking progress in 
strengthening of health systems, which WHO and its partners have been lacking over the 
years. SARA uses record review to assess data which serves as an accurate reporting 
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system on quality of health facilities. However, the limitation of SARA is that, though it is 
developed to measure quality of maternal healthcare services, it is a global assessment tool 
developed by WHO without taking into account the different needs of end-users from 
different countries and cultural settings. In addition, the developers of SARA did not 
incorporate the views of pregnant women and nursing mothers. In view of these situations, 
its adaptation and application may pose some challenges considering the varied 
developmental stages of member countries and their socio-cultural backgrounds. 
Afulani et al. (2017) developed a more-recent tool for assessing patient-centred maternity 
care in Kenya which is appropriate for developing countries. This tool focuses on views of 
pregnant women and nursing mothers by giving a voice to the end-users of maternal 
healthcare services. However, Afulani's tool failed to assess technical quality of care, 
which was identified by Donabedian (1966) as a structural dimension of quality of care. 
Also, the views of healthcare service providers were not included in the development of 
the tool. For a more holistic development of a maternal tool, the perspectives of both 
healthcare providers and women are important requirements. The narrowness of this tool 
therefore makes it inappropriate for this study; hence, the need to develop a more holistic 
tool which is relevant to this study. 
2.7 Theoretical Framework 
In the past, quality of care has often been measured by assessing adverse medical 
outcomes such as disability or death, the latter being the most dominant outcome in the 
evaluation of quality in the perinatal period (Salinas et al., 1997). In sub-Saharan Africa, 
for example, quality of maternal healthcare has frequently been assessed in terms of 
facility readiness to provide delivery services (structural quality) or evaluated outcomes 
using case fatality rates and similar indicators (Kendall & Langer, 2015). Some 
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researchers have also evaluated quality in tenns of women's satisfaction with health 
services, identified by Donabedian as a care outcome, without assessing technical quality 
of care (Baltussen et a!., 2002; Anwar et aI., 2009; Anwar, 2009), However, the work of 
Av edis Donabedian provides a good theoretical framework, which defmes quality of care 
by three components namely, structure, process and outcomes (Donabedian, 1966). 
This study adopted the Donabedian framework (Avedis Donabedian, 1966). The 
framework consists of three components: structure, process and outcomes (see Table 2). 
Table 2: Dimensions of quality of care according to the Donabedian model 
Structural Indicators Process Indicators Outcome Indicators 
I.Financial resources 1. Preventive care 1. Health status 
2. Personnel 2. Diagnosis 2. Outcomes of deliveries and 
preventive care 
3. Equipment 3. Therapeutic care 3. Patients' well-being 
4. Facilities 4. Rehabilitation 4. Patient satisfaction 
5.lnformation system 5. Infonnation and instruction 5. Good use of resources 
of the patient 
Source: Bureau regional de I' Europe de I' organisation Mondiale de la sante( 1998) 
The "Structure" component refers to relatively- static characteristics of the personnel who 
provide care and of the settings where the care is delivered. These characteristics include 
personnel in respect of education, training, experience and certification. The availability of 
qualified personnel with adequate experience and a good service provider-client ratio are 
indicators of quality (EI Hajj, Lamrini, & Rais, 2010). Thus, even though Traditional Birth 
Attendants are not regarded by Ghana Health Service as skilled birth attendants their 
training as part of a community-based intervention package has been reported to have had 
significant impacts on referrals, early breast feeding, maternal morbidity, neonatal 
mortality and perinatal mortality by improving quality of care (ten Hoope-Bender et al., 
2014). An adequate number of midwives has also been identified as important factors for 
maternal healthcare quality (ten Hoope-Bender et aI., 2014). 
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The settings where the care is provided, which involve the adequacy of the facility's 
staffing, equipment. safety devices and overall organization, have been identified as other 
important component of structural quality. For example, the availability of soap and 
running water or an alcohol-based hand rub to prevent infection and the availability of a 
safe, uninterrupted supply of oxygen during labour and childbirth are core indicators of 
structural quality (WHO, 2013a). Also, stock-outs of drugs and consumables in health 
facilities affect the quality of care. 
The "process" component denotes all the activities taking place during the delivery of care 
to the patient (for example diagnosis, prescription, treatment, and information and 
instruction). It concerns the way in which care is delivered according to two further 
aspects: the technical and inter-personal. The technical aspect refers to the application of 
current medical science and technology to maximize the balance between benefits and 
risks. This aspect concerns the timeliness and accuracy of diagnosis, the appropriateness 
of therapy, complications and incidents that may occur during treatment and coordination 
between the various stages of the care delivery and between different disciplines involved 
(Ransom, Joshi, & Nash, 2005). The inter-personal aspect is related to the clinician-patient 
relationship and refers to the rules and standards regulating client-service provider 
interaction as well as ethical standards specific to health and to the patients' expectations 
(information, answering questions, asking about their preferences and involvement in 
taking decisions). Inter-personal relationship is important because it affects the technical 
performance. A study showed that women who were delivered in a health facility and 
were provided with information to notify health extension workers of labour and birth 
within 48 hours were closely linked with receipt of postnatal care in Ethiopia (Tesfaye et 
aI.,2014). 
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When evaluating the quality of care and services in a health institution in terms of process, 
Ransom et al. (2005) suggested that it is useful to distinguish between two aspects on 
which quality can vary. The first aspect appropriateness shows (whether the right actions 
were taken). The second aspect skill relates to how well actions were carried out in the 
client-service provider interaction). 
Quality of care may also be assessed in terms of outcome measures, which seek to capture 
whether the goals of care were achieved (Donabedian, 1997; Ransom et aI., 2005). In 
addition to the health-status indicators, there are other indicators related to the cost of care 
and patient satisfaction. Health-status indicators, according to EI Hajj et al. (2010), are of 
two main types: indicators of intermediate and final outcomes. Indicators of intermediate 
outcomes refer to the activity and quality of the process steps such as the rate of operating 
site infection, immunization rate, percentage of unplanned readmission and failure rate (EI 
Hajj et aI., 2010). On the contrary, indicators of final outcomes refer to the effect of the 
provision of care on health (quality of life, disability, death, complications) and either the 
presence of good events or the absence of bad events expressed in terms of quality of life 
and in clinical and physiological terms (EI Hajj et aI., 2010). 
In summary, Donabedian (1966) theorized that high quality care, measured in the form of 
the delivery of safe, effective and efficient healthcare provided in a timely manner and 
equitably distributed, is a function of structure, process and outcomes. Once the structural 
and procedural components of quality of care are achieved, it is expected that there would 
be reduction in adverse patient outcomes such as disability, hospital-acquired disease, 
dissatisfaction among clients and death (Gupta, 2008). 
The first strength of the Donabedian Framework lies in the fact that it gives a broad 
overview of how t-Ilth,.. ..... ' ....\ lity should be assessed m.  genera l const'd en .o g both the 
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technical and process dimensions of quality assessment. This framework is, therefore, 
applicable to the general healthcare environment. Second, the three dimensions of the 
Donabedian model are linked in multiple dimensional and complex ways but, together, 
they cover all the areas in which we can observe quality issues and improvement in the 
health care settings. 
Despite its strengths, the Donabedian model conceptualizes healthcare indicators in 
general and is not tailored to specific health needs like women's health, maternal health 
and men's health. Also, the Donabedian model is not context specific and may not be 
applicable to certain cultural settings like those in Africa. In view of these weaknesses, the 
Donabedian model was adapted to develop a new conceptual framework (see Figure I) for 
use in this study. 
2.8 Conceptual Framework 
Based on the Donabedian theoretical framework above, a conceptual framework (see 
Figure I) were developed to explain possible factors that could affect women's assessment 
of the quality of maternal healthcare in Northern Region. 
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Predict rs of quality of car Domains 
~ 
• Socjo-ciemographjc Amenities 
Human resources 
~ Range of services 
Age, education, marital status, 
Environment/sanitation 
tribe, location, district type, 
Logistics and supplies 
type of facility, religion, Health facility/proximity 
occupation and income 
• Community factors 
Decision-making Quality of 
.~ 
Means of transport Maternal care: Privacy 
Availability of transport Interpersonal • High 
relationship • Moderat 
e 
• Obstetric factors Discrimination /fairness • Low 
Parity Safety for mother during 
Gravida delivery 
Pain management 
. ~ 
Availability of health facility .~ 
Distance to health facility Satisfaction 
Waiting time at health facility Safety for mother 
immediately post 
delivery 
Safety for baby post 
delivery 
Figure 1: Conceptual Framework of Quality of Maternal Healthcare 
The framework presents three dimensions for conceptualizing quality of maternal 
healthcare. lbese dimensions are the factors that could affect how women defme or 
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perceive the quality of care they receive, the domains of quality of care and the assessment 
of quality of maternal healthcare services. 
2.8.1 Factors tbat influence quality of care 
The factors that could affect maternal healthcare quality are the fundamental determinants 
of quality assessment process. These factors consist of the socio-demographic elements of 
care recipients (that is women), obstetric factors, socio-economic factors, socio-cultural 
factors and access. The socio-demographic factors include woman's age, educational 
level, marital status, ethnic background, place and district of residence and type of health 
facility available in that district. The socio-economic factors consist of the occupation of 
the women who are the users of maternal healthcare and their income levels. Community 
factors include the health decision-making process of women who utilize maternal 
healthcare services, the means of transport to a healthcare facility and accessibility to the 
health facility. 
The obstetric factors that influence the ratings of quality of maternal healthcare services 
provided to women include parity and gravida. Thus, the number of children a woman has 
and the number of times she has been pregnant before has influence on the ratings of 
quality of maternal healthcare assessment. The elements of access to the available 
healthcare facility, the distance to the health facility and the waiting time at the health 
facility before being attended to by a heaIthcare provider influence the rating of quality of 
maternal healthcare assessments. Each of these factors also influence the rating of each 
domain of healthcare quality and influences directly the quality of maternal care services. 
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2.8.2 Structure, process and outcome domains 
The structure dimension indicates all the vital resources that are needed to produce quality 
maternal healthcare. These resources include accessible and safe amenities such as 
buildings, adequate and functional equipment, appropriate hours of operation and stable 
financial status that will provide good quality care on a consistent basis to women. Human 
resources and the environment consist of enough well-trained maternal healthcare staff 
like medical doctors. gynaecologists, midwives and laboratory technicians who either 
directly or indirectly provide services at health facilities to women. These services should 
be delivered in a safe and clean environment that is necessary to provide quality care to 
women. The range of services provided to women that have a significant influence on the 
rating of quality of care provided include laboratory, ultra-sounds and scan services. 
Women expect these services to be available and accessible within the health facility so 
that they do not have to walk or travel to different locations to access them. 
The second dimension of the domains is that of process. This level involves all the patient-
provider interactions during care. Elements in the process dimension include fairness and 
access to good quality care, privacy and inter-personal relationship. Fairness and access to 
accuracy of diagnosis and treatment based on scientific and professional knowledge, non-
discrimination and elimination of stigma and bias with regard to insurance policies as a 
domain has influence on the rating of the quality of maternal healthcare women receive 
during antenatal, delivery and postnatal care services. Women need privacy and 
confidentiality in the consultation rooms during examination, diagnosis and treatment. 
This domain is particularly important in Islamic communities. Inter-personal relationship 
here refers to the interactions during diagnosis between the women who seek care and the 
healtbcare provider. These interactions should be based on dignity and respect without 
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abuse of any kind. Thus, failure at this level affects the treatment regime or the continuum 
of the care services provision process. 
2.8.3 Outcome 
The final domain is the outcome domain, which is referred to as the result of care. 
Outcome of care can be either a subjective or objective measure. Subjective measures can 
be women's perceptions of symptoms or self-rated pain. Outcome measures for maternal 
health care include women's satisfaction, safety for mother and safety for the baby. 
Women's satisfaction with the use of healthc are services influences positively the rating of 
quality of services received. Ideally, women should be provided with the needed care and 
should be very satisfied with the services. However, in practice, the situation is different in 
many contexts. The safety of women during delivery and the immediate post-delivery 
periods is critical and therefore, it is considered a very important outcomes of the care 
process. These are usually the stages when skilled birth attendance averts and manages 
complications and hence averts preventable deaths. This period is thus considered the most 
important aspect of the care stages for healthcare providers and the women as well. This 
factor, therefore, influences the ratings of quality of maternal care services. The safety of 
the baby during and after delivery is said to have an influence on the rating of the quality 
of care by both healthcare providers and the women who patronize maternal healthcare 
services. 
In summary, the predictors in this framework which include the socio-demographic 
factors, (such as economic factors), community factors, obstetric factors, and access 
factors influence directly the rating of quality of care as either low, moderate or high. This 
conceptual framework differs from the Donabedian Model in several ways. First, whilst 
the Donabedian model looks at general healthcare, the framework in this study looks at 
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only quality of maternal healthcare. Second, the developed framework considers the socio-
demographic factors, (including economic and cultural factors), community and obstetric 
factors which are not found in the Donabedian model. Furthermore, the Donabedian model 
does not consider the various domains that influence healthcare quality whilst the 
framework this study did. Moreover, the Donabedian model does not indicate how various 
factors interrelate and influence the rating of quality of healthcare by clients. Finally, 
while the Donabedian model conceptualises quality and helps us identify quality issues in 
the healthcare settings, the framework developed for this study goes beyond just 
identifying quality issues to indicating how mothers rate the various heaIthcare services 
they received during the most recent pregnancy. 
2.9 Chapter summary and gaps in literature 
From the literature review, quality of maternal healthcare has become an important aspect 
of efforts to improve maternal and new-born health. However, many of the tools that have 
so far been developed to measure maternal heaIthcare quality only measure quality at 
various stages of the maternal care period with none covering the whole spectrum of all the 
stages- that is, from the antenatal through the delivery to the postnatal from antenatal, 
delivering and postnatal stages. In addition, these tools have been developed in middle and 
high-income countries. However, studies have clearly shown that indicators of quality of 
care differ between low-income and high-income countries (Moyer, 2014). Furthermore, 
the available tools often focus on the technical aspect of maternal healthcare with little 
attention given to women's perspectives. It is on the basis of these gaps in literature that 
this study developed a tool that encompasses the entire spectrum of the three stages of 
maternal healthcare services and to use this tool to assess the quality of maternal healthcare 
WOmen received during pregnancy, labour and childbirth in four districts in Northern 
region of Ghana.. In the next chapter, the empirical research methods are discussed. 
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CHAPTER THREE 
METHODS 
3.1 Introduction 
This chapter discusses the methods of the research. The chapter is divided into three parts. 
The first part presents the research design and its epistemological underpinnings. The 
second part describes the research setting, the study population, sample size estimation, 
sampling, data collection and analytical methods. The third part discusses ethical 
considerations in the study. 
3.2 Study Design: mixed methods and its philosophical underpinnings 
A sequential mixed methods design was adopted in this study. By mixed methods, I mean 
a research design that is opened to multiple methods of data collection and analysis, 
including a combination of qualitative and quantitative methods of investigation for the 
purpose of answering a research question in a single study. This approach involves 
gathering and integrating both qualitative and quantitative data in a study such that it 
ensures that the ultimate strength of the study is enhanced compared to using only 
qualitative or quantitative methods (Creswell, 2009). 
It must, however, be noted that various terminologies have been used to describe this type 
of mixed methods study design. Some authors refer to it variously as integrating 
qualitative and quantitative methods; interrelating qualitative and quantitative data; 
methodological triangulation; multi-methods design and linking qualitative and 
quantitative data (Fearon & Laitin, 2008; Morgan, 2013). Others refer to it as a mixed 
methods research (plano et al., 2008; Creswell, 2009). What is important to note in all 
these tenninologies is the central focus on combining and integrating multiple methods in 
a single study as defined by Creswell et al (2008): 
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A mixed methods study involves the collection or analysis of both 
quantitative and/or qualitative data in a single study in which the data are 
collected concurrently or sequentially, are equal given a priority and 
involves the integration oft he data at one or more stages in the process of 
research (pp. 165). 
Creswell (2009) adds that a mixed methods study also includes mixing different data 
collection tools within qualitative (e.g. focus group discussions and key informant 
interviews) or quantitative research (e.g. surveys and cohort studies). The assumption 
underlying a mixed methods approach is that combining both qualitative and quantitative 
methods of data collection and analysis provides a more holistic understanding of the 
research question under investigation. Again, in conducting mixed methods studies, 
several typologies for classifying the strategies used in generating data have been 
described (Plano et aI., 2008; Creswell, 2009). Even though three main mixed methods 
designs have been proposed - that is, sequential, concurrent and nested approaches- there 
has been agreement on three basic designs, namely exploratory, sequential mixed method 
and convergent parallel mixed methods design. Sequential mixed method design occurs 
when one method of data collection precedes the other, so that the outcome of the initial 
research informs the next data collection process. However, when two or more sets of data 
are collected using different methods at the same time or simultaneously, the process is 
termed concurrent design. The concurrent design is particularly useful when the ordering 
of the data collection process is not important in determining the outcome of the study 
(Creswell,2009). 
In the current study, the exploratory sequential design was used with both qualitative and 
quantitative methods being given equal priority at each stage of the research process (see 
Figure 2). 
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Stage 3 
Stage 1 Stage 2 
Development and Quantitative Qualitative 
validation of tool 
• FGDs • Cross-to assess quality sectional 
• lOIs of maternal survey 
healthcare 
Figure 2: Stages of tbe Study 
The first phase of the data collection process was a qualitative exploration of clients' and 
providers' perceptions of quality of maternal healthcare. Qualitative research involves a 
holistic approach to research in which where the researcher develops a level of detail from 
high involvement in the actual experiences of what is being studied and the data presented 
in textural form (Creswell, 2009; Williams, 2007). The outcome of this qualitative study 
informed the second phase of data collection, which involved the development of key 
indicators for assessing maternal care quality. The third and final phase involved 
administering the maternal healthcare quality assessment tool to women in a survey to 
assess quality of maternal healthcare. The quantitative component of this research also 
helped to create meaning through numerical measurement of the situation (Williams, 
2007). Data sets from the three research phases were analyzed and reported separately but 
the two methods were integrated at the discussion stage. 
A mixed methods design was used in this study for several reasons. First, previous studies 
in developing tools on quality of antenatal care have largely employed quantitative 
methods. To address the limitations inherent in either solely using a qualitative or 
quantitative study design, this study employed mixed sequential methods to address the 
existing methodological gap/weakness. Second, Creswell & Garrett (2008) have observed 
that a strong mixed methods design necessitates that qualitative and quantitative data bold 
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independent research purposes and that the qualitative and quantitative components work 
together to mutually strengthen the research findings from each source. In the current 
study, four specific objectives were pursued. The fU"St 2 objectives, namely to assess the 
perspectives of women and maternal healthcare providers on what constitutes quality 
maternal healthcare; and to assess women views about how quality of maternal healthcare 
should be assessed, lent themselves very well to qualitative analysis. However, the last 
two (2) objectives, namely to develop and validate a tool for measuring quality of maternal 
health care in Northern Region of Ghana and to assess the quality of maternal healthcare 
women received during their most recent pregnancy, labour and childbirth in the region, 
lent themselves to quantitative analysis. These opposing views suggest that using either 
qualitative or quantitative methods alone would have been inadequate. Third, 
triangulation, complementarity, development, initiation and expansion have been outlined 
as the five main purposes served in conducting mixed methods research (Plano et aI., 
2008). In this current study, the purpose for employing the mixed methods approach was 
for the development of a tool aimed at measuring quality of maternal healthcare from the 
perspective of clients and service providers. To achieve this purpose, focus group 
discussions and in-depth interviews were conducted among clients and service providers 
to assess their perceptions of what constitutes quality of maternal healthcare and how 
quality of maternal healthcare can be assessed. This exercise too suggested that using only 
a qualitative or quantitative design would not have been helpful in generating indicators of 
maternal healthcare quality and subsequently developing a quantitative tool to measure 
quality of care from the perspective of clients. 
In terms of the epistemolOgical and! or philosophical underpinnings of the mixed methods 
design used in this study, pragmatism has been proposed (Plano et aI., 2008). Pragmatism, 
as an istem l' . . 
ep 0 ogIcal onentatton to knowledge and its generation, maintains the practical 
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use of any of the research methods, be it constructivist (which is aligned with qualitative 
research) or post-positivist (quantitative) worldviews in answering one' s research 
question. In other words, the pragmatist concentrates on the nature of the research 
questions and finds the most suitable approach to addressing the issue without aligning 
itself to only one reality or philosophical paradigm (plano et al., 2008). Hence, the central 
focus for the mixed methodologist or pragmatist is the "what" and "how" of the research 
problem under investigation and the best approach to understanding issues pertaining to it. 
As the objectives of the present research lent themselves most to the use of mixed 
methods, a pragmatic epistemology was indeed apt. 
3.3 Study Location 
This study was conducted in four selected districts in the then Northern Region of Ghana 
(see Figure 3). Before the creation of two additional regions Savanna and North East 
Regions out of Northern Region in 2019, it was the largest among the three regions in the 
northern part of Ghana. Indeed, it occupied an area of about 70,383 square kilometre, and 
this constituted the largest region in Ghana in terms of land area. It shared boundaries with 
Upper East and Upper West Regions to the north, Brong Ahafo and Volta Regions to the 
south, and RepUblic of Togo to the east and La Cote d' Ivoire to the west. The region was 
divided into 26 political/administrative districts headed by District Chief Executives. 
The region had a projected 2014 population of 2,779,877, which was about 10.2% of the 
total national population. Females formed the larger proportion: 1,249,574 (50.3%) versus 
1,229,887 (49.7%) for males. Population growth rate was about 2.9 per annum (GSS, 2011). 
The population was characteristically distributed in small settlements with popUlations of 
between 200 and 500 people (GSS, 2011). There were over 5,000 settlements in the 
region, out of which 54.4% had populations less than 200 people (GSS, 2011). The 
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distances between settlements were ft en Io ng, and this peculiar pattern of distribution of 0 
the population in the region have adverse implications for health service delivery as Sub-
district Health Teams (SDHTs) have to travel long distances during out-reach programmes 
to deliver services to only small proportions of their target populations. 
K 
\' 
H 
t I 
AdjOining Otlb'lota 
AcQolnlng Region 
Figure 3: Map of Northern Region Showing Study Districts 
The major ethnic group in the region is Dagomba. Other major groups are the Gurma, 
Konkomba Basaari Bimoba, Chokosi, Gonja and Chumburu. Islam is the dominant 
religion (60%) (GSS, 2014). This proportion, however, varies from one district to another. 
Regarding education and literacy, the 2010 Population and Housing Census (GSS) 
indicated that 63% of the population who were 11 years old and above were illiterate in 
English and Dagbani. However, about 19% were literate in English and a Ghanaian 
language. 
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The primary economic activities are agriculture, hunting and forestry (GSS, 2014). 
Subsistence agriculture is predominantly practised, although commercial farming is 
gradually becoming popular among a section of the population. Over 95% of the 
economically-active population are employed in the informal private sector (primarily 
agricultural-related employment). In the relatively urban centres, the main common 
commercial activities are provision of services including transport and trading. Trading in 
the region is dominated by women. Many women are engaged in retail trade; however, a 
few also engage in inter-regional trading activities (Awedoba. 2006; GSS, 2013). 
In terms of socio-cultural organisation, although Northern Region is ethnically diverse, it 
has a lot of common social and cultural organisational characteristics. Polygyny is the 
dominant form of marriage in most parts of the region (Awedoba, 2006). This form of 
marital arrangement ensures that more children are produced to serve as farmhands for 
parents (Awedoba. 2006; GSS, 2014). In recent times, however, this practice is on the 
decline due to the challenges associated with meeting the needs of every child (Awedoba, 
2006). After the marriage ceremony, couples are expected to live together with the wife 
joining her husband on a compound that may be headed by the latter's father, in most cases 
when the husband is still young. The household typically comprises the couple, their 
children and other close kin of the husband (Awedoba, 2006). In the past, married adult 
sons may remain in their fathers' households or break away and found their own 
households but in recent times, moving out of the fathers' compound is more common 
resulting in increased sizes of nuclear families at the expense of extended families 
(Awedoba, 2006). According to Ghana Statistical Service (2014), the average size of 
households in Northern Region is 5.4 persons, which is higher than the national average of 
4.0 persons. The possible reasons for the large sizes of households are polygyny, high 
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fertility and the common practice whereby members of nuclear and extended families live 
together (GSS, 2013). 
Child betrothal and early marriage are other common practices in most parts of Northern 
Region (Awedoba, 2006). Girls as young as 14 years are given out for marriage with older 
men usually old enough to be their fathers. This situation has resulted in some girls 
migrating out of both their communities and their matrimonial homes to cities to avoid 
being married out of their will (Awedoba, 2006). In addition, males often wield authority 
and are the bread-winners of the families whilst women are subordinates and dependants 
who support their men in managing the affairs of families. This practice is common 
because Northern Region is largely patriarchal. Men are therefore the main decision-
makers in most communities in the region but women, especially the elderly, are 
sometimes consulted before main decisions are taken (Awedoba, 2006). Since men wield 
greater authority in many patriarchal societies, they have access to land, information and 
many other resources while women are supposed to be taken care of by the former and 
therefore should be subservient (Buor, 1996; Awedoba, 2006). Despite this dominant 
practice, the average percentage of female heads of household in the region (14%) is 
higher than the national average of II %. This phenomenon could be attributed to either 
deaths or migration of the substantive male heads of families. Thus, in recent times, the 
traditional trend in the region is gradually changing. giving females the opportunity to 
wield power in some sections of society. 
Furthermore, most communities in Northern Region are predominantly organized along 
patrilineal descent. The patrilineal system of family arrangement and inheritance 
determines one's membership and status in a family and commuru·ty . SI' Dce thi s practI'ce.  IS 
sustained by patriarcbal beliefs, the associated rights to access and use of family or 
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community resources are traced to ties with the father (Apusigah, 2009). Succession and 
inheritance therefore depend on status in the family. Since women in Northern Region 
have lower status in both their biological and matrimonial families, they do not inherit 
from either their fathers or husbands but sons do so and even inherit from their mothers. 
This practice denies women the opportunity to own important resources such as land, 
which is a basic factor of production. Even though married women may temporarily 
acquire pieces of land from their husbands or brothers, the produce from such land is 
meant for only household consumption while the land can be taken back at the whims of 
the husband or brothers (Apusigah, 2009). Women in such situations have no power in the 
allocation and control of resources in terms of decision-making in the family (Pearson 
1992). The lack of control and power over resources leads to the subordination of women. 
(Apusigah, 2009). 
In terms of fertility, mortality and maternal and child health in the region, data from the 
2010 Population and Housing Census show that Northern Region has a total fertility rate 
(TFR) of 3.5. The general fertility rate is roughly 102. This means that for every 1,000 
women in the region, there are likely to be 102 births (GSS, 2014). Early child-bearing is 
common in the region. Child-bearing in the region begins as early as ages 12-14 years 
with the mean number of children ever born being 1.3 (GSS, 2014). Although the mean 
number of children ever born at ages 12-14 is higher in urban (1.4) areas than in rural 
areas (1.3), for the rest of the age groups, the rural mean number of children ever born is 
higher than the urban mean (GSS, 2014). 
The 2010 PHC report further shows that the deaths of infants (children under 1) in 
Northern Region is slightly higher than the national rate. According to Ghana Maternal 
Health Survey (2017), during the years 2015 and 2016, Northern Region recorded a total 
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of 1,655 pregnancies out of which 90.3% were live births, with 1.7% stillbirths, 6.8% 
miscarriages and 1.2% abortions. 
In terms of provision of maternal healthcare services, Ghana Health Service 2016 report 
indicates that Northern Region recorded the highest coverage of over 100% of ANC 
services. The findings in the last 5 years show that 50% of districts in the region even 
recorded ANC coverages of over 150% and, in some cases, over 200% in urban areas like 
Tamale Metropolis (GHS, 2017). As many as 97.7% of the women sought antenatal care 
from skilled health providers. Also, 87.2% of the pregnant women met the WHO 
recommended 4+ ANC visits while 65.8% were protected against neo-natal tetanus. In 
addition, 59.3% were delivered by health professionals in health facilities (59.2%) (GHS, 
2017). 
Northern Region has, however, recorded consistent increases in anaemia prevalence 
among pregnant women since 2016, even though the rates in regions in the south have 
stagnated. In connection with maternal mortality, the Ghana Health Service reports for the 
periods 2014-2016 show that Northern Region has an increasing proportion of women 
who are at risk of dying in comparison with women in other regions even though seven 
out of the ten regions recorded increases in maternal mortality ratio (GHS, 2017). 
Specifically, 107, 144, and 207 maternal deaths were recorded in the region in 2014,2015 
and 2016 respectively. The Northern Region however recorded one of the least rates of 
teenage pregnancy cases in the country. But contraceptive use in in the region is lowest 
(17%) in the country (GSS et aI., 2017). 
Generally, supervised delivery in Northern Region increased marginally between 2013 and 
2015. For instance, Northern Regional Ghana Health Service Report (2016) showed that 
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supervised deliveries increased from 47.4% in 2013 to 53.3% in 2014. This rate, however, 
declined marginally to 52.8% in 2015. This decline has been attributed to fluctuations in 
the doctor-population ratio in the region since 2012 (GHS, 2017). The doctor-population 
ratio for the region in 2012 was 1: 109,391. Though this ratio slightly declined to 
I: 112,563 in 2013 and further to I: 115,828 in 2014, it improved drastically to I: 60,862 
in 2015. The nurse-population ratio in the region has nonetheless seen some improvement. 
In 2012, the ratio was I: I ,407 but it rose to I: 1, 231 in 2013. The ratio improved further to 
I: 1,222 in 2014 but in 2015 it declined to 1:1,670 (GHS, 2017). 
3.4 Description of selected study districts 
Within the then Northern Region, a total of four districts were selected as study sites. Two 
of these districts - Tamale Metropolis (urban) and Sagnarigu district (rural) - were initially 
selected and used as sites for the qualitative study. These two districts were purposively 
selected based on specific factors. All the 26 districts were grouped into urban and rural 
based on Ghana Statistical Service's classification. Health indicators for each district 
under each category were reviewed. From the review, Tamale Metropolis emerged as the 
district with highest numbers of both ANC and post-natal (PNC) registrants of 22,727 and 
24, 144 respectively. The corresponding rural district with the highest number of ANC and 
PNC registrants was Sagnarigu with 5, 713 and 4, 141 respectively (GHS, 2016). The two 
districts were also reported to have the highest maternal mortality in the region (GHS, 
2016). Antenatal care attendance is high in the study area in both Sagnarigu and Tamale 
metropolis. However, skilled birth attendance is low: 54% in the region compared to the 
national average of 74%. Thus, while antenatal attendance is high, skilled delivery is low 
leading to maternal mortality at the facilities. 
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The other two districts - Savelugu-Nanton Municipality (urban) and Kumbungu (rural) 
were later randomly selected as the two initial districts for the quantitative survey. The random 
selection process involved writing the names of the reminder of the 24 districts on pieces 
of paper, mixing the papers in a hat and allowing a blind-folded person to randomly select 
district numbers. It was necessary to include these two additional districts to ensure 
representativeness of the study and to ensure that there were sufficient numbers of 
potential respondents to meet the minimum sample required for the quantitative survey in 
the third stage of the research process. A brief profile of each of the four study districts is 
provided below. 
3.4.1 Profile of Tamale Metropolis 
Tamale Metropolis is located in the central part of the region and shares boundaries with 
Sagnarigu District to the west and north, Mion District to the east, East Gonja to the south 
and Central Gonja to the south-west (GSS, 2011). It had a population of 233,252, 
representing 9.4% of the region's population. Females constituted 50.3% of the 
population. Total Fertility Rate is 2.8, which is slightly lower than the regional average of 
3.5. The General Fertility Rate is 79.9 births per 1000 women aged 15-49. 
The municipality has a teaching hospital in addition to one district hospital, Tamale West 
Hospital (TWH). The number of health facilities within the metropolis is quite 
satisfactory. However, most of these facilities which are in the rural areas, are poorly 
equipped. Tamale Teaching Hospital and Tamale West Hospital are the only well-
equipped facilities. Even though efforts have been made to improve access to health 
services, patronage of these facilities have been low particularly in the rural areas owing 
due to poverty, illiteracy, ignorance and poor staffIDg of the facilities. 
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3.4.2 Profile of Sagnerigu District 
Sagnarigu District shares boundaries with Savelugu-Nanton Municipality to the north, 
Tamale Metropolis to the south and east, Tolon District to the west and Kumbungu 
District to the north-west. The district had a population of 148,099, representing 6% of the 
region's total population (GSS, 2014). There were 74,886 (51%) males and 73,213 (49%) 
females in the district. Although the district has only 20 urban communities out of a total 
of 79, 63% of the population live in the urban communities, making it a relatively-
urbanised district. There are approximately 23,447 households in the district with an 
average of 6 persons per household. Children constitute the largest proportion of the 
composition of households (43%). The district has a Total Fertility Rate of 3.3, which is 
slightly higher than the regional average of 3.5 (GSS, 2014). Out of an estimated number 
of 582,897 women within the 15-49 age group in Northern Region, 38,548 (6.6%) are in 
the Sagnarigu District. 
The majority of households (84.2%) are engaged in agriculture. They are involved in the 
production of crops, including cereals like maize, rice and millet. Some local and exotic 
vegetables are also grown in the dry season around mini-dams and dug-outs. 
Regarding literacy, 60% of the population who are aged 11 years and above are literate 
while 40% are illiterates. The proportion of male literates (68%) is higher than that of the 
females (52%) in the population aged II years and above. 
In connection with economic livelihoods in the district, 59% of the population aged 15 
years and above are economically active while 41 % are not. Regarding the economically-
active population, 92% are employed while 8% are unemployed. The proportion of the 
population who are not economically active consist of those in school,  tho se pe.l1..0cm.u'n g 
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household duties and those who are either disabled or too sick to work. The employed 
population are engaged in a variety of economic activities such as services and sales, crafts 
and related trades, agriculture, forestry and fishing. More than half (57%) of the 
population are self-employed without employees. The private informal sector employs the 
majority of the economically-active population in the district. 
3.4.3 Kumbungu District Profile 
Kumbungu District covers a land mass of approximately 1,599 km sq. The district is 
bordered by Mamprugu/ Moagduri District to the north, Tolon and North Gonja Districts 
to the west, Sagnerigu District to the south and SavelugulNanton Municipality the east. 
The district is made up of 115 communities. The administrative capital is Kumbungu. 
The 2010 population and housing census estimates the total population of Kumbungu 
District to be around 39,341, made up of 19,686 (50.04%) males and 19,655 (49.96%) 
females. The population of the district is largely youthful. Out of the 115 communities in 
the district. only Kumbungu and Dalun are urban, therefore, the greater proportion of the 
population live in rural communities with poor health services. 
More than half (61%) of the population in the district aged 12 years and above are 
married. In terms of literacy, only 26 per cent of the population 11 years and above are 
literate while 74 per cent are illiterate. The proportion of males who are literate is higher 
(32.9%) than that offemales (19.3%). A high proportion (81%) of the population aged 15 
years and above are economically active while 19 percent are not. Virtually every 
household in the district is engaged in agriculture with crop farming dominating albeit 
poultry is the dominant livestock reared in the district. 
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3.4.4 Profile of Savelugu-Nanton Municipality 
With a total population of 1,596,159 and a total land area of 1, 760square kilometres, 
Savelgu-Nanton municipality is predominantly a rural area with 60% of its population 
being rural and 40 % urban (GHS, 2014). The population has almost equal proportions of 
males and females: 48% males compared with 52% females. Akin to the national 
population, the municipality has a large youthful population, who are predisposed to 
migrate. Islam is (95.4%) is the dominant religion. More than half (60%) of the population 
aged 12 years and above are married whilst 33% have never been married (GSS, 2013). 
The Census Report also revealed that 59% of the population in the municipality who are 3 
years and above have never attended school. The report further indicated that 31 % of the 
population who are II years and above are literate whilst 69% have never received any 
form of formal education (GSS, 2014). The data further shows that more than half of the 
population in the municipality lack the requisite expertise to work in the formal sector of 
the economy and may resort to migration. 
The municipality has a total Fertility Rate of 4.3, which is above the national average. The 
General Fertility Rate of the municipality is 126.7 births per 1000. Regarding under-5 
mortality, Savelugu-Nanton District experienced the highest death rates (149 per 1,000 
live births) in the region. In terms of healthcare delivery, the district has a municipal 
hospital as the main referral health facility. Other health centres and CHPS compounds 
complement the district hospital in service delivery. 
3.5 Study PopUlation 
The population for this study included postnatal women aged 15-49 years who have had 
interactions with the formal health system for ANC, delivery or postnatal care. The study 
popUlation also included health workers such as midwives. doctors and administrators in 
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selected health facilities. Experts and! or policy makers from Ghana Health Service and 
the Ministry of Health, university lecturers in the field of maternal heaJthcare service as 
well as other development partners in maternal and child health such as the National 
Population Council of Ghana, USAID and UNICEF were interviewed. 
3.5.1 Inclusion and exclusion criteria 
Since the study was measuring quaJity of maternal healthcare comprising ANC, delivery 
and postnatal, only women who had experienced facility delivery and attended postnatal 
clinics were recruited into this study. Only women with live birth were included. Women 
who experienced still-births during their most recent pregnancy were excluded because 
they may be experiencing emotional distress. Interviewing people going through grieving 
process has been reported to increase their pain and may affect the quality of data provided 
(Rosenblatt, 1995). For healthcare providers, the study included only those with at least 
three years of experience in the provision of maternal healthcare services to women. 
Hence, those with working experience of less than three years were excluded. The reason 
for excluding of healthcare workers who had working experience of less than three years 
was to recruit only workers who had sufficient engagement with women seeking antenatal 
and postnatal care services and had adequate relevant knowledge of the fonnal healthcare 
system. Thus, professional nurses and doctors who worked at the maternity units and who 
directly met clients seeking ANC, delivery and postnatal care services were included in 
the study. 
3.6 The Qualitative study 
The qualitative component of this study combined descriptive phenomenology with 
narrative qualitative enquiry. Descriptive phenomenology is used to gain an understanding 
of the meaning of a phenomenon of interest through in-depth engagement using various 
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qualitative data collection strategies (Laverty, 2003; Lopez & Willis, 2004). This approach 
allows researchers to collect detailed data on a particular phenomenon of interest in this 
case, quality of maternal healthcare to gain deeper insight about the situation (Creswell, 
1998; Green & Thorogood, 2004). This approach is relevant in studies that try to better 
understand a phenomenon through engagement with participants who have experienced 
that phenomenon as well as people who may have understanding of the phenomenon 
through their engagement with it (Green & Thorogood, 2004). In this study, postnatal 
women were recruited for interview. In addition, midwives, nurses and doctors who have 
had contacts with women seeking care along the maternal healthcare continuum were also 
recruited into the study. 
Narrative qualitative inquiry study allows participants in a study to share their experiences 
on a given situation or on a research topic of interest (Andrews & Tamboukou, 2013). In 
this case, the study participants had the opportunity to share with the researcher their 
beliefs and perceptions about quality of maternal healthcare based on their knowledge and 
personal experiences. 
3.6.1 Sample Size for the qualitative research 
In qualitative studies, sample sizes are not large compared to quantitative studies. Rather, 
in qualitative research, recruitment stops when saturation occurs (no new information is 
emerging from data) and themes are fully developed (Morgan, 1998). The reason is that 
the main purpose of qualitative research is not to present what is representative of the 
wider population of interest but rather to reach a much in-depth understanding of the 
phenomenon under investigation. In this study the aim was to have a h l' ti' • 
, 0 IS C perspective 
of women's and healthcare workers' understanding of what constitute quality of maternal 
care and how it should be assessed in Ghana. Generally satur t' f th 
, a Ion 0 emes was reached 
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in this study after 92 participants made up of 85 women and 7 healthcare providers were 
engaged in both FGDs and IDIs (Morgan, 1998). Saturation was reached for each question 
for the 92 participants after no new information was emerging from each of the questions. 
3.6.2 Sampling and recruitment procedures into the qualitative study 
Purposive sampling methods were used to recruit participants into the qualitative arm of 
the study. This is a popular sampling method often used in qualitative research (Cannella 
et al, 2005; Silverman, 2013). In purposive sampling, the investigator guarantees that the 
participants being recruited have the desired experiences or knowledge. Purposive 
sampling techniques were used to sample women and healthcare providers including 
midwives, nurses and doctors who had three or more years of working experience at the 
maternity and childcare department. 
Recruitment refers to the actual processes undertaken to reach and gain the consent of 
women and healthcare providers who met the inclusion criteria. It is important to point out 
that access to a field environment does not guarantee successful recruitment of participants 
as they may refuse to participate in a given research even though ethical and 
administrative approval for the research may have been given (Parfitt, 1996). Incentives 
given to participants have been criticized by some researchers as having the potential to 
induce participants and potentially introduce biases into the outcomes of a study 
(Parfitt,1996; Cannella et ai, 2005). Cognizant of this, no incentives were offered to 
potential participants during the recruitment process in this study. A few procedures were 
followed to recruit participants. Letters of introduction were provided by the School of 
Public Health to be given to selected health facilities and community leaders. The letters 
contained brief infonnation about the purpose of the study and as well introduced the 
principal investigator and her research assistants. Once permission was obtained from 
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health facility managers and community leaders, information leaflets about the research 
were provided at each selected health facility and in the communities. Midwives and 
nurses also made regular announcements at postnatal care clinics about the study. This 
strategy was particularly important given the relatively-high rates of illiteracy in the study 
districts. Women who were interested in participating were asked to contact the research 
assistants. 
For the healthcare providers, introductory letters were written to each of them inviting 
them to participate in the study. The invitation was effected after their respective 
institutions gave clearance for the conduct of the study. Those who expressed interest in 
the study were recruited and subsequently interviewed. 
3.6.3 Qualitative Data Collection methods and tools 
The choice of data collection methods was informed by a need to explore and understand 
participants' experiences, meanings and overall worldviews; therefore, face-to-face in-
depth qualitative interviews and focus group discussions were conducted. These data 
collection methods helped to gather data that responded appropriately to the research 
questions. As Bryman (2008:238) argued, through face-to-face qualitative interviews, "a 
unique. subjective, detailed personal story can be told as to how the interviewees 
understand and explain various phenomena, their actions and their general overview of the 
world around them". The two qualitative data collection methods and tools are elaborated 
below. 
3.6.3.1 In-depth Interviews 
From a life history perspective, in-depth interviews can give rich information on personal 
experience and ideology as well as on social structures and institutions (Leckenby & 
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Plummer, 1983). In an in-depth interview, the ~esearcher sets the agenda in tenns of the 
topics covered but the interviewee's responses detennine the kinds of infonnation 
produced about those topics and the relative importance of each of them (Creswell & 
Garrett, 2008). With this approach, participants had the opportunity to situate their own 
life experiences within the larger social context. While some researchers argue that 
personal reflections may not be fully accurate, others assert that the strength of telling 
one's own story rests precisely in this interaction between the participant and hislher past 
self (Green & Thorogood, 2004). In-depth interviews (IDIs) were conducted with selected 
postnatal women to explore their views on what constituted quality of care and their 
experiences of facility-based childbirth care. IDIs were also conducted with healthcare 
providers of different calibres (e.g. nurses, midwives and medical officers) working in the 
selected facilities to explore their views on what constituted quality maternal healthcare 
and how it should be measured. In all, 46 lOIs were conducted with 39 postnatal women 
and 7 healthcare workers. Table 3 shows the distribution of participants that were 
individually interviewed. 
Table 3: Distribution ofiDI Participants by district 
Tamale Metropolis Sagnarigu Total 
Participant 
Categories 
Postnatal women 24 IS 39 
Healtbcare workers 
Doctors 2 0 2 
Nurses I 2 
Midwives 2 3 
Sub-total 5 2 7 
Total 29 17 46 
In tenus of the data collection instrument, an unstructured thematic interview guide was 
designed by the researcher based on e xtensi'v 
0 
e 1lteratl.U"e reVoiew on. m dicators of quality of 
m....a..t e~rn .•a•l•  h__e_a l._th_c__a_re_ . T.he. gu,ide was desif.>-.U."AU  m0  EnglI' Sh . b ut the questi0 ons were translated 
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into and asked in Dagbani, the vernacular for those who could not speak English and there 
was back- to- back translation in order to ensure meaning was not lost. For the healthcare 
providers as well as women who could speak English, the interviews were conducted in 
English. The tool covered a wide range of issues that included what should constitute 
quality and how it should be measured. It also took into consideration the Donabedian 
structural, process and outcome dimensions for measuring quality of healthcare. Each 
interview lasted approximately 60 minutes. Generally, each interview ended when data 
saturation on all major themes was attained. Interviews were conducted by trained 
research assistants who were fluent in English and the Dagbani. In cases pennission was 
obtained, all interviews were audio-recorded with a digital voice recorder. Fieldnotes were 
taken in addition. 
3.6.3.2 Focus Group Discussions 
Focus group discussions (FGDs) were conducted with women to further explore the 
research topic. The focus group method is a type of interview that comprises several 
people on specific issues, topics or subjects. Bryman (2008: 345) argued that an FGD is 
"essentially a group interview" as it involves more than one person and, usually, at least 
four persons. FGDs were used because they are a valuable method for generating data on 
how a group of people in this case, women communally make sense of an issue. It is 
useful for developing consensus and convergence on issues in a meaningful manner. Thus, 
in the focus group discussions, the researcher was interested in such issues as how people 
responded to one another's views and build up a view out of the interactions that took 
place within the group (see also Bryrnan 2008 :346). 
In total, six (6) FGDs three in each of the two study districts for the qualitative study 
comprising a total of 46 women were conducted with stnatal 
po women between the ages 
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of 15 and 49 years who had experienced ANC, facility delivery or attended postnatal clinic 
in a facility during their most recent pregnancy. Although the populations in both Tamale 
metropolis and Sagnarigu are different, the researcher decided to recruit an equal number 
of respondents for the study since these two local districts recorded the highest number of 
antenatal registrants. Qualitative study does not usually involve huge numbers and since 
the selected districts had similar characteristics, the researcher did not see the need to 
undertake the qualitative studies in all the four districts. These women were different from 
those who participated in the lOIs. However, they shared similar characteristics. Women 
were segmented into three groups: women aged 15-24 years, 25-34 years and above 34 
years (see Table 4). 
Table 4: Distribution of Focus Group Discussants by Age group and district 
Tamale 
Age Group Metropolis Sagnarigu Total 
15-24 7 6 13 
25-34 8 8 16 
>34 9 8 17 
Total 24 22 46 
Each group was carefully constituted to include a mix of participants from different social 
backgrounds who may not know one another (that is, women from different religious 
backgrounds and socio-economic classes). Women were segmented into different age-
groups not only because the researcher wanted to highlight the differences in opinions 
concerning what constituted quality of maternal healthcare but also because it was to 
ensure that age-hierarchy conflicts did not prevent younger women from talking in the 
presence of older women. The number of discussants in groups ranged from 6 to 9. This 
number allowed broad latitude for participants' views to be explored in breadth and depth, 
a very important feature of qualitative research (Bryman, 2008). 
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Like the in-depth interviews, a focus group guide was designed and used to facilitate 
discussions in the groups. The guide explored such issues as what should constitute quality 
and how it should be measured. 
Discussions in each group lasted 60 - 90 minutes and were conducted by one moderator 
(teacher) and note-taker (teacher). Discussions in each group were usually ended when 
data saturation on all major themes was attained. Discussions were conducted in Dagbani. 
With the pennission of discussants, all group discussions were audio-recorded with a 
digital voice recorder. Fieldnotes were taken in addition. 
3.6.4 Data Quality Assurance 
The quality of a qualitative research is safeguarded by following key ethics of 
rigour/trustworthiness. This requirement, therefore, implies that results of any research 
that does not apply rigour in ensuring quality cannot be reliable and the phenomenon 
under study becomes distorted (Cho & Trent, 2006). In this research, the principles of 
ensuring credibility during data collection and analysis enumerated by Patton (1999) were 
followed. The significant principles of rigour in qualitative research are credibility by 
ensuring findings can be trusted; transferability by ensuring results can be compared with 
a similar context, dependability by ensuring that similar results can be obtained when 
repeated and confinnability by ensuring results can be validated by others (Talbot, 1995; 
De Vos et al., 2013). To ensure rigour in the study, first, mUltiple data collection methods 
such as the in-depth interviews and focus group discussions were undertaken to enable this 
research to answer the objectives of the study. Thus, the credibility of the research was 
ensured using multiple data collection methods (Creswell, 1998; Mason, 2006). 
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Second, pretesting was undertaken to ensure that questions in the interview guide elicited 
appropriate responses, thus ensuring credibility of the study results. Further, credibility 
was ensured by the research team by reviewing the data and coding it. Variations between 
coded data were discussed and rectified. Finally, the research assistants received a one-
week intensive training at a workshop, where they were trained to appropriately ask 
questions as well as take infonned consent. 
3.6.5 Qualitative Data Analysis 
All qualitative data generated from FGDs and lOIs were digitally recorded and transcribed 
verbatim in the original language (Dagbani). Transcription was perfonned immediately 
after the IDlslFGDs were completed before the next batch ofinterviews. Observations and 
assessments during interviews were written up as field notes to complement these 
transcripts. The transcripts in the local language were translated into English by two 
independent translators and the transcripts compared for consistency. All translated 
transcripts underwent another round of consistency check by a language expert to ensure 
data quality. Thematic content analysis was employed in the analysis of the data with the 
aid of NVivo 10 software. Guest, MacQueen & Namey (2012) have summarized the 
process of thematic analysis as consisting of reading through textual data, identifying 
themes in the data coding those themes and then, interpreting the structure and content of 
the themes. 
Following the steps outlined by Guest, MacQueen & Namey (2012) for thematic content 
analysis, data generated from the field were analyzed. Descriptive and reflexive notes 
were derived during the reading of transcripts. The notes included unique words, the 
context of the comments, the frequency of comments, whether comments were extensive 
and how participants comments were consistent or influenced by other participants (Watt 
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et aI., 2005; Koopman-Esseboom et al., 1994; Motlagh et al., 2018). This exercise 
included manual process; therefore, meaning was derived from the field data and themes 
were initially organized before transferring the data into NVivo 10. Codes were then 
assigned to segments of the text and comparable codes grouped together. Sifting of data 
was done and it was separated into free nodes and tree nodes. Free nodes included data 
that were not related to the research objectives but were retained. Tree nodes consisted of 
data that directly related to the objectives of the research. (Burnard, 1991; Morse & Field, 
1995). As the analysis advanced, minor categories were grouped and later they were all 
incorporated into major themes by re-grouping and breaking up similar minor themes 
(Burnard, 1991). The research questions guided various stages in the progression of 
analysis. Descriptive terms were later allocated themes and abstract terms assigned. 
3.7 The Quantitative Study 
The quantitative component of the study was a cross-sectional study, whereby a randomly 
selected sample of postnatal mothers as well as maternal healthcare experts were selected 
and surveyed. From this sub-sample, data were collected at one point in time to help gain 
inference about the general population of childbearing women or maternal healthcare 
experts (Bowling, 2014). Thus, a cross-section of experts in reproductive healthcare were 
first recruited to validate the tool for measuring maternal healthcare quality, which was 
developed from the qualitative aspect of the study. After the validation of the tool, a cross-
section of postnatal women was recruited and surveyed to assess the quality of the 
maternal healthcare they received during the most recent pregnancy in Northern Region of 
Ghana. 
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3.7.1 Development of Quantitative Tool for Quality of Care Assessment 
The first part of the quantitative arm of the study involved the development of a 
quantitative tool for quality of maternal healthcare assessment. The tool was based 
primarily on the findings from the qualitative component of this research, although 
relevant guidelines were drawn from previous literature. The tool covered areas such as 
perspectives on quality of maternal healthcare amongst clients, service providers and 
various stakeholders. These issues also covered various aspects of maternal healthcare 
from antenatal to the post-natal period and included the various dimensions of care 
provided during this period taking into consideration the Donabedian model. Several 
stages and processes were followed to develop and validate the quantitative tool for 
measuring maternal healthcare quality as described below. 
3.7.1.1 Domain identification and item generation 
The first stage of the tool development started with domain identification and item 
generation. Through literature, the researcher first identified key areas and items that 
needed to be considered when assessing quality of care. After the identification of these 
key areas and principles of quality of care, several qualitative interviews in the form of 
lOIs and FGDs were conducted to solicit more ideas to establish how the escape already 
identified items would be relevant to the Ghanaian setting. At the end of this process, 57 
Likert-type questions/items were formulated and classified into 13 domains. All items 
were rated on a scale of 1 to 5 (where I =Strongly disagree, 2=Disagree, 3=Undecided, 
4=Agree, 5=Strongly agree). 
3.7.1.2 Content validation 
10 order to check the suitability and appropriateness of the initially proposed 57 questions 
on quality of maternal care, the content validity of the tool was assessed. Fifty-five (55) 
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maternal and child health experts were purposively selected to assess each item for clarity 
and relevance on the 5-point Likert scale (where, 1= Strongly disagree, 2=Disagree, 
3=Undecided, 4=Agree and 5=Strongly agree). The experts were asked to assess the 57-
items to ensure that the content adequately measured quality of maternal healthcare. Item-
level Content Validation Index (CVI) and overall content validity score were then 
estimated. According to the CVI index, a rating of four (agree) or five (strongly agree) 
indicated that the content was valid and consistent with the conceptual framework. The 
clarity and conciseness of each item as well as completeness of the construct were also 
assessed by the experts. An item was retained in the construct if it had high interpretability 
and low ambiguity, was not a double-barrelled item that is, two issues were not combined 
in the same item. did not involve the use of slangs or jargons and did not mix positive and 
negative issues (DeVellis. 2017). 
To measure suitability quantitatively, the Content Validity Index (CVI) was computed for 
each item in the construct. Based on the formula propounded by Kyriazos and Stalikas 
(2018), Content Validity Index (CVI) was mathematically computed as follows: 
N 
CVl=~ 
2 
Where, 
n1 = number of experts who rated an item either strongly agree or agree 
N = total number of raters 
The minimum required CVI cut off for each item was set at 0.60. All items which fell 
short of the value within a margin of 0.1 were modified per the suggestions of the experts 
and retained; otherwise they were discarded from the tool. The revised tool comprised 57 
items across the 13 domains. 
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3.7.1.3 Pretest oftbe tool 
After the questions had been modified according to the suggestions of the experts, there 
was pre-testing to ensure that the 57 items were meaningful to the target population before 
the actual survey was conducted. This pretest was done to minimize misunderstanding. It 
was also meant to check the suitability of wording of the questions and to reduce the 
cognitive burden on research participants (Boateng, et al., 2018). 
The pretesting was conducted by administering the questionnaire to 50 randomly sampled 
postnatal women in the regional hospital of Upper East Region of Ghana to evaluate 
whether the structure, questions and response formats of the tool were understood and 
were measuring what it intended to measure before the main study. After completing the 
pilot study, the data was entered into the ST AT A software and analyzed. Afterwards, the 
same women were resampled and interviewed again using the same questionnaire. These 
interviews were conducted by the Principal Investigator with the assistance of trained 
research assistants. The test-retest stability of the scales, as measured by the intra-class 
correlation coefficient, was then used to assess the reliability of the tool. 
3.7.1.4 Toollengtb optimization and item reduction 
In order not to overpopulate a study tool with questions, there is a need to always check 
that there are no set of questions soliciting for the same information and to ensure that 
only effective and functional items are maintained in the final tool. This exercise is done 
through the questionnaire item reduction (questionnaire length optimization) procedure. 
To achieve this, the following activities were carried out. First, the ability of individual 
items to correlate with one another (i.e. polychoric correlation co-efficient) was assessed 
and any items which did not correlate well with others was dropped from the scale 
(Kyriazos & Stalikas, 2018). A polychoric correlation co-efficient was used to assess the 
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correlation between items in each construct (Ekstrom, 2011). Items with correlation 
coefficients of~ 0.3 were desirable while those with values < 0.3 (at most) were discarded 
(Kyriazos & Stalikas, 2018). As shown later in Chapter Five of this study, all proposed 57 
items correlated well and were thus retained. 
Second, to ensure that each question (item) could discriminate between cases that would 
grade quality of care as either low, moderate or high, the Item Response Theory (IRT) 
model was used in estimating the discrimination indices of the items of the construct. 
Specifically, items with statistically significant index (p <0.05) were retained; otherwise 
they were dropped from the construct (Abel, 2016; Boateng et aI., 2018; Kyriazos & 
Stalikas. 2018). As shown later in chapter five, ten items were dropped from the scale for 
not meeting this criterion (p < 0.05). The 47 items were retained to form the final construct 
with 13 domains. 
3.7.2 The quantitative survey design and data collection 
The second component of the quantitative study arm aimed to assess the quality of 
maternal healthcare services women received during their most recent pregnancy. A cross-
sectional survey design was therefore employed. A cross-sectional survey is a type of 
study where a subset of a population is selected and data are collected to help answer 
research questions of interest at a given point in time (Rindfleisch et aI., 2008). In this 
phase a cross section of postnatal women was selected and the validated tool was used to 
assess the maternal health quality in Northern Region. 
3.7.1.1 Determination of sample size for the Survey 
The quantitative survey comprised postnatal women aged 15-49 years who had had 
encounters with the formal health system for ANC, delivery or post-natal care. To estimate 
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a minimum sample size that would allow statistical associations between the outcome and 
exposure variables to be detected if they existed, Kasiulevi~ius, Sapoka and Fi1ipavi~iUte's 
(2006) formula for determining sample size in a cross-sectional survey with categorical 
outcome was used. The formula is denoted as follows: 
where: 
n = minimum required samples size 
Z1 -ah  = the standard normal variate at 5% significance level = 1.96 
P = expected proportion of the sample who would rate quality of care high since no 
previous study had reported on this issue in Ghana, it was assumed that the proportion of 
women who would rate the quality of maternal healthcare they received during their most 
recent pregnancy high was 50% (i.e. p=0.50) 
e= margin of error; which was assumed to be 5%. 
DefJ = design effect 
The design effect was considered since the sampling technique that was used in this study 
is multi-stage. The sample size had to be adjusted to cater for the design effect. The design 
effect is defined as the ratio of the variance when a complex sample design is used to the 
variance that would be expected for a simple random sample of the same size (Bowling, 
2014). This effect was calculated as DEFF = 1 + (m - 1) r (2) 
where 
• m = number of elements selected in each cluster; 
• r = intra-class (or intra-cluster) correlation coefficient, dermed as r = sc2/(s2 + 
sc2); (or the ratio of between- cluster variability to total variability) (Som, 1973). 
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Using this fonnula, a design effect of 1.35 was estimated. 
n 2 1.96 xO.S (1-0.5) X 1.35 = 519.6 
0.052 
n.",S20 
3.7.2.2 Sampling Technique for quantitative Survey 
After the selection of the four study districts described earlier in this chapter, sampling of 
respondents for the quantitative survey started with selection of health facilities. A multi-
stage sampling technique was used to select facilities and respondents. At each district 
level, all health facilities rendering postnatal care services were listed and four of these 
facilities were randomly selected. While the sample size of 520 was equally divided 
among the four districts giving 130 respondents per study district. The allocation of the 
number of women to be interviewed among the 16 selected health facilities was 
detennined in proportion to the respective sizes of the populations of postnatal women. 
Table 5 shows the districts and the selected health facilities that were included in this 
study. 
Table 5: Districts and selected health facilities 
Tamale Metropolis Sagnarigu District Savelugu District (N=130) Kumbungu Distrct 
(N=130) (N=130) (N=130) 
Tamale West Taha Health Centre Savelugu Government Kumbungu Health 
Hospital (n=33 ). (n=33 ). Hospital (n=33 )* Centre (n=33 ). 
Tamale Central Fuo Community Health JK Health Centre- Nanton Mbanaayili Health 
Hospital (n= 33). Centre (n= 32)** (n=32 )* Centre (n=32 )* 
Moshie-Zongo KaIpohin Health Moglaa Health Centre 
Health Centre (n= Kings Village Medical cCentre (n= 33)* (n=32 )* 
32)· Centre (n=33 )*** 
Vittin Health Centre Kanvili Health Centre Diari Health Centre (n= 
(n= 32)* (n= 32)* Vogu Health Centre 32)* (n= 32)* 
Nota: *Govemment health facility; "Partly government and partly private facility; 
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In terms of sampling, a systematic sampling approach was used to select the respondents 
within each health facility. In the systematic sampling, a sample interval was calculated 
for each facility by dividing the sample to be selected over the total estimated eligible 
population of postnatal care attendants for that facility. For example, if a facility had 60 
postnatal care registrants who met the study's inclusion criteria and 30 respondents had to 
be selected for the study, 60 was divided by 30 to get the sampling interval, which in this 
case was 2. At each facility. a list of eligible respondents was compiled and numbered 
starting at 0 I. A random starting number was then determined using a google-based 
electronic random number generator. Using the respective sampling interval for each 
facility, the required number was number of respondents was then systematically selected. 
For instance, if sampling interval for a facility was 2 and the random starting number was 
determined to be 01, then respondent numbers 03, then OS, 07 and so on were selected 
until the required sample size for that health facility was attained. All the selected 
participants were then approached on their various postnatal clinic days to participate in 
the study. 
3.7.2.3 Quantitative Data Collection methods and tools 
The survey approach was used to collect data. The data collection tool was a fully 
structured questionnaire. The first part of the questionnaire aimed to collect socio-
demographic infonnation on each respondent. The second part collected infonnation on 
maternal and obstetric characteristics of respondents. The third part of the questionnaire 
aimed to assess the quality of maternal healthcare services women received during their 
most recent pregnancy. The 57-item tool that was developed and validated based on the 
qualitative research described earlier constituted the questions for the third part of the 
questionnaire. 
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The questionnaire was designed in English and administered to respondents in two 
different ways. Respondents who could speak and write English, were given copies of the 
questionnaires to them to self-complete and return to research assistants. However, in 
respect of respondents who could not speak and write English, the questions were 
translated into Dagbani, vernacular. The questionnaire was administered to such 
respondents by trained research assistants who were fluent in both English and Dagbani. 
3.7.2.4 Data Quality Assurance 
At each study site, a trained research assistant for a given facility assisted the Principal 
Investigator in data collection. All the research assistants who took part in the data 
collection process were trained teachers and nutritionist working in the Northern Region. 
The selection of the research assistants was based on their ability to speak the local 
language of the respondents and their level of education. Prior to data collection, a one-
week training session was conducted for all the research assistants. The training session 
included explanation of the objectives of the study, data collection procedures, practice 
sessions with the tools as well as ethical, safety and confidentiality considerations. 
During data collection, 20 respondents who had been interviewed by research assistants 
were re-sampled and interviewed by the PI to compare responses. At the end of the 
validation exercise, a comparison analysis was carried out, but no disparities were 
recorded or observed. The Principal Investigator (PI) also conducted one monitoring visit 
per site during the data collection period. 
3.7.2.5 Data processing 
Data collection was done with Research and Electronic Data Capture (REDCap) software 
and exported into STATA version 13 for cleaning and analysis. Data validity was cross-
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checked by running basic statistics of each variable to identify outliers and wrong entries 
after each field day's work and identified errors were corrected after cross-checking from 
the research assistant in charge. In addition, random cross-checks were made to ensure that 
entered data corresponded with the right respondents by comparing the data with the 
printed questionnaire. 
3.7.2.6 Variables and measurements 
Two main variables were considered in this study: outcome and independent variables. 
The outcome variable was quality 0/ maternal healthcare. This variable was measured 
using the validated tool developed by the researcher in the second phase of this research 
work. The tool comprised 47 Likert-scale items categorized into 13 domains (with 
responses rated I - (Strongly disagree) to 5 - (Strongly agree). In this study, the levels of 
rating were explained to the participants using the descriptions of a ladder. So, the higher 
the step on the ladder, the higher the rating and the better the quality of service received. 
As explained earlier, each of the 13 domains had a specific number of items: health 
facility domain 3 items; inter-personal relationship domain - 10 items; privacy domain - 3 
items; amenities domain - 3 items; range of services domain - 3 items; the human resource 
domain 6 items; environment domain - 2 items, safety domain - 2 items; logistics and 
supplies - 3 items; pain management domain - 1 item; clients' satisfaction domain 7 
items; health insurance domain 2 items; and outcome domain 2 items. Responses to each 
item were rated on a scale of 1 to 5, with I indicating lowest quality rating and 5 being the 
highest. Additive or average scores were then generated for each of the domains and 
followed by a composite or overall quality of care score, which was generated by finding 
the average of ail the 47 items in the construct The average scores ranged from 1 to S. The 
overall quality of maternaI heaIthcare as well as the individual domains was each 
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categorized into low (average score of 1.0 - 2.0), moderate (average score of 2.1 - 3.9) 
and high (average score of 4.0 - 5.0). 
The explanatory/independent variables studied and their measurements are shown in 
Table6. 
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Table 6: Independent variables and their measurements 
Variable Type Scale of Level 
measurement 
Socio-demographic 
Age of respondents as at last Quantitative Continuous 
birthday in completed years 
Number of times pregnant as at Quantitative Count 
the time of the survey 
Number of deliveries as at the Quantitative Count 
time of the survey 
Health facility type Categorical Nominal Public 
Private 
District Categorical Nominal Tamale Metro 
Sagnarigu 
Kwnbungu 
Savelugu 
Residence type Categorical Dichotomous Urban 
Rural 
Marital status Categorical Nominal Never in union (Single) 
Currently in union (Married 
/Cohabiting) 
Formerly in union (Divorce, 
Separated / Widow) 
Educational level Categorical Ordinal None; Primary; Secondary 
Tertiary 
Religion Categorical Nominal Traditional and others; 
Christianity 
Islam 
Tribe Categorical Nominal Dagomba; Mamprusi; Bimoba 
Kusaasi 
Socio-economic 
Categorical Nominal 
Occupation Farmer; Trader; Housewife; 
Community factors Civil; Student; Artisan 
Household decision-maker Categorical 
Nominal Self; In-Iaws/ co-wives 
Transportation issues Husband Categorical Ordinal Do not have to worry at all 
I worry some of the time 
I worry most of the time 
Distance to health facility I worry all the time Categorical Ordinal < 30 mins walking distance 
30 mins - I-hour 
1.1 - 2 hours 
2.1 - 3 hours 
> 3 hours 
Means of transportation Categorical Ordinal By walking 
By bicycle/tricycle, motor bike 
By car 
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Table 6: Continuation 
Variable Type Scale of Level 
measurement 
Access 
Availability of health facility Categorical Dichotomous Yes; No 
Distance to health facility Quantitative Ordinal < 30 mins walking 
distance 
30 mins - I-hour 
1.1 - 2 hours 
2.1 - 3 hours 
> 3 hours 
Waiting time at health facility Quantitative Ordinal < 30 mins 
30 mins - 1 hour 
1.1 - 2 hours 
2.1 - 3 hours 
> 3 hours 
Obstetric factors 
Parity Quantitative Count 
Gravida Quantitative Count 
3.7.2.7 Statistical Analysis 
Descriptive statistical analyses were first done to describe respondent's important 
demographic and maternal health characteristics. To assess quality of maternal healthcare 
women received during their most recent pregnancy, mean quality of care scores were 
obtained for each domain by adding the scores for individual items and dividing the results 
by the number of items in each domain. Based on this score for each domain, the quality 
of care under each domain was then re-categorized 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 proportions of respondents who rated the quality of care they received as either 
low, moderate or high. 
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3.8 Ethical considerations 
3.8.1 Ethical approval 
The protocol for this study was reviewed and approved by the Ethics Review Committee 
of Ghana Health Service (GHS) which is mandated to undertake ethical review of research 
involving healthcare facilities in Ghana. The study was therefore conducted only after the 
protocol received approval from GHS indicating Protocol ID Number 
GHSERC:Olll1l2020 
3.8.2 Administrative Approval 
Following the approval by the Ghana Health Service Ethical Review Committee, 
introductory letters were sent to the selected facilities in the study districts to seek 
approval before the commencement of the study. All facilities gave their approval. 
3.8.3 Informed consent 
All potential participants and respondents received information about the study in Dagbani 
or English. The information was easy to understand and free of technical jargon. 
Participants were given enough time to reflect on the information and ask questions. Those 
who gave their consent to participate in the study were requested to sign a consent form 
before participating in it. For participants who could not read, the information was read to 
them in Dagbani they understood, after which they were required to thumbprint as an 
indication of acceptance to participate in the study. Even though an assent form was 
available for participants who may be under the age of 18 years, none of the women 
interviewed was below that age. 
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3.8.4 Confidentiality and Privacy 
All participants and respondents were assured of their privacy and non-disclosure of their 
identities in the dissemination of ftndings of this study. This assurance was provided by 
assigning ID numbers to the various participants. 
3.8.5 Right of withdrawal 
It was made clear to participants in the qualitative study and respondents in the survey that 
they were free to withdraw from the study at any stage without risk of any negative 
consequences to them. However, no participant withdrew from the study. Participants and 
respondents who travelled to participate in any component of the study were fully 
reimbursed for travel expenditure. 
3.8.6 Risks and Benefits 
There were no obvious risks to participants. However, it was possible that women who 
had either experienced maltreatment during ANC and childbirth or a traumatic birth 
experience could have felt more distressed during interviews. Interviewers were trained on 
how to provide support to any woman who became upset during the interview, including 
how to initiate and follow up on referral to appropriate sections of the hospital where the 
woman could receive psychological support. While there were no immediate direct 
benefits for participating in this study, it was explained to participants and respondents 
that their views and responses as regards what constituted quality maternal healthcare and 
how it should be measured could help improve the quality of maternal healthcare women 
receive during pregnancy in Northern Region and other parts of Ghana in the long term. 
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3.S.7 Data Storage and Use 
The data collected was used solely for the research purposes and people who were not 
involved in this study did not have access to it. Both the voice recordings and transcripts 
will be kept under lock and key for 5 years. 
3.9 Same gender- interviewing: ethics and reflexivity 
Edwards (1990:482) explained that "characteristics such as class, sex and race belong not 
just to the people who we conduct our research on or about but are also characteristics of 
the researcher". Therefore, I recognized my characteristics as a female researcher and a 
mother from the study area researching into women's perspectives of quality of maternal 
healthcare and how it should be assessed in Ghana were likely to have had effects on the 
data collection process and the outcome thereof. The question whether it was difficult to 
understand women's experiences related to maternal healthcare was irrelevant. The reason 
was that whereas it could have been difficult for a man to emotionally show some 
understanding of these women as they related their experiences of bad interpersonal 
relationship with some health personnel, it was rather easy for me since I could identify 
with their perspectives. This characteristic, thus, gives credence to Bryman's (2008: 438) 
view that qualitative research interview is not just an instrument for collecting data but 
that it is an interactive process that is two directional. During the focus group discussions, 
a woman remarked "she is a mother, therefore, she would understand us better". This 
statement, certainly, reinforced the view that in order to be successful, the interview 
process must have all the warmth and personality exchange of a conversation with the 
clarity and guidelines of scientific searching" (Goode & Han, 1952: 191 in Roberts et al., 
1981). 
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My code of dressing further identified me as part of them and my gender further ensured 
my acceptability. In this study area, where the majority of the population are Muslims, the 
research team made a conscious effort to maintain a moderate dress code for Babbie 
reminds us that "as a general rule, the interviewer should dress in a fashion fairly similar 
to that of the people she will be interviewing" (Babbie 1973, in Bailey, 1994). Babbie 
emphasized that richly-dressed interviewers will probably have difficulty getting co-
operation and good responses from poorer respondents. Similarly, a poorly-dressed 
interviewer will have difficulties with richer respondents (Babbie 1973, 173, in Bailey, 
1994). Thus, in this study, the code of dressing for both sexes emphasized moderation, 
which we believe had a positive influence on the data collection processes. Rapport was, 
thus, excellent although Hyman warns of too much of it (Hyman et aI., 1954, in Bailey, 
1994). In the qualitative arm of the study, only female research assistants were used. These 
research assistants were themselves Muslims (teachers and nutritionists by profession) and 
always dressed strictly in line with the Islamic code. A male research assistant was 
however added to the team during the 520-participant. This research assistant was also a 
Muslim and his code of dressing was in accordance with that of the Islamic faith and the 
data collected was not affected in anyway. 
3.10 Chapter summary 
In this chapter, the research methods have been discussed. The discussion was divided into three 
parts. The first part detailed the research design and its epistemologicaVphiiosophical 
underpinnings. The second part described the research setting, study population, estimation of the 
sample size, sampling procedure/technique, data collection methods and instruments, variables and 
measurements as well as data analysis methods. The third part discussed how issues of ethics were 
addressed in the study. In the next chapter, results of the qualitative study that was undertaken in 
phase one are presented. 
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CHAPTER FOUR 
RESULTS: PERSPECTIVES ON QUALITY OF MATERNAL HEALTHCARE 
4.1 Introduction 
This chapter presents results from the qualitative component of the study, which sought to 
address the first two objectives of the study. The first objective sought to investigate 
women's and maternal healthcare providers' understanding of what constitute quality 
maternal healthcare while the second was to assess women's and providers' perspectives 
on how quality of maternal healthcare should be measured in Ghana. The participants' 
socio-demographic characteristics are first presented followed by an exploration of 
participants' perspectives on quality of maternal healthcare and its measurement. 
4.2 Participants' socio-demographic characteristics 
A total of 85 postnatal women participated in the qualitative interviews. Forty-six ofthem 
participated in the focus group discussions and 39 in the in-depth interviews. In addition to 
the women. 7 maternal healthcare service providers were interviewed. They consisted of 2 
medical doctors, three midwives and 2 nurses. The women's selected socio-demographic 
characteristics are summarised in Table 7. 
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-85 
Table 7: Partici ants'socio-demo ra hic characteristics 
RURAL,n(%) TOTAL, n(%) 
Variables Urban, n(%) 
Age 15 (35.71) 16 (37.21) 
31 (36.47) 
18-25 15 (35.71) 16 (37.21) 31 (36.47) 
26-34 12 (28.57) II (25.58) 23 (27.06) 
35-49 
Marital status 0 
Single 0 0 
43 (100) 85 (100) 
Married 42 (100) 
Number of children 
32 (76.19) 26 (60.47) 58 (68.24) 0-3 
4-5 9 (21.43) 
17 (39.53) 26 (30.59) 
1(1.18) 
6+ 1 (2.38) 0 
Physiological state 
Antenatal Care 10 (23.81) 15 (34.88) 
25 (29.41) 
16 (18.82) 
Just delivered 9 (21.43) 7 (16.28) 
Postnatal Care 23 (54.76) 21 (48.84) 
44 (51.76) 
Educationalle\'el 
51 (60.00) 
None 21 (50) 30 (69.77) 
Primary 4 (9.52) 7 (16.28) 
11(12.94) 
16 (18.82) 
JHS 12 (28.57) 4 (9.3) 
SHS 5 (1 1.90) 1 (2.33) 6 (7.06) 
Post-Secondary 0(0) 12.33) 1(1.81) 
Occupation 
Unemployed II (26.19) 9 (20.93) 20 (23.53) 
Farmer 0(0) II (25.58) 11 (12.94) 
Hairdresser I (2.38) 0(0) I (1.18) 
Trader 26 (61.90) 17 (39.53) 43 (50.59) 
Tailor 4 (9.52) 5 (11.63) 9 (10.59) 
Teacher 0(0) 1(2.33) 1(1.18) 
Income per week (GUc) 
None II (26.19) 22 (51.16) 33 (38.82) 
I-50 12 (28.57) 16 (37.21) 28 (32.94) 
51-100 7 (16.67) 2 (4.65) 9 (10.59) 
101+ 12(28.57) 3 (6.98) 15 (17.65) 
Religion 
Muslim 41 (97.62) 43 (100) 84 (98.82) 
Christian 1(2.38) 0(0) 1(1.18) 
Facility type 
Hospital 42 (100) o CO) 42 (49.41) 
Health Centre o CO) 43 (100) 43 (50.59) 
TOTAL 42 (49_4) 43(50.6) 85 (100) 
Women aged 18-25 and 26-34 had similar proportions of 35.7% and 37.2% in both urban 
and rural locations respectively. All the women were married. Women with up to 3 
children dominated the sample in both urban (76.1%) and rural (60.47%) areas. Sixty 
pen;ent oftbe samnle had nn MlI. .....n o:l, Trading was the dominant occupation (50.6%). A 
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higher proportion of women in the rural than in the urban areas had no income (51.16% as 
against 26.19%) while a higher proportion in the urban areas (28.57%) had weekly income 
of at least GHC 101.00. Almost all the women (98.82%) were Muslims. Hospitals and 
health centres were the only types of facilities attended by women in urban and rural areas 
respectively. 
4.3 What Constitutes Quality Maternal Healtbcare: Women and Maternal 
Healtbcare Providers' Perspectives 
Findings from the qualitative interviews suggest that participants - that is, both healthcare 
providers and women - discussed quality maternal healthcare in terms of three main 
themes. The themes were good antenatal, labour/delivery and postnatal care services. 
4.3.1 Good Antenatal Care (ANC) services 
Good antenatal care services emerged as the first theme that constituted good maternal 
healthcare. Participants argued that in order to have quality maternal healthcare services, 
good ANC is of top priority because it lays the foundation for safe delivery and for 
postnatal care. A good ANC process, according to the participants, provides both mother 
and the unborn baby with the necessary care to ensure their well-being as well as safe 
delivery. In laying emphasis on the importance of antenatal care, participants drew a sharp 
contrast between seeking care at the health facility during pregnancy and not seeking care 
at all. 
'If you're just at home without seeking care at the health facility when 
you're pregnant, you won't be able to tell if all is well with you and your 
baby" (Woman, IDl, Rural) 
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A woman in a rural community had this to say in respect of the importance of seeking care 
at the facility, using her past pregnancy experience ofa negative outcome: 
"With my first pregnancy, I wasn't going for antenatal care because we 
had no health centre here. Unfortunately, the liquor around the foetus was 
gelting smaller and 1 didn't know. 1 only got to know it because I foil very 
sick and was admitted at Tamale Teaching Hospital. Unfortunately, the 
baby died in my womb. I could have died too but luck was on my side. 
Now, my husband and I don't joke with antenatal care because if I had 
been going for it, the nurses would have been able to detect the problem 
early and even saved my child's life" (Woman, IDl Rural). 
The importance of obtaining antenatal care services was buttressed by healthcare providers 
as expressed by a nurse at a rural health facility: 
"It's important for women to come for antenatal services because we need 
to know both the unborn babies and the mother's health status to know 
whether there's any medical condition of the mother that might be 
transforred to the baby. We do many tests as well and then we take their 
medical history. Sometimes there are some families with medical history 
that may not be goodfor the children. So, when these women come, we're 
able to reduce the rate at which some sicknesses can attack the children" 
(Nurse, IDI, Rural). 
In terms of what constitutes quality ANC, five sub-themes emerged. The sub-themes 
included time and patience on the part of healthcare providers to listen to clients, 
availability of equipment and provision of medicines, and protection of mother and unborn 
baby's well-being. The two other sub-themes were education on general management of 
pregnancy and regular check-up and monitoring by the midwives. 
4.3.1.1 Time and Patience on the part of healthcare providers to listen to clients 
The data suggest that most women interpreted quality of ANC to mean health providers 
having the patience to listen to clients' health problems and provide treatment for their 
health needs. This issue was raised by participants in both urban and rural settings as 
expressed in the following narratives: 
"For quality ofm aternal healtheare, I think it's when you go to the facility 
and ,they get time f?~ you and try to find out what your problem ;s and why 
you re at the /acI/zty that day. It's when they also try 10 solve your 
problemfor you" [Woman, IDI, Urban]. 
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One participant contributed to the discussion and had this to say: 
''I'll say that quality care is when you're well taleen care ofa t the hospital by 
the doctors and nurses and they get the patience to listen to all your health 
worries without insulting you. That, to me, is quality care" (Woman, FGD, 
Rural) 
Many healthcare providers corroborated the women's views on what constituted quality 
care. They stressed that most women come to the facility not only to seek care but also 
for psychological counselling on matters relating to their marriages, specifically, their 
relations with their husbands: 
"Hmm! Sometimes too they come with some personal issues they want you to 
listen to. Especially when you ask questions like "what happened and you 
didn't do this?" Then, they would tell you a whole story and expect you to 
listen and say something. Well. we do listen to them especially when we 
realise that the person is so passionate ... Some of them talk and cry so you 
have to leave the rest and take them inside. Most often, the stories are about 
their husbands ,. (Nurse, IDI, Rural). 
4.3.1.2 Availability and provision of medication 
Participants pointed out that a successful antenatal service should have the needed 
medication for its clients to easily assess for the protection of both mother and child 
against malaria and anaemia. Availability of medication within a health facility, 
according to the women, means it is well equipped and, hence, offer quality ANC 
services, which can contribute to good quality maternal healthcare. An FGD participant 
at an urban area pointed out that: 
"Quality antenatal care is when you get all your medicines that you need and 
you don't have to worry about how to get those medicines '" that's quality 
care" (Woman, FGD, Urban). 
Another participant from the rural area also corroborated the views expressed in the 
urban area: 
"Whenever you go to the health centre and nurses look after you well and 
after that you get some medication 10 lake home and lake so that your baby 
grows well and strong, then you can say that there 's quality antennal care" 
(Woman, FOD, rural), 
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Many health providers too interpreted quality maternal healthcare as being able to 
provide all the care needed by pregnant women and this perception encompassed 
providing medications, having access to scans and managing complications during 
pregnancy to ensure safe delivery. A medical doctor emphasised the need to manage 
complications and to ensure the safety of both mother and baby as key components of 
quality maternal care: 
"What I think is quality maternal healthcare is to see a pregnant mother go 
through her pregnancy normally or have it managed adequately even if with 
complications and to be delivered safely of a healthy baby" [Doctor, 101, 
Urban]. 
A midwife at an urban facility added her views as follows: 
"What 1'1/ call quality care is when the health workers come together to take 
care of the clients' needs so that they have safe deliveries. It also means the 
hospital having modern equipment like scans and good laboratory systems to 
help in delivery ofg ood service ... that, to me, is quality care" (Midwife, ID 1, 
Urban). 
Another midwife at a rural facility expressed her views as follows: 
"If the women come and we're able to solve all their health problems and they 
get satisfied with our performance and we're also able to handle all other 
complications that arise, with a/l required machines available, then I'll say 
quality care is available at the health facility " (Midwife, IDI, rural). 
4.3.1.3 Protection and provision of care for mother's and unborn baby's well-being 
The study found that women attending ANC would go to facilities that would ensure their 
own well-being and their unborn babies'. For many participants, quality care means the 
ability of service providers to provide the essential care for mother and baby during ANC 
visits. The narrative by an urban participant in the quotation below highlights what she 
thinks constitute quality maternal care: 
"Antenatal services that give us food supplements and monitor how our 
babi~s are faring, leading to both the mother and baby's well-being is what I 
consider as good antenatal service" [Woman, FGD, Urban]. 
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One rural participant also noted as follows: 
Obtaining antenatal care services at the health facility where immunization 
services are provided to protect our unborn babies and let them grow well 
and healthily is considered good antenatal care" (Woman, FGD, Rural) 
Many of the healthcare providers interviewed agreed with the women's perceptions of 
quality ANC services. A midwife at an urban facility indicated the need to provide all 
essential services such as weighing and monitoring the progress of the pregnancy and 
providing education on nutrition to ensure the safe delivery of the client: 
"Quality antenatal care is when a mother is pregnant and she's able to attend 
ANC to receive all the needed care such as weighing her. educating her on 
nutrition and monitoring the progress ofh er pregnancy until she is delivered of 
her baby successfully without any complications. However. if there are deaths. 
then it means the quality ofs ervice is bad" (Midwife. IDI. Urban), 
4.3.1.4 Education on general management of pregnancy 
Another important factor that featured in quality ANC was the ability of healthcare 
providers to educate mothers on management of pregnancy to avoid pregnancy-related 
complications. Participants explained that general education on the importance of 
antenatal care services is vital so it should constitute the requirement for defining quality 
maternal care. This sub-theme was especially important for first-time mothers, Most of 
the participants indicated that quality ANC should have an educational package for ANC 
clients on the general management of pregnancy. This education should include the 
reasons for immunization, pregnancy food supplements, nutrition and management of 
pregnancy. The participants, thus, prefer to attend ANC clinics that offer such services. A 
woman in a rural area was emphatic about the importance of management of pregnancy 
education during ANC in the following narrative: 
"/ think that the provi~i,on ofi nformation during ANC so that my unborn baby 
gets ,the needed nutritIOn to grow well is one of the constituents of good 
quality maternal care. The nurses should also give us more information on 
I?re~ management and some food supplements. These are very important 
In quality maternal care services" (Woman, IDI, Rural), 
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An urban healthcare provider emphasized the need for women to be educated on 
pregnancy-related issues: 
"And education too; we need to educate the women to come to the hospital for 
delivery because some oft hem are still delivered at home. When you see some 
of them at the hospital, it could mean that they're in labour that have delayed 
and are afraid so they quickly rush to the hospital. Or, maybe the baby is dead 
or something. But ift hey know that (f they're delivered at the hospital, it is saft 
and they '/l have fewer complications, they will come. And it isn't good to take 
any local concoction when you're pregnant" (Midwjft, IDI. Urban). 
".3.1.5 Regular check-ups and monitoring the unborn baby's growth 
The women did indicate that during the provision of antenatal services, each pregnant 
woman should be checked and monitored by a midwife and records taken into their 
various antenatal record books. This act, according to the women, will ultimately lead to 
delivery of healthy babies. A woman in a focus group discussion session stated what 
makes antenatal services good thus: 
"A good antenatal care service should comprise regular availability of 
services during which food supplements are provided. Regular ANC also 
oJfors the opportunity for a pregnant woman to be monitored by the midwife 
and progress of the pregnancy recorded. When this is done, you know your 
unborn baby is okay and healthy" (Woman, FGD, Urban). 
Some healthcare providers confirmed this view. For example, a midwife at an urban 
facility pointed out the kinds of services her facility offers to pregnant women to attract 
them to her facility. These services, according to her, should constitute good antenatal 
care: 
'The women come for antenatal care services because ofw hat we offer them. 
We measure and monitor the progress of their unborn babies and the women 
the~elv~s. We give them pregnancy food supplements and some drugs when 
they re SICk. Therefore, good ANC services must have midwives who measure 
a~ ~onitor the progress of women and their unborn babies regularly. The 
midwives mus~ aI~o be able to oJfor the clients pregnancy food supplements 
and some medIcatIOns when they're sick" (Midwife. IDI. Urban). 
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A rural nurse agreed with the above perception: 
"Most pregnant women know that we offer good antenatal service to them 
and, for that matler, they come over to the facility. Some of the services we 
offer them include taking their records and giving them some pregnancy 
management lessons to keep both themselves and their unborn babies 
healthy. This also is an important component ofg ood antenatal care" (Nurse, 
IDI, Rural). 
4.3.2 Good quality care during labour and delivery 
Participants discussed two sub-themes to explain quality care during labour and delivery. 
These sub-themes were the ability of the care regime to prevent and manage complications 
as well as ensuring the mother's and baby's safety during labour and delivery. These two 
aspects of quality care are explained below. 
4.3.2.1 Prevention and management of complications during labour and delivery 
Participants indicated that quality maternal healthcare should ultimately produce a smooth 
delivery process without complications. According to the women, delivery without 
complications is the main reason for seeking care and, therefore, constitute an aspect of 
good quality maternal healthcare. A woman who was delivered at an urban facility made 
this point precisely: 
"I decided to come to the facility to be delivered because I want my baby girl 
to be delivered safely. I want to avoid any complications that I can '( handle" 
(Woman, IDI, Urban). 
Another new mother from an urban community had this to say: 
"I ~onsider my child's safety and mine very seriously and wouldn't risk being 
~ellvered at home, where there aren't trained medical personnel to assist me 
~n c~e of ~ny emergency. Provision of good quality maternal healthcare 
Implies babies should be delivered safely and without any complications" 
(Woman, lDI, Urban). 
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A new mother from a rural community expressed similar views as follows: 
"The traditional birth attendants are helpful but can't do so much in case you 
need blood or an operation so it's very important to come to the health 
facility and be delivered where you can be assured ofy our ~afety. Ther~fore, 
I consider the provision ofs ervices that ensure the safe dellvery of babIes an 
important component ofq uality care" (Woman, 101, Rural) 
For many healthcare providers, the capacity to manage pregnancy-related complications 
is indeed a key ingredient of quality maternal healthcare: 
"Having the capacity to manage complications is key in the definition of 
quality care. Some might have complications but you can manage them and 
they '/I still be delivered whether at term or not term" (Medical doctor, IDl 
Urban). 
4.3.2.2 Mother and baby's safety during labour and delivery 
The second sub-theme, safety, emerged especially with frrst-time mothers. They indicated 
that since this was their first experience of pregnancy, they needed to seek care that 
would ensure their safe delivery. This perception was expressed clearly by a rural 
woman: 
"Getting the needed proftssional support to be delivered safely is one of the 
constituents of good maternal healthcare. I came here to be delivered since 
this was my first delivery and I was a bit scared to be delivered at home. 
Here, I got the support to be delivered safely" (Woman, 101, Rural). 
4.3.3 Good postnatal care services 
Participants discussed the components of quality care during the postnatal period. The two 
key components mentioned were access to appropriate and timely immunization and 
access to appropriate general check-up to ensure babies' welfare. 
4.3.3.1 Access to appropriate and timely immunization 
Immunization of babies, according to the women, was very important and should be a 
good indicator of quality maternal healthcare. Immunization was considered important for 
their babies as it protected them against infections such as poliomyelitis and measles. 
_n_ .... _-- -_! .. thAt they preferred facilities that offered their children 
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immunization services. The importance of immunization was emphasised by an urban 
woman: 
'Nurses at health facilities encourage us to bring our children for them to 
administer very important injections that '1/ help keep our children safe from 
dangerous diseases. Access to these services is what I consider one of the 
maries ofq uality maternal care' (Woman, IDl Urban). 
A woman from a rural community expressed her views about immunization as follows: 
"This is my first delivelY and to ensure that the child is safe from all diseases, 
I often take her to the clinic for check-ups and to get some injections for her. 
We're told by the nurses during the delivery time that it's very important to 
bring back the babies for regular monitoring and injections. Good maternal 
care services should therefore ensure that babies are given the right 
immunization to enhance their health" (Woman, FGD, Rural.) 
4.3.3.2 Access to appropriate general check-ups to ensure babies' welfare 
Participants indicated provision of regular check-ups and monitoring of their babies' 
development and growth as indicators of quality maternal heaIthcare. They further 
indicated that postnatal care offered them the opportunity to have their children checked 
regularly to ensure their growth and welfare, and hence, offered them the assurance of the 
children's safety. In the opinion of an urban woman: 
"Regular attendance for children to be weighed and given the necessary care, 
which we're told protects them against childhood diseases, is one of the 
important components of quality maternal healthcare. The nurses further say 
that if you give your child the injections, and he/she happens to get the 
disease, it won't be all that serious. This, I think, is good news" (Woman, 
FOD, Urban). 
A woman from a rural community echoed the urban woman's views this way: 
"I ta!'t my child often for postnatal care because I want him to be healthy all 
the tlme. The ~u~ses w.i11 also monitor him and see whether he's growing well 
or. not by we~ghmg him. o[te~ The nurses also have specific dates for us to 
brmg the c~lldren for Iryectzons against diseases that might threaten their 
~owt~. I thmk offermg these services that ensure our children grow healthily 
IS an Important component of good quality maternal care" (Woman FGD 
R~. ' , 
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4.4 Measuring/Assessing Quality of Maternal Healtbcare: Women and Healtbcare 
Providers' perspectives 
The second objective of the study sought to understand how quality of maternal healthcare 
should be measured Thirteen indicators emerged as important for the assessment of 
quality of maternal care. The first set of indicators included proximity of health facilities 
to clients, availability of infrastructure and other amenities, availability of logistics 
including equipment and medicines and good environmental sanitation. The second set of 
indicators emphasized human resource/workforce, non-discriminatory provision of 
maternal healthcare services, range of services and inter-personal relationship. Privacy of 
clients, pain management and clients' involvement in the care decision-making process, 
mother and baby's safety, outcome of pregnancy and client's satisfaction are the last set of 
indicators. 
Among these 13 key indicators, mother and baby's safety and the outcome of pregnancy 
were the two dominant indicators health providers considered to be the most important. 
On the contrary. even though the outcome of pregnancy and safety were important to the 
women, inter-personal relationship and range of services were the two dominant 
indicators. 
4.4.1 Proximity of health facilities to clients 
Proximity of health facilities to clients is a recurrent theme in the data in terms of 
assessing the quality of maternal healthcare in Ghana. Participants argued that health 
facilities in any given community should be close to women for optimum utilization of 
their services. Proximity of the healthcare facility was an important consideration in the 
choice of place for women to seek skilled maternal healthc are services. An urban woman 
highlighted the significance of proximity: 
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"The hospital is just close to where I live. I usually walkfrom the hou~e to the 
hospital. The distance makes it easier for me to carry my baby for him to be 
checked whenever he has fever. I bring him for weighting and to take some 
injections so he can stay healthy" (Woman, IDI, Urban). 
A participant in an FGD session in a rural community could not agree more with her urban 
counterpart's perception that proximity is an important indicator for accessing healthcare: 
"The health centre where I come for my regular antenatal check-up is 
actually very close to my home so I don't have to walk for a long distance 
since I'm highly pregnant and my husband has no other means oft ransport to 
take me to a very distant hospital. l therefore, just walkfor some minutes and 
am at the health centre" (Woman, FGD, Rural) 
Healthcare providers corroborated the women's report that proximity of health facilities 
influenced their utilisation of their services. A midwife from a rural facility corroborated 
the women' s view that distance to a health facility was an important consideration for 
assessing quality of maternal care: 
"We believe women come here because oft he proximity oft he health centre to 
the community. The centre is just within the community and it's just a walking 
distance for the women to come for antenatal and postnatal services" 
(Midwife. IDI, Rural). 
In view of the above perceptions that proximity was an important factor for women to seek 
maternal healthcare. both women and healthcare providers in both rural and urban 
communities were of the view that the availability of health facilities in close proximity to 
children's homes should be a key consideration in measuring quality of health care. A rural 
woman was of the opinion that proximity of health facilities to clients' homes was a good 
measure of quality of care because it could save costs of travelling long distances to seek 
care: 
"Fi:~t, ~o measure quality of ANC service, you look at how close the health 
faci/Ity IS to the community. Ifi t's far and we don 'I have Ihe money to travel to 
that place, it'll be a problem" [Woman, FGD, rural]. 
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An urban participant agreed with the rural woman's perception of the benefits of 
proximity of health facilities to clients' homes: 
"I think it's true to consider the issue of proximity in assessing quality of 
maternal healthcare because, even if a facility is well equipped and we don't 
have the means to travel to seek care there, what is the point? So, the closer it 
is to the user, the better" (Woman, IDJ. Urban). 
Healthcare providers perceived proximity of facilities to clients as an important indicator 
for assessing quality of maternal healthcare not only because it saves time and financial 
resources on the part of clients but also because it makes it easier for health providers to 
give of their best in terms of service provision. According to a rural nurse, proximity of 
facilities to health service providers deserves equal attention: 
"The health facility shouldn't be closer to only the clients but also the 
healthcare provider so that she/he is more accessible to the clients all the 
time. We have to travel all the way to come and attend to them and then travel 
back home, and because our homes are far, weren't available all the lime for 
emergency cases and this absence may result in the client suffering" (Nurse, 
IDI, Rural) 
4.4.2 Availability of infrastructure and other amenities 
Participants indicated that measurement of quality of maternal healthcare should also be 
based on the availability of physical infrastructure and its associated amenities such as 
beds, enough spaces in labour wards, toilets and urinals at the health facility. In addition, 
these facilities according to the clients should be kept clean at all times. One woman could 
not hide her disaffection with the current poor status of certain amenities: 
"Space to ac~ommod~te all women in labour as well as the availability of 
enough beds IS very Important to consider when measuring quality of care. 
Currently, there aren '( enough beds to accommodate all of us in the ward and 
some women are sleeping on the floor and can easily gel infections. The 
washrooms 100 need regular clean-up before you can say there is quality 
maternal care" (Woman, IDI, urban). 
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Indeed, many participants discussed the issue of toilets passionately. They say access to 
these facilities are very necessary and, therefore, saw them as necessary indicators for 
measuring quality of maternal healthcare. A participant in a focus group discussion 
session explained the importance of toilets thus: 
''Toilets are very important in measuring quality of maternal healthcare. 
When we come for ANC, they ask us to bring urine and stool for examination, 
so the toilet should be clean for us to use. This requirement is very important 
for us as we can develop infections by using urinals or toilets that aren't 
clean" [Woman, FGD, urban]. 
Views from the focus group discussion in rural communities equally pointed out the 
importance of ensuring the availability of clean toilets at the facility. One rural woman 
supported her views of the need for decent toilets with an unreserved condemnation of the 
poor status of the toilets at the facility: 
"Toilets should be provided in the building ... that makes it a good health 
facility, but that isn't what we currently have in this health centre. The toilets 
here aren't functioning so we usually must go out somewhere to relieve 
ourselves and come back or wait for many hours before going home to be able 
to go to toilet. This can't be called quality and so it should be considered in 
the measurement" (Woman, FGD, rural) 
Another female FGD participant echoed the call to consider the calibre of ewaiting space 
and seating arrangements in an assessment of quality of care at a given facility: 
''The health facility and where we attend the weighing for the children should 
be big enough and have more seats but this isn't the situation here, I have 
stood in the queue for a long time before getting a seat; even that seat wasn't 
good So, quality of healthcare should consider having enough seats for all 
clients" [Woman, FGD, urban]. 
Rural female IDI participants were equally convinced about the importance of seating 
space. Her assessment of the status-quo not less negative then that by FGD participants: 
",There's the ~eed for health facilities to get more benches and chairs for us to 
~" O~iffi~,,!:I'h~es'fiwe come, ~nd ~he benches are full so we must stand, which 
IS a UI ",,...t mg or us considenng our conditions" (Woman, ID/, Rural). 
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Healthcare providers generally agreed on the need to consider infrastructure and amenities 
in assessing quality of maternal healthcare. They argued that providing enough seats and 
toilet facilities for clients is essential in improving quality of maternal healthcare services. 
"I think you should consider the space in the facility as an important 
indicator. There should be enough space for the clients. So, you think about 
the capacity. Jfyou want to cater for 30 patients you have to provide 30 beds. 
This way, the issue of over-crowding and its associated problems would be 
minimized. (Midw!fe, IDI. Urban). 
4.4.3 Availability of logistics including equipment and medicines 
Women explained that availability of logistics including equipment (such as ultrasound 
machines, scans, X-rays and blood pressure apparatus) and consumables (such as hospital 
cards, cotton wool, sterilised pads, gloves, syringes and canola) to facilitate efficient 
rendering of health services in the facility should be used to measure quality of care. 
Drugs and essential medicines, blood and constant flow of water were other logistics that 
were deemed relevant for inclusion in the measurement of quality of care, According to 
them, availability of equipment and machinery is necessary for the delivery of quality of 
maternal healthcare, One female rural IDI participant stressed a link between availability 
of equipment and drugs on one hand and mother and baby's safety on the other hand: 
''I'll also say that quality should be measured based on the ability to avoid 
any death by having the right machines and drugs to save the mother and the 
baby. Measuring quality of care should also include whether the facility has 
all the machines needed to make usfeel well and safe" (Woman, IDI, Rural) 
A link between availability of medicines and blood on the one hand and women's safety 
on the other hand was implied in a female urban IDI participant's call for the former 
(availability of the logistics) to be considered in an assessment of the quality of care at a 
facility: 
"You can measure the quality of care by observing whether the hospital has 
enough medicines and blood available for we the women in case of 
emergency" (Woman. IDI. Urban) 
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Healthcare providers added the constant flow of water to the list of indicators for 
assessing quality of care. A health provider from an urban facility vented out his 
frustrations on the poor quality of services they provide and the need to consider the 
calibre of logistics in assessing quality of mate mal healthcare: 
"Sometimes there is no blood. Sometimes you have to go to the central hospital 
to get blood. And in emergency situations when you need blood there is a 
problem. Also, basic consumables like plaster, sterilised gloves and pads, 
cards, colton, canoia, syringe and saline are a/l a problem. Even water is a big 
issue for us. Equipment such as ultrasounds, scans, air-conditioners not 
working at the theatre and many more ... it is a real problem" (Medical doctor, 
FDG, Urban). 
An urban nurse justified the need to consider the availability of water in an 
assessment of quality of maternal healthcare: 
"Water too is very important and must be considered in assessing quality of 
maternal healthcare we render to our clients. If there 's no water, the theatres 
can't junction, labour ward too can't function ... because it's water we use to 
prevent infections. So, water is very important" (Nurse, IDI, Urban). 
4.4.4 Good environmental sanitation 
Participants, particularly women from urban areas, were of the view that quality of 
maternal healthcare could further be measured by considering how clean and neat the 
health facility and its surroundings were. For instance, they stated the need for consulting 
rooms and maternity wards where clients received care to be improved in terms of 
ventilation since those places were almost always crowded with clients. The over-crowded 
nature of the rooms and wards, according to participants, could not be considered as 
evidence of quality service and should be considered as an indicator for measuring quality 
of care: 
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"The environment o/the health/acility needs to be considered in a~sess~ng 
the kind 0/ health services we receive in this facility. Look a! the ~ltuatlO~ 
here, the place is small, and we have many mothers and their babies. .T hls 
makes the place stuffy and smelly. This is obviously not an Ideal 
environment for delivering quality healthcare. Therefore, one must 
consider the state of sanitation at the facility environment to determine 
whether they are offering good quality care or not" (Woman, IDI, Urban). 
In respect of the limited space and its effect on environmental sanitation, another woman 
reiterated that because of the over-crowded nature of the facility, there is poor ventilation, 
making mothers and their babies very uncomfortable: 
"The space is so small and when we're many here, no fresh air gets in; so it 
starts to smell and makes the babies uncomfortable and they begin to cry. 
This unsanitary outcome makes it imperative to consider the environment 
important/or assessing quality ofm aternal health" (Woman, FGD, Urban). 
Many healthcare providers supported the need to consider the state of environmental 
sanitation of healthcare facilities as an indicator for the assessment of quality of care. 
4.4.5 Human resource/workforce 
The workforce or human resource at health facilities emerged from the data as an indicator 
for assessing quality of maternal healthcare. Participants argued that it was very important 
to always have healthcare providers on duty at health facilities to provide quality care 
services to women. Both women and healthcare providers added that the quality of 
maternal healthcare could be assessed by looking at the health workforce - that is, the 
number and scope of availability of workers at a health facility. Some women in the group 
discussion sessions complained that there were times when they came to the health 
facilities only to learn that the midwives were absent from duty. Others stated that the 
Waiting time before they were attended to. Punctuality and regularity of being on duty 
among bealthcare providers were cited by both urban and rural women. Their experiences 
were miserable: 
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"One thing that should be considered when measuring quality is how many 
midwives and doctors are available and attending to patients. You come here 
early and you only have a few midwives attending to so many of us and t~is 
causes unnecessary delay ... I told my husband to accompany me to hospital 
for ANC and he refosed because oft he delay that he experienced the first time 
he came with me. We spend the whole day here" [Woman, FGD, Urban]. 
A female urban FGD participant justified the need to make the human resource one of the 
indicators for assessing quality of health care: 
"Sometimes you come here and there're only one or two midwives on duty, 
but you look, and see that the number of women waiting to see the same 
midwife is so high. We don't even talk about the doctors because they are very 
few. This shortage of staff makes you wait and wait forever. I think the best 
decision is to consider the number of health workers in the measurement of 
quality" (Woman, FGD, urban). 
A rural FGD participant attributed the scope of home deliveries to the non-residence of 
service providers in the communities: 
It's equally important that we've some doctors and midwives to be staying in 
our community because most often, labour starts unexpectedly and in many 
cases in the middle of the night. When the health centre nurses have closed 
and gone to Tamale. With the difficulty of transport here, you have no other 
choice than to be delivered at home. So, I think availability of qualified 
maternal health professional should be considered in the measurement of 
quality of care" (Woman, FGD, Rural). 
The women's views were corroborated by some of the healthcare providers. An urban 
doctor supported calls to consider human resource in assessing quality of care. He 
accounted for the poor service provider-client ratios as follows 
.. The number and quality ofs taff are a problem because most oft he midwives 
are getting closer to retirement so the strength of the workforce is weak and 
so we try to improvise with nurses who aren't trained midwives. These nurses 
are just posted here maybe as general health assistants or trained nurses, but 
they are not midwives. They're just posted to help because the midwives are 
not many. So, staffing is a quality of care issue and must be considered" 
(Doctor, IDI, Urban]. 
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An urban midwife agreed with the urban doctor's justification for the long periods clients 
have to wait to be seen by service providers: 
"The time spent here by the women is just too much because there aren't 
enough doctors or midwives that can take care of them on time. There 're just 
few of us here and the women seeking care are so many; so, you can just 
imagine the workload on us and the time that these women will have to speed 
here" (Midwife, IDI. Urban). 
4.4.6 Discriminatory provision of maternal healthcare services 
The National Health Insurance Scheme is another vital theme that emerged from the data. 
Women, in particular, indicated that accreditation of national health insurance services at 
the facility level is essential in measuring quality. The women argued that although the 
cost burden of healthcare is taken care of by the introduction of the insurance, there is 
discrimination in tenns of access to healthcare provided. They explained that healthcare 
providers tended to render better services to women who paid for healthcare services out-
of-pocket. According to them, since the government did not reimburse facilities on time, 
care providers attended to those paying their bills out-of-pocket before attending to those 
with health insurance. The women argued that this practice was unacceptable and, hence, 
not a good indicator of quality maternal healthcare. 
·'Good quality maternal care services should cover the facility accepting 
insurance and providing the best ofc are to those either with or without health 
insurance. The practice of attending first to those without insurance is 
unacceptable" (Woman, FGD, Urban). 
An ANC client continned the discrimination in favour of clients who footed their 
bills: 
"There's discrimination between those with insurance cards and Ihose who 
come and pay cash, which shouldn't be the case. The workers don 'I regard us 
as equal and those without insurance gel treated first. This isn 'I good, and it 
should be considered in assessing quality" (Woman, FGD, Urban). 
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Another discussant with health insurance narrated her unfavourable experience at a health 
facility: 
"Once, I brought in my sick baby but some women who came later were 
treated before my baby just because they paid cash for their treatment but 
because I had no money to pay, I had to wait. It's quite uncomfortable but if 
something is ofg ood quality, it shouldn't make you feel that way. So, it should 
be considered in the measurement" (Woman, IDJ. Urban). 
On the issue of discrimination in the provision of maternal healthcare, healthcare 
providers rationalised it in terms of delays in insurance reimbursements. They indicated 
that because of delays in reimbursing insurance claims, the health facilities more often 
than not, ran out of funds to restock supplies. Consequently, they often tended to offer 
services first to people with the ability to pay for services. An urban doctor rationalised 
the discrimination that resulted from recourse to the ability to pay principles as follows: 
"But sometimes comfort comes at a cost because the health insurance will 
not give that kind of comfort. The health insurance scheme has put more 
stress on the health facilities than it ever anticipated. Because of delays in 
reimbursement of insurance funds, sometimes the basic consumables are not 
there to work with ... and yet, you still have to deliver care. Sometimes there 
are no canola, no syringes... all these little things should be considered in 
measuring quality ofm aternal care" (Medical doctor, IDJ, Urban). 
4.4.7 Range of services 
Women stated that the ability to have access to a range of services at a health facility was 
of grave importance to them and, thus, a sign of quality care. They indicated that some 
facilities provided services ranging from diagnostic testing and x-rays, to treatment and 
medications - all being offered at the same place. They, however, explained that in some 
facilities, clients are requested to go to other facilities to have certain aspects of their 
conditions investigated before coming back for treatment. This action was deemed to 
compromise the quality of care: 
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"! think the availability of medications is very important, which you di~n 'I 
mention, Madam. For ify ou go to seek care at a facility and you aren 'I given 
any medications but rather told to go elsewhere to get it, then it isn't worth 
going there after all" (Woman, FGD, Urban). 
Another woman felt satisfied with the range of services available at her current facility: 
"! decided to come here because they've certain facilities that can detect your 
health problems and you're given immediate treatment unlike the place where 
! had my first delivery. Other hospitals have no machines that can check 
whether the baby is growing well or not" (Woman, IDI, Urban). 
4.4.8 Inter-personal relationship 
Most of the women explained that the quality of maternal healthcare could be measured by 
the quality of interpersonal relationship that existed between healthcare providers and their 
clients. Several of the women added that inter-personal relationship should be the main 
measure of quality of maternal healthcare. Their main concern was that the prevailing 
standard of healthc are communication between them and service providers was poor: 
"You can measure the quality of care by observing what happens daily at the 
hospital between the nurses and us - the women. The way they treat and talk 
10 us will show it" (Woman, FGD, Urban). 
Another FGD participant elaborated on the poor state of inter-personal relationship at her 
urban health facility: 
"Poor communication ... ! mean lack ofr espect for us is a very big issue here. 
The hea~/hcare providers don't listen to us at all when we come here; they're 
always m a ~urry to examine us and get rid of us quickly without listening to 
ollr complamts. So, for me, good communication should be considered in 
assessing quality ofc are" (Woman, FGD, Urban). 
Some clients of rural facilities supported the consideration of inter-personal relationship 
in the assessment of quality of care: 
"Measuring quality of care should look at the relationship between the 
workers at the clinic and us, the women, who go there to be delivered" 
(Woman, FGD, Rural). 
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Many women argued that healthcare providers should explain care procedures to clients 
and treat them with respect. This argument was echoed during focus group discussions: 
"Measuring quality of maternal healthcare should include how healthcare 
providers treat patients regarding respect" (Woman, FGD, Rural). 
Some healthcare providers admitted that the relationship between the service providers 
and women was not the best. They, however, did not agree that inter-personal relationship 
was the most important indicator of quality of maternal healthcare: 
"To be honest with you, we sometimes get angry with them but it isn't that we 
blow it out. I'll express my displeasure to my client but we don '/ scold them 
like that. In fact, if we do so, it '/I deter them from coming to us" (Midwife, 
lDI, Urban). 
4.4.9 Privacy of clients 
Many women reported that privacy in the consulting or examination rooms was very 
important. Privacy was extremely necessary for religious reasons as many of the 
participants were Muslims and their religious norms prohibit exposure of a woman's 
private parts to persons other than her husband. An urban woman was unhappy about the 
current level of privacy: 
"As a Muslim, you know we aren't supposed to expose our bodies to people 
who aren't our husbands. So, to me, privacy should be number one in any 
assessment of quality of care assessment. I'm sometimes not comfortable the 
way health workers just enter the examination rooms. Sometimes the place is 
full of students and yet you're supposed to be examined in their presence" 
(Woman, FGD, Urban). 
A Muslim woman from a rural location confirmed the urban woman's unfortunate 
assessment of the quality of privacy at the facilities: 
.. We Muslim women aren't supposed to expose our nakedness to men that are 
not our husbands because it is against our religious practices... but this is 
often not the case when you go for antenatal care services. I will say that this 
concern of ours should be included in the assessment oif quality if " 
(Woman, FGD, Rural) 0 care 
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4.4.10 Clients' involvement in the care decision-making process 
Many women indicated the need for healthcare providers to involve clients in the care 
decision-making process and to provide answers to their questions with courtesy, 
decorum and respect. The women explained the need for healthcare workers to make time 
to explain treatment procedures to them for them to be able to make informed decisions. 
Both urban and rural women, but not the healthcare providers, said this indicator was 
relevant in assessing quality of maternal healthcare. In the opinion of a female urban FGD 
participant, client's involvement in the decision-making process was currently non-
existent: 
"Health workers must always explain all procedures to us and involve us in 
the decision-making process. For now, you just tell them your problem and 
they don't ask for your opinion, they just write medicine for you. So, 
assessment of quality must consider engaging patients in the entire care 
process. If you ask any question, they get angry and talk to you any how" 
(Woman, 101, Urban]. 
A similar unsatisfactory picture of the state of clients' involvement in the care 
decision-making process was painted by a rural FGD participant: 
"Inclusiveness is zero. If you decide to go for antenatal care services at the 
health centre, then consider that your body is for the nurses. They chose to 
examine it the way they want without making you to understand why they do 
certain things. And when they're done with you, they ask you to dress and go. 
Explaining to us why they need to examine us should be part of measuring 
quality ofc are" (Woman, FGD, Rural). 
4.4.11 Mother and baby's safety 
Another issue of great importance that emerged was safety. Many participants stated that 
care and treatment procedures should be conducted in ways that ensured clients' safety. 
They argued that safety should be included in assessing quality of maternal healthcare 
since it is the ultimate outcome of the care process. Healthcare providers also considered 
this theme and outcome of pregnancy (discussed in secti'on 4412) th 
.. ,as e two most 
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important indicators for measuring quality of maternal healthcare. The importance of 
safety was narrated by a female rural FGD participant: 
"Safety is very important and should be included in the assessment of quality 
of maternal care. If procedures in the hospital aren't conducted well, then 
they'// compromise quality. I've heard a story about a child losing the hand 
because the health workers didn't set the infusion well. So, safety is very 
important. My first born was given an injection and he developed abscess 
because the nurse didn't do it weir (Woman, FGD, urban). 
A female rural IDI participant established a link between the levels of clients' safety and 
the calibre of physical infrastructure in the form of buildings with good storage facilities: 
"When we talk about safety, it means we should have a good hospital 
bui/ding with a good storage facility for our medicines and injections so that 
when our babies take it, they won't be sick but will get better. But this isn't the 
case at the health centre. They don't have any place for their medicines, so 
they keep carrying them to and fro on motorbikes and I don 'f think this 
practice is safe. So, the clients' safety should be considered in the 
measurement ofq uality" (Woman, IDJ. Rural). 
4.4.12 Outcome of pregnancy 
Both women and healthcare providers agreed that the outcome of pregnancy should be 
considered in measuring quality of maternal healthcare. However, healthcare providers 
placed a lot more premium on this indicator. Emphasis was laid on the ability to safely 
deliver healthy babies with no complications to mothers. According to a doctor at an urban 
facility, 
?ositil'e outc?me.s like good antenatal services resulting in safe deliveries 
WIthout compilcatlOns should be indicators of quality of care ... it should be 
measured by the outcome of the pregnancy. Some might have complications, 
but you can manage them, and they will still be delivered whether at term or 
not term. If the mother is fine and the baby too is fine it's the best way to 
measure quality" (Doctor, IDI, Urban). ' 
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A midwife at an urban facility was also emphatic about the importance of outcome in the 
assessment of quality of care: 
"The outcome ofp regnancy should be used to assess whether there is quality 
care or not. The end-result should always be healthy mother and baby. 
Without these positive results. you can't say there's quality care (Midwife, 
IDI. Urban). 
A rural midwife held similar views about the importance of outcome in the assessment of 
quality of care: 
"Ify ou think of measuring quality, then you have to look at the outcome ... how 
best we manage complicated situations and are able to deliver safe babies and 
the mothers are equally healthy ... that is the best indicator of quality care" 
(Midwife, IDI, rural). 
4.4.13 Clients' satisfaction 
Many women argued that women's satisfaction affects utilization of health facilities and, 
therefore, should be a priority in the assessment of quality of maternal healthcare in 
Ghana. Participants stated that clients' satisfaction can be the basis for assessing quality of 
care. From participants' narratives, it could be inferred that individual clients perceived 
quality of care differently, hence their perceptions must be considered in measuring care. 
According to the data, while some clients based their perceptions on treatment and 
medicines, others based theirs on clients' recovery from health problems they presented at 
health facilities. Other participants talked about quality in terms of the attention given to 
patients by healthcare providers. Whichever way their perceptions go, many of the women 
agreed that their level of satisfaction is key in measuring quality of care. A rural FGD 
participant's view was as follows: 
"/ think ~e can measure quality by looking at how women are satisfied with 
how they re treated when they seek care at the facility. (Woman, FGD, Rural). 
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A female urban FGD participant agreed with her rural counterpart's perception of clients' 
satisfaction as an indicator for measuring quality of care: 
.. We, as the patients, are customers to the health facility so we should leave 
being satisfied So, patients' satisfaction is a good measure of quality" 
(Woman, FGD. Urban). 
4.5 Chapter summary 
This chapter presented findings from the qualitative arm of this study. Findings were 
presented in line with objectives one and two of the study. In addition to discussing what 
maternal healthcare quality meant to them, both women and healthcare providers shared 
their views on how the quality of care should be assessed. Key indicators that participants 
said needed to be considered when assessing quality of maternal healthcare have been 
presented in the findings. In total, 13 domains were identified. Each domain had specific 
sets of indicators that participants said should be used to assess quality of maternal care 
quality. These domains will be described and validated in the next chapter. 
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CHAPTER FIVE 
RESULTS: MATERNAL CARE QUALITY ASSESSMENT TOOL 
5.1 Introduction 
This chapter presents the results on the development and experts' validation of the quality 
of care assessment tool, the suitability of individual items of the tool and their suggested 
modifications. The first part of the chapter describes the experts' basic characteristics, 
while the second part focuses on the tool development and validation. 
5.2 Selected characteristics of tbe experts 
Table 8 presents selected background information about the experts who were surveyed to 
assess the content suitability and validity of the proposed tool for measuring quality of 
maternal care. A total of 55 experts were recruited, with most of them being females 
(54.5%,30/55). The median age of the experts was 35.5years (lQR: 32 - 45). About seven 
in every ten (71.7%, 32/55) selected experts worked at hospitals. Nurses/midwives were 
the majority (69.1%, 38/55). Half of the experts had a maximum working experience of 
six years while the remaining half had over six years of experience (median: 6 years). 
Most of the experts worked in urban communities (87.3%, 48/55). 
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Table 8: Experts background characteristics 
Frequency (n-55) Percentage Characteristic 
Age in years 
Median (LQ, UQ) 35.5 (32,45) 
7 12.73 < 30 
30 54.55 31-40 
32.73 
41+ 18 
Sex 
Male 25 45.5 
Female 30 54.6 
Place of work 
Hospitals 38 69.1 
Ghana Health Service 8 14.5 
Universities 4 7.3 
Ministry of Health 5 9.1 
Profession 
Public health officerl Administrator 6 10.9 
Lecturer 4 7.3 
Gynaecologists/doctor 12 21.8 
Nurse! midwife 33 60.00 
Working years 
Median, (LQ, UQ) 6 (3, 14) 
1-3years 3 5.5 
4-6years 10 18.2 
7-9years 25 45.5 
>9years 17 30.9 
Work setting 
Urban 48 87.3 
Rural 7 12.7 
LQ= Lower quartile, UQ= Upper quartile 
5.3 Domains of assessment 
Based on the qualitative results presented in Chapter Four, a maternal quality assessment 
tool was developed. The tool was proposed to comprise 57 indicators/items across 13 
different domains of quality with varying measurable numbers of items. These 13 domains 
and specific quality of care indicators are presented below. 
5.3.1 Health facility domain 
Five items/indicators were proposed to be used to assess the health facility aspect of 
quality of maternal care (see Table 9). The question on availability of health facility was 
regarded to be essential by 94.5% (52/55) of the experts as they either agreed or strongly 
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agreed on its relevance. It also had a content validity index (CVl) score of 0.89. The 
Proximity of health facility to clients question also had a CVI score of 0.89 as 94.5% 
(52/55) of the experts responded that they agreed or strongly disagreed to it. Availability 
of adequate seats was the least-rated item as an indicator for measun.n g quaf 1t y 0 f health 
facility as it scored a CVI of 0.67, with only 83% of the experts strongly agreeing or 
agreeing to its relevance. 
Table 9: Indicators for assessing bealtb facility domain 
SD D U A SA CVI 
Indicator/item n(%) n(%) n(%) n (%) n (%) 
Availability of health 
2 (3.64) 0(0) I (1.82) 
facility 9 (16.36) 43 (78.18) 0.89 
Proximity of health facility 
to clients 1 (1.82) 0(0) 2 (3.64) 16 (29.09) 36 (65.45) 0.89 
Health facility being 
spacious to accommodate 0(0) 5 (9.09) 2 (3.64) 21 (38.18) 27 (49.09) 0.75 
all clients 
Availability of adequate 
seats 2 (3.7) 6 (11.11) 1 (1.85) 24 (42.59) 22 (40.74) 0.67 
Availability of adequate 
beds 1(1.85) 3 (5.56) 3 (5.56) 15 (25.93) 33 (61.11) 0.74 
CVI: Content validity index, n: frequency, %: percentage, SO= Strongly disagree, O=Oisagree, U= 
Undecided, A = Agree, SA = Strongly disagree 
5.3.2 Amenities in bealtb facility domain 
The amenities aspect of quality of maternal was proposed to be assessed using four 
questions (see Table 10): Urinal is clean and neat and toilet is clean and neat were both 
regarded to be essential by 85.2% (47/55) of the experts as they agreed or strongly agreed 
to their relevance. They both had a CVI score of 0.70. Availability of adequate number of 
toilets for clients and availability of adequate number of urinals for clients were, however, 
rated below 0.6 and, hence, needed some modification to improve their suitability. 
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Table 10: Indicators for assessing amenities in bealtb facility domain 
SD D U A SA CVI 
Indicator/item n(%) n (%) n(%) n(%) 0(%) 
Availability of adequate number of 3 (5.45) 7 (12.73) 2 (3.64) 22 (40.74) 21 (38.89) 0.59 
urinals for clients 
Availability of adequate number of 3 (5.45) 7 (12.73) 2 (3.64) 19 (34.55) 24 (43.64) 0.56 
toilets for clients 
Toilet is clean and neat 1(1.85) 4(7.41) 3(5.56) 19(33.33) 28(51.85) 0.70 
Urinaliscleaandneat 1(1.85) 4(7.41) 3(5.56) 19(33.33) 28(51.85) 0.70 
CVI=Content Validity Index, n- frequency, %: percentage. SD Strongly disagree, D Disagree, 
U= Undecided, A = Agree. SA = Strongly agree 
5.3.3 Healtb Facility Environment domain 
The 'environment of the health facility is clean' and the 'environment is airy and fresh' 
were the only two questions proposed to be used to assess the quality of environment of a 
health facility. Both questions were rated as 'strongly agree' or 'agree' by 89.1% (49/55) 
and 87.3% (48/55) of the experts respectively with CVI scores of 0.78 each (see Table \1). 
Table 11: Indicators for assessing bealtb facili!): environment domain 
SD D U A SA CVI 
Indicator/item n(%) n(%) n (%) 0(%) 0(%) 
The environment of the 
I (1.82) 1 (1.82) 4 (7.27) 
is 17(30.91) 32 (58.18) 0.78 health facility clean 
The environment is airy 
I (1.85) 2 (3.7) 4 (7.41) 
and fresh 19 (34.55) 29 (52.73) 0.78 
CVI=Content validity index, n= frequency, %=percentage, SD= Strongly disagree, D=Disagree, 
U= Undecided, A = Agree, SA = Strongly agree 
5.3.4 Privacy in bealtb facility domain 
Three items/indicators were proposed to be used to assess privacy in health facilities as 
indicators of quality of care. These items/questions are shown in Table 12. Privacy in the 
consulting room, privacy in the examination room of the facility and healthcare providers 
respect the privacy of patients were generally regarded as appropriate as they had CVI of 
0.82 or more. 
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Table 12: Indicators for assessing privacy in health facilities 
SD D U A SA CVI 
Indicator/item n(%) n(%) n (%) n (%) 0(%) 
There is privacy in the consulting 3 (5.45) 2 (3.64) 0 (0) II (20) 39 (70.91) 0.82 
room 
There is privacy in the examination 1(1.82) 1 (1.82) I (1.82) 13 (23.64) 39 (70.91) 0.89 
room of the facility 
Healthcare providers respect the I (1.82) I (1.82) 2 (3.64) 14 (25.45) 37 (67.27) 0.85 
privacy of patients 
CVI=Content Validity Index, n=frequency, % percentage, SD Strongly disagree, D Disagree, 
U= Undecided, A = Agree, SA = Strongly agree 
5.3.5 Inter-personal relationship domain 
Regarding quality of inter-personal relationship, seven items/questions were proposed. 
Experts regarded all items as essential to measuring quality of inter-personal relationship 
as all the questions had a CVI of 0.75 (see Table 13). 
Table 13: Indicators for assessing quality of inter-personal relationship 
Indicator/item SD D U A SA CVI 
n(%) n (%) D (%) D (%) n (%) 
Healthcare worker explain 
procedure well to clients 1(\.82) 3 (5.45) 2 (3.64) 8 (14.55) 41 (74.55) 0.78 
Healthcare providers treats clients I (1.82) 3 (5.45) 0 (0) 
with respect 8 (14.55) 43 (78.18) 0.85 
Healthcare providers request 
consent before clinical procedure 2 (3.64) 2 (3.64) 0(0) 17 (30.91) 34 (61.S2) 0.85 
Healthcare providers answer 
clients' questions satisfactorily I (1.82) 2 (3.64) 0(0) 20 (36.36) 32 (58.IS) 0.89 
Healthcare providers involve 
clients or partner in decision- 1(\.82) 3 (5.45) 3 (5.45) 19 (34.55) 29 (52.73) 0.75 
making 
Healthcare providers are polite to 
clients 1(\.82) 4(7.27) 0(0) 16(29.09) 34(6I.S2) 0.82 
CVI= Content validity index, n= frequency, %-percentage, SD= Strongly disagree, D=Disagree, 
U= Undecided, A = Agree, SA = Strongly agree 
5.3.6 Human resource domain 
Quality of human resource questions were rated generally as appropriate (CVI ~ 0.60) (see 
Table 14). However, the question on availability of health assistants to attend to clients 
was not rated good enough as it had a CVI of < 0.6 and, hence, was later modified in line 
with suggestions by the experts. 
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Table 14: Indicators for assessing guali~ or human resources in health racm~ -- --U------T --
Indicatorlltem SD D SA CVI 
n (%) n(%) n (%) n(%) n(%) 
Midwives on duty are adequate and attend to different clients at the same time 2(3.64) 6(10.91) 2(3.64) 9(16.36) 36(65.45) 0.64 
Adequate doctors are on duty 2(3.64) 5(9.09) 1(1.82) 15(27.27) 32(58.18) 0.71 
Availability of health assistants to attend to clients 1(1.82) 6(10.91) 5(9.09) 19(34.55) 24(43.64) 0.56 
Availability of medical records staff to facilitate fast retrieval of medical records 1(1.82) 3(5.45) 2(3.64) 20(36.36) 29(52.73) 0.78 
Healthcare provided to clients in a timely manner 1(1.82) 3(5.45) I( 1.82) 12(21.82) 38(69.09) 0.82 
Ability of service providers to provide all services needed 3(5.45) 6(10.91) 2(3.64) 18(32.73) 26(47.27) 0.60 
CVI=Content validity index, n=frequency, o/o=percentage, SD= Strongly disagree, O=Disagree, U= Undecided, A = Agree, SA = Strongly agree 
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5.3.7 Safety in health facility domain 
Only two items were proposed to be used to assess the safety aspect of maternal care in 
health facilities (see Table 15). Both questions were regarded as relevant as they had CVI 
of at least 0.75. Details of items on the safety of health facility assessment are shown in 
Table 16. 
Table 15: Indicators for assessing safety in health facilities 
SD D U A SA CVI 
Indicator/ltem 
n(%) n(%) n(%) n(%) n(%) 
Adequate measures are put in place 0(0) 2(3.64) 5(9.09) 11(20) 37(67.27) 0.75 
to ensure patients safety 
The environment of the health 
0(0) 1(1.82) 2(3.64) 18(32.73) 34(61.82) 
facility is safe 0.89 
CVI=Content validity index=, n- frequency, %-percentage, SD- Strongly disagree, D-Disagree, 
U= Undecided. A = Agree, SA = Strongly agree 
5.3.8 Range of Services domain 
In terms of the range of services domain, three items/questions were used, namely 
availability of all services clients need, availability of specialists to provide required 
services in the health facility and all service delivery points located within the health 
facility. Apart from the question on availability of all services clients need, the other two 
questions were regarded as appropriate by the experts as they had CVI scores of over 0.60 
(Table 17). 
Table 16: Indicators to assess range of services in health facilities 
Iodicator/item SD D U A SA CVI 
n(%) n (%) n (%) n(%) n (%) 
Availability of alI services clients need 1(1.82) 8(14.55) 5(9.09) 11(20) 30(54.55) 0.49 
Availability of specialists to provide 
needed services at the health facility 1(1.82) 3(5.45) 3(5.45) 17(30.91) 31(56.36) 0.75 
All service delivery points located 
within the health facility 0(0) 5(9.09) 5(9.09) 18(32.73) 27(49.09) 0.64 
CVI=Content validity index, n frequency, % percentage, SD= Strongly disagree, D-Disagree. 
U= Undecided, A = Agree, SA = Strongly agree 
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5.3.9 Health insurance domain 
A total of three (3) indicators/items were used to assess the quality of health insurance 
domain in health facilities. All the items were rated generally as appropriate (CVI ~ 0.60) 
except one, namely insurance covers all services provided to clients. Details are provided 
Table 18. 
Table 17: Indicators for assessing health insurance domain 
SD D U A SA CVI 
Indicator/item 
n (%) n (%) n(%) n(%) n (%) 
Facility accepts national health insurance 2(3.64) 2(3.64) 3(5.45) 14(25.45) 34(61.82) 0.75 
Non-discrimination between insured and 
non-insured clients 1(1.82) 1(1.82) 2(3.64) 16(29.09) 35(63.64) 0.85 
Insurance covers all services provided to 1(1.82) 
clients 6(10.91) 6(10.91) 17(30.91) 25(45.45) 0.53 
CVI=Contcnt validity index, n-frequency, %=percentage, SD= Strongly disagree, D Disagree, 
U= Undecided, A = Agree, SA = Strongly agree 
5.3.10 Logistics and supplies domain 
Questions on the quality of logistics and supplies proposed were five in all and were rated 
generally appropriate (CVI ~ 0.60) with the exception of the question on informing patient 
on nature of pain which had a CVI score of < 0.60. Details of items on quality of logistics 
and supplies assessment are shown in Table 19. 
Table 18: Indicators for assessing logistics and supplies in health facilities 
Indicator/item SO 0 U A SA CVI 
n (%) n (%) n (%) n (%) n (%) 
Availability of prescribed medications 
at the health facility 2(3.64) 2(3.64) 1(1.82) 15(27.27) 35(63.64) 0.82 
Availability of diagnostic test 
(laboratory, ultrasound) atthe health 2(3.64) 1(1.82) 2(3.64) 12(21.82) 38(69.09) 0.82 
facility 
Measures taken to relieve pain to 
patients during labour I( 1.82) 4(7.27) 1(1.82) 15(27.27) 34(61.82) 0.78 
Measures to reduce pain during labour 
are effective 1(1.82) 3(5.45) 3(5.45) 17(30.91) 31(56.36) 0.75 
Informing clients of nature of pain 2(3.64) 3(5.45) 7(12.73) 14(25.45) 29(52.73) 0.56 
CVI=Cont~nt validity index, n=frequency, %=percentage, SD= Strongly disagree, D=Disagree, 
U= Undecided. A = Agree, SA = Strongly disagree 
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5.3.11 Pain management domain 
Three items were proposed to be used to assess quality of pain management (see Table 
20). Only one of the three questions had a CVI less than 0.60 and was subsequently 
modified in line with suggestions provided by the experts. 
Table 19: Indicators for assessing quality of pain management in health facilities 
SD D U A SA CVl 
Indicator/item n (%) n (%) n (%) n (%) n (%) 
Measures taken to relieve pain during 
1(1.82) 4(7.27) 1(1.82) 15(27.27) 34(61.82) 0.78 
labour 
Measures to reduce pain during labour 
1(1.82) 3(5.45) 3(5.45) 
are effective 17(30.91) 31(56.36) 0.75 
Clients informed of nature of pain 2(3.64) 3(5.45) 7(12.73) 14(25.45) 29(52.73) 0.56 
CVI=Content validity index. n=frequency, %=percentage, SD= Strongly disagree, D-Disagree, 
U= Undecided, A = Agree, SA = Strongly agree. 
5.3.12 Clients' satisfaction domain 
The quality of care as regards clients' satisfaction domain was proposed to be assessed 
using seven questions. Generally, the experts rated all the items as appropriate (CVI ~ 
0.60) (see Table 21). 
Table 20: Indicators for assessing clients' satisfaction with care received 
SD D U A SA CVI 
Indicator/item n(%) n(%) n(%) n (%) n(%) 
Client satisfied with treatment 
outcome for self 1(1.82) 3(5.45) 1(1.82) 19(34.55) 31(56.36) 0.82 
Client satisfied with treatment 
outcome for baby 1(1.82) 1(1.82) 4(7.27) 17(30.91) 32(58.18) 0.78 
General satisfaction with treatment 
received at health facility 2(3.64) 1(1.82) 2(3.64) 21(38.18) 29(52.73) 0.82 
Satisfaction with healthcare 
providers' attitude 1(1.82) 8(14.55) 2(3.64) 13(23.64) 31(56.36) 0.60 
Satisfaction with education received 
on condition 3(5.45) 5(9.09) 0(0) 20(36.36) 27(49.09) 0.71 
Satisfaction with inter-personal 
communication (between health 2(3.64) 5(9.09) 2(3.64) 12(21.82) 
care provider and client) 34(61.82) 0.67 
Satisfaction with review 
information received from 1(1.82) 4(7.27) 1(1.82) 
healthcare providers 21(38.18) 28(50.91) 0.78 
CVI=Content validity index, n=frequency, o/o=percentage, SD= Strong! d' D=O' 
U= Undecided, A = Agree, SA = Strongly agree. Y lsagree, lsagree, 
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5.3.13 Overall outcome 
The two questions were proposed to be used to assess the overall outcome were rated 
generally as appropriate (CVI ~ 0.80) according to the experts (see Table 22). 
Table 21: Indicators for assessing overall outcome of care 
SA CVI 
n (%) n (%) n (%) n (%) n (%) 
No injury to mother 1(1.82) 1(1.82) 0(0) 18(32.73) 35(63.64) 0.93 
Live birth achieved 2(3.64) 0(0) 0(0) 18(32.73) 35(63.64) 0.93 
CVI=Content validity index, n=frequency, %=percentage, SD- Strongly disagree, D Disagree, 
U= Undecided, A = Agree, SA = Strongly agree. 
5.4 Additional items suggested by experts and final tool 
During the evaluation and validation of the proposed tool for assessing quality of care, the 
55 experts were requested to suggest for inclusion new domains and items as well as 
modification of existing items. Table 23 shows a summary of experts' suggestions. The 
three dominant suggestions were to incorporate questions on periodic training and 
workshops for staff. motivation of staff and adequate supply of water, electricity and other 
utility services. Using these recommendations in combinations with the domains and items 
described above, a quality of maternal care assessment tool was developed. The revised 
tool comprised 57 items across the 13 domains. This tool was then pre-tested on a sample 
of 50 women (not included in the actual study) and the tool was further assessed for 
validity. Results from the further assessment based on the pre-test are discussed below. 
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Table 22: Suggestions from experts 
Tbemes Frequency Proportion 
Staff to clients ratio and other ratios 5 8.8 
Discrimination against clients 3 2.7 
Housekeeping services at filcility 3 2.8 
Periodic training and workshop for staff 13 12.6 
Waiting time by clients 4 4.4 
Motivation of staff 7 8.1 
Adequate supply of water, electricity and other utility services 9 11.4 
Appropriate referral system 3 4.3 
Catering services at the health facility I 1.5 
Education of clients on maternal care 6 9.1 
Availability of specialists (Gynaecologists, etc.) I 1.7 
Attendance to clients 2 3.4 
5.5 Item reduction and validity analysis 
Item reduction and validity analysis was perfonned using the results from the pretest to 
ensure that only parsimonious, useful and internally consistent items were finally included 
in the tool. An item was considered functional if it correlated with other items, 
discriminated between individual cases, underscored a single or multi-dimensional domain 
and contributed significantly to the construct. Results from the pretest based on the 57 
items show that the correlation coefficient between items ranged from 0.31 to 0.93, 
indicating that the items were functional in tenns of communing together to measure 
quality of maternal healthcare. The discrimination ability of the items was measured with 
the item discrimination indices. The results are shown in Table 23. Generally, the item 
discrimination indices ranged from -0.21 to 2.30. Items which were identified not to be 
effective were those with discrimination indices whose p-values were greater than 0.05. 
As can be seen in Table 23, items 1-10 had p-values greater than 0.05. Consequently, these 
items were discarded. The final tool comprised 47 items distributed across the 13 domains 
(Table 24). 
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Table lJ: Item discrimination indices of construct items 
Discrimination 95%CI P-value 
IItmll.dicator Index 
-0.414.0.0001 0.05 
I. Healtll fadlity uses computerized systems for retrinal of records -0.2070 -0.4455.0.0391 0.1 
1. I.fol'llli., clients of nature of pain -0.2032 -0.4587. 0.093 I 0.194 
3. I.suraote conring IU sen'ices pro\'ided to dients -0.1828 -0.1998,0.1461 0.761 
4. Health facility uses manual retrieval of records -0.0268 
S. -0.2741.0.2452 
0.9lJ 
,\vlillbllity of toilet facilities separated for males and females -0.0145 
-0.259. 0.2474 0.964 
6, You get .11 )our medication "ilhin the health facility -0.0058 0.274 
7. All service delive!') points are locI ted within the health fadli!) 0.1294 -0.1023. 0.36 \l 
-O.U69,O.396 0.286 
8. ".ailability of diagnostic I~ts O.lJ96 -0.0423,0.343 0.126 
,. food provided by the facility ill good 0.1503 0.215 
10. AVllllbility of prescribed medications at the heallh facility 0.1734 -0.1007.0.4475 
II. Non-discrimmation between inSured and non-Insured clients 0,2371 0.0359,0.4383 0,021 
12 Women who are richer thlll! you are trelled much faster and bener at the health 
0.3614 0.1104.0,6124 0.005 fIClllt' 
13 You have home "isitation after the delivery at the health facility 0.3622 0,1252, 0.5993 0.003 
14, You feel discrimmated against at any POInIIn time In the health facihty because 
)OU do nol come from a rich background 0.4188 0.1727, 0,6648 0,001 
(5, You have to wal~ a long dlslance in order 10 gel the medicines that are available 0.4353 0.1714.0.6992 0.001 
16 Pro~imlty of health facility to chents 0.4475 0,2599,0,6351 <0.01 
17 Availability of adequate urinals for chents 0.4800 0,2055,0,7545 0,001 
18 Health filcility has an effectIVe referral system in place 0,4828 0.2546. 0,711 <0.01 
19. Health facility being spacious 10 accommodale all clients 0.5092 0,2524, 0,766 <0,001 
20 Tollells clean and neat 0.5587 0.3208. 0.7965 <0,001 
21 AVlJlabllit)' of needed sel"'lce, 10 chenls 0.5735 0.2849, 0.8621 <0.001 
22 You pay for the medications Ihat you get 8tthe health facllily 0,5980 0,3202, 0.8758 <0,001 
2l Availability of cxpens for sel"lces In the health facililY 0.6000 0,3241.0.8758 <0,001 
24 Urinal is clean and neat 0,6331 0.3815.0.8847 <0,001 
25 You buy your medication outSide the health facllily 0,6702 0.3943, 0,9461 <0,001 
26 Healthcare proVided to you in a timely manner 0,6889 0.4835,0,8943 <0,001 
27 Ability of se"'lce providers 10 prm ide needed services 0,7019 0.4295.0,9743 <0,001 
28 Facihty accepl<; national health msurancc 0,7288 0,5006,0,957 <0,001 
29, MidWIVes on duty arc adequate and attend to dilTerent chents at the same time 0.7558 0.5128,0,9987 <0,001 
30 Healthcarc prOVider involves you or partner in deCision-making 0,7851 0.5243, 1.046 <0.001 
31 Healthcare ... orkers prOVide adequale mformation and education on my 
pregnancy 0.7867 0.5026, 1,0707 <0,001 
32. AVlJlabilily of adequale seats 0,8323 05998, 1.0648 <0001 
3l Live binh achieved 0.8631 05946,1.1316 <0,001 
34. Availabillly of medical records staff to facilitate fast retrieval of medical records 0.9058 0,6474, 11641 <0,001 
3', Many doctors are on duly 0.9351 06778, 11923 <0,001 
36 Tbere is privacy in the exammation room of the facility 0,9465 0,6489, 1.2442 <0.001 
37. AvatlallJlity ofpcople or health asSistants to assisl clients 0,9923 o 7422, 1.2425 <0,001 
38 Healthcare.provider answers YOID" questions salisfactorily 1.0095 0,7086. 1.3104 <0,001 
39. There is pnvaq In the consulting room 1.0316 0,7544, U089 <0,001 
40, The environment is airy and fresh 1.0796 0,7745, 1.3847 <0.001 
41 No injury to mother 1.1069 0,8159,1.3979 <0,001 
42, HeIIthcare prOVider requests consenl hefore clinical procedure 1.1421 0.8538, 1.4304 <0001 
41 SIltSfactlon about review of information received from healthcare providers 1.2336 0,9169, 1.5503 <0,001 
44, The enVlJOnment of health facilil) is clean 1.2774 0,9893, 15655 <0.001 
45. Healthcare providers respect clients' privacy 1.3114 1.0024. 1.6204 <().OOI 
46, Sallsfactlon about education received on condition 13315 0,9389. I. 7242 <0,001 
47, Health pro"ders are polite to clients 1.3728 I ,0476, I 698 <0,001 
48. Chem's satisfied wilh treatment outcome for bab) 1.3819 0,9574, 1.8064 <0,001 
49, HeaIthcare worker explains procedure 10 you 14181 11072.1.7289 <0,001 
SO. I feel the environmenl at the health facility is safe 1.6290 1.2668, 1.9912 <0.001 
51, Measures pUi in place to reduce pain during labour are effective 
S:, 1.7552 1,2375,2,2729 <0,001 Measures pUi in ,place to ensUR clients' safety are adequate 1.7730 
So. HeIIthcare proVider with respect 1.3899,2.1561 IRaled you <0.001 18007 1.4108,2.1905 
54. alent 15 satisfied with Irellmenl oUicome for self <0,001 1.8451 
~. 1,2945, 2.3957 GcneraI Sllisfaction with lrea1ment received at health facility <0,001 2.0277 1.5393, BI61 
:faction WIth mter-personaJ communication between bealthcare prOVider and <0001 
22207 
51 s.tisfltaion with healtbcare providers' attitude I. 7587. 26828 <0.001 2.3017 
.... WillI JHliue<O,05 were retained 1.8627. 2,7408 <0,001 
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Table 24: Final tool for assessing quality of maternal care 
SD D N A SA 
Domains and items 
Health Facility Domain 
I. Proximity of health facility to clients (less than Sian) 
2. Health facility is spacious to accommodate all clients 
3. Health facility has seats 
Amenities Domain 
4. Health facility has adequate urinals for clients 
5. Toilet is clean and neat 
6. Urinal is clean and neat 
Environment Domain 
7. The environment in health facility is clean 
8. The environment is airy and fresh 
Privacy Domain 
9. There is privacy in the consulting room 
10. There is privacy in the examination room 
II. Healthcare providers respect clients' privacy 
Inter-personal relationship domain 
12. Healthcare worker provided adequate infonnation and education on 
your pregnancy 
13. Healthcare worker explained procedures to you 
14. Healthcare provider treated you with respect 
15. Healthcare provider requested your consent before clinical 
procedures 
16. Health provider answered your questions satisfactorily 
17. Health provider involved you or partner in your care decision-
making 
18. You have home visitation after the delivery at the health facility 
19. You felt discriminated against at any point in time in the health 
facility because you do not come from a rich background 
20. Women who are richer are treated much faster and better in the 
health facility than poor women 
21. Healthcare providers are polite to clients 
SD= Strongly disagree, D=Disagree, N= Neutral, A = Agree, SA = Strongly agree 
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Table 24 cont. 
SD DNA SA 
Domains and items 
Human resource domain 
22. Midwives on duty were adequate and attending to different clients at 
the same time 
23. Doctors on duty were enough 
24. Healthcare providers are readily available to assist clients 
25. Medical records staffare readily available to facilitate fast retrieval of 
medical records 
26. Healthcare provided to you in a timely manner without delay (within I 
hour) 
27. Service providers can provide needed services to you 
Sarety domain 
28. Adequate measures put in place to ensure patients' safety 
29. I feel the environment in the health facility is safe (e.g. free from 
dangerous animals and hazards) 
Range of services domain 
30. Health facility has all services I needed 
31. Health facility has adequate specialists/experts to provide services I 
need in the health facility 
32. Health facility has an effective referral system in place 
Health insurance domain 
33. Health facility accepts health insurance 
34. There is non-discrimination between insured and non-insured clients at 
health facility 
SD= Strongly disagree, D=Disagree. N= Neutral, A =A gree, SA = Strongly agree 
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Table 24 cont. 
SD DNA SA 
Domains and items 
Logistics and supplies domain . . 
35. You pay for the medications that you get at the health facilIty 
36. You buy your medication outside the health facility . . 
37. You have to walk for long distance in order to get the medlcmes 
that are available at the health facility 
Pain management domain 
38. Measures to reduce pain during labour are effective 
Clients' satisCaction domain 
39. You are satisfied about treatment outcome for yourself 
40. You are satisfied with treatment outcome for your baby 
41. You are generally satisfied with treatment received at health 
facility 
42. You are satisfied with healthcare providers' attitude 
43. You are satisfied with education received on condition 
44. You are satisfaction with inter-personal communication between 
healthcare provider and clients 
45. You are satisfied with review information received from 
healthcare providers 
Outcomes domain 
46. No injury to mother 
47. Live birth achieved 
SD= Strongly disagree. D=Disagree, N= Neutral, A = Agree, SA - Strongly agree 
5.6 Cbapter summary 
This chapter presented results from the development and validation of the tool for 
assessing quality of maternal care. Generally, the items of the construct were rated to be 
above a content validity index (CVI) of 0.6, where 0.6 was the bar below which items 
would be rated as irrelevant/inappropriate. In the fmal analysis, however, only 47 items 
had acceptable item discrimination indices and were therefore included in the final tool. In 
the next chapter, results from women's assessment of the quality of maternal care they 
received during their most recent pregnancy and childbirth are presented. 
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CHAPTER SIX 
RESULTS: QUALITY OF MATERNAL CARE IN NORTHERN REGION 
6.1 Introduction 
This chapter presents results from the main survey on women's assessment of the quality 
of care they received during their most recent pregnancy in four selected districts in 
Northern Region of Ghana. The first part presents data on women's background 
characteristics while the second presents women's rating of the quality of care they 
received. The chapter ends with a summary. 
6.2 Respondents' socio-demograpbic characteristics 
A total of 520 women were planned for the quantitative survey component of this study. 
Questionnaires were successfully completed for all of them, giving a response rate of 
100%. Table 25 shows the respondents' background characteristics. The respondents' 
average age was 28.86 (SD = ± 5.93). The majority (45.38 %, 2361520) of the respondents 
had no formal education. Less than a hundredth (0.96%, 51520) of them were either 
separated, divorced or widowed while about 97% (502) were currently married. The 
majority (88.85%, 462/520) of the respondents were affiliated to the Islamic religion. 
Husbands were the main decision-makers on maternal health issues (59.23%, 308/520). 
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Table 25: Respondents' socio-demograpbie characteristics 
Characteristic Frequeocy Perceotage 
Age (yean); Mean:!: SD 28.86:!: 5.93 
15 - 25 161 30.96 
26-36 297 57.12 
37 -49 62 11.92 
Study Areas 
Tamale Metro 130 25.00 
Sagnarigu 130 25.00 
Kumbungu 130 25.00 
Savelugu 130 25.00 
Educatiooallevel 
None 236 45.38 
Primary 156 30.01 
Secondary 57 10.96 
Tertiary 71 13.65 
Marital status 
Single 13 2.50 
Married! Cohabiting 502 96.54 
Widowed! Separated! Divorced 5 0.97 
Religion 
Traditional I 0.19 
Christianity 57 10.96 
Islam 462 88.85 
Tribe 
Dagomba 458 88.08 
Mamprusi 20 3.85 
Bimoba 28 5.38 
Kusaasi 14 2.69 
Type of Residence 
Urban 264 50.80 
Rural 256 49.20 
Occupation 
Farmer 66 12.69 
Trader 164 
Housewife 31.54 171 
Civil servant 32.88 47 
Student 9.05 18 
Artisan 3.46 54 10.38 
Decisioo-maker on materoal health issues 
Self 
175 
Mothers in-Iaw/ co-wives 33.65 
Husband 37 7.12 
308 
Distance to nearest health facility 59.23 
<30 mins walk 
178 
30 mins - I-hour walk 34.23 183 
1.1- 2 hours walk 35.19 
>2 hours walk 1I2 21.54 
47 
MeaDs of traosportatioo 9.04 
Walking 
238 
BicyclelMotor cycleffricycle 45.77 
Car 205 39.42 
77 14.81 
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6.3 Respondents' maternal characteristics 
Table 26 shows the respondents' maternal characten.s t 'I CS. On the average , each of the 
respond e nts had conc.e ivd e2.  7 times (SD=± I .4 9) and had delivered averagely 2.3 times 
(SD=± 1.42). The average number of ANC visits by each respondent was 3.71 (SD=± 
1.68). 
Table 26: Respondents' maternal characteristics 
Cbaracteristic Frequency Percentage 
Number of times pregnant 
Mean± SO 2.7 ± 1.49 
1-2 260 50.00 
3-4 198 38.08 
5+ 62 11.92 
Number of deliveries 
Mean± SO 2.3 ± 1.42 
o 26 5.00 
\-2 306 58.85 
3-4 147 28.27 
5+ 41 7.88 
Number of ANC Visits 
Mean± SO 3.71 ± 1.68 
None 27 5.19 
I 26 5.00 
2 56 10.77 
140 26.92 
4+ 271 52.12 
Mode of Delivery 
Caesarean Section 47 9.04 
Spontaneous Vaginal Delivery 473 90.96 
6.4 Women's rating of the quality of mate mal care domains 
A key objective of this study was to assess the quality of maternal care women received 
during their most recent pregnancy. Tables 27a, 27b, and 27c show women's assessment 
of the quality of maternal care they received during their most recent pregnancy based on 
the 13 domains used in the assessment. Under the health facility domain, the mean score 
on the five-point scale for proximity of health facility to clients was approximately 3.3, 
with 72 (14.42%) of the respondents strongly disagreeing, 105 (20.19%) disagreeing and 
52 (l 0.0%) remaining neutral. One hundred and sixty-three respondents (31.35%) agreed 
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and 125 (24.04%) of them strongly agreed. Under amenities domain. the mean score on 
the five-point scale for urinal is clean and neat was 3.21. with 54 (10.38%) of the 
respondents strongly disagreeing. 117 (22.5%) of them disagreeing. 61 (11.73%) 
respondents being neutral, 241 (46.35%) respondents agreeing and 47 (9.04%) of them 
strongly agreeing. 
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Table 27a: Women's assessment of quality of maternal care they received during their most recent--...::p.:..rc:::Jgc.:":::a::.:D:;::c:.,YL.-_____________  
m DNA ~ 
QaaUty of care domaias aDd iDdicaton Mean ± SD n (%) n (%) n (%) n (%) n (0/.) 
Health fac:iUty domain 
1. Proximity of health facility to clients (less than 5km) 3.3 ± 1.4 75(14.42) 105(20.19) 52(10) 163(31.35) 125(24.0{0000 
2. Health facility is spacious to accommodate all clients 3.53 ± 1.07 19(3.65) III (21.35) 31 (5.96) 292(56.15) 67(12.88) JJJJ 
3. Health facility has seats 2.89± 1.24 53(10.19) 218(41.92) 36(6.92) 160(30.77) 53(10.19) 'P'P'P'P 
Amenities domain 
4. Health facility has adequate urinals for clients 3.53 ± 1.09 34(6.54) 81( 15.58) 43(8.27) 300(57.69) 62( 11.92) -p.-p.-p.-p. 
5. Toilet is clean and neat 2.91 ± 1.16 70(\3.46) 126(24.23) 143(27.5) 144(27.69) 37(7.12) IIII 
6. Urinal is clean and neat 3.21 ± 1.19 54(10.38) 117(22.5) 61(11.73) 241(46.35) 47(9.04) ))) I 
Environment domain 
7. The environment of health facility is clean 4.05 ± 0.68 4(0.77) 15(2.88) 37(7.12) 358(68.85) 106(20.38'8888 
8. The environment is airy and fresh 4.08 ± 0.72 5(0.96) 12(2.31) 51(9.81) 321(61.73) 131(25.19.~1 ~I ~I ~I 
Privacy domain 
9. There is privacy in the consulting room 4.01 ±0.96 10(1.92) 48(9.23) 32(6.15) 268(51.54) 162(31.15} .--
10. There is privacy in the examination room 4.14±0.89 6(\.1 S) 42(8.08) 13(2.5) 272(52.31) 187(35.96) 
11. Healthcare providers respect clients' privacy 4.07 ± 0.82 6(\.1S) 31(S.96) 30(5.77) 305(58.65) 148(28.46) 
Interpersonal relationship domain 
12. Healthcare workers provide adequate information and education on my 4.13 ± 0.81 9( 1.73) 21(4.04) 24(4.62) 303(58.27) 163(31.35) 
pregnancy 
13. Healthcare worker explained procedures to you 3.89± 0.82 7(1.35) 39(7.5) 49(9.42) 335(64.42) 90(17.31 ) 
14. Healthcare provider treated you with respect 3.93 ± 0.77 4(0.77) 26(5) 72(13.85) 321(61.73) 97(18.65) 
15. Healthcare provider requested your consent before clinical procedures 3.81 ± 0.89 6(1.15) 60(11.54) 50(9.62) 315(60.58) 89(17.12) 
16. HeaJtbcare provider answered your questions satisfactorily 3.99± 0.77 6(1.15) 26(5) 41(7.88) 341(65.58) 106(20.38) 
17. Healthcare provider involved you or partner in your care decision-making 3.49 ± 1.00 21(4.04) 88(16.92) 70(13.46) 296(56.92) 45(8.65) 
18. You have home visitation after the delivery at the health facility 1.99 ± 1.30 282(5423) 98(18.85) 30(5.77) 85(16.35) 25(4.81) 
19. You felt discriminated against at any point in time at the health facility 2.33 ± 1.25 148(28.46) 2]0(40.38) 44(8.46) 76(14.62) 42(8.08) 
because you do not come from a rich background 
20. Women who are richer are treated much faster and better at the health facility 2.32 ± 1.25 146(28.08) 220(42.31) 43(8.27) 66(12.69) 45(8.65) 
than poor women 
2I.Healthp~viders_~politetoclients 3.8I±0.84 12(2.31) 31(5.96) 75(14.42) 326(62.69) 76(14.62) 
N=frequency, %--percentage, SD= Strongly disagree, D=Disagree, N= Neutral, A = Agree, SA = Strongly agree 
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....b l.27b: Women'. lUl8eAment of quality of maternal care tbey received during their most recent ~regoancy 
SD D N A SA 
Quali!l of care domaios and indicators Mean ±SD n (%) n(%) 0(%) n(%) n(%) 
Human resource domain 
22. Midwives on duty were adequate and attending to different clients at 3.38 ± 1.06 17(3.27) 137(26.35) 45(8.65) 276(53.08) 45(8.65) 
the same time 
23. Doctors on duty were sufficient 2.55 ± 1.28 126(24.23) 178(3423) 60(11.54) 117(22.5) 39(7.5) 
24. People or health assistants are readily available to assist clients 3.63 ±0.93 8(1.54) 79(15.19) 71(13.65) 299(57.5) 63(12.12) 
25. Medical records staff are readily available to facilitate fast retrieval 3.56 ± 0.90 7(1.35) 84(16.15) 84(16.15) 302(58.08) 43(8.21) 
of medical records 
26. Healthcare provided to you in a timely manner (without delay or 2.97 ± 1.13 50(9.62) 167(32.12) 14(14.23) 208(40) 21(4.04) 
within I hour) 
21. Service providers have the ability to provide needed services to you 3.79 ± 0.88 18(3.46) 48(9.23) 17(3.27) 380(73.08) 57(10.96) 
Safety domain 
28. Adequate measures put in place to ensure clients' safety 3.92± 0.73 5(0.96) 25(4.81) 56(10.77) 357(68.65) 77(14.81) 
29. I feel the environment at the health facility is safe (e.g. free from 3.91 ± 0.80 5(0.96) 32(6.15) 61(12.88) 311(60.96) 99(19.04) 
dangerous animals and hazards) 
Range of services domain 
30. Health facility has all services I needed 3.79 ± 0.98 23(4.42) 52(10) 21(4.04) 340(65.38) 84(16.15) 
31. Health facility has adequate specialists/experts to provide services 3.48 ± 1.04 23(4.42) 95(18.27) 66(12.69) 282(54.23) 54(10.38) 
you needed at the health facility 
32. Health facility has an effective referral systems in place 3.10± 0.89 15(2.88) 29(5.58) 121(24.42) 213(52.5) 76(14.62) 
Health insurance services domain 
33. Health facility accepts health insurance 4.71 ± 0.46 1(0.19) 3(0.58) 108(20.77) 408(18.46) 
34. There is non-discrimination between insured and non-insured clients 3.58± 1.26 32(6.15) 103(19.81) 61(11.13) 171(34.04) 141(28.21) 
at health facility 
N=fTequency, %=percentage, SD= Strongly disagree, D=Disagree, N= Neutral, A = Agree, SA = Strongly agree 
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Table 27c: Women's asseasmen. of9uality ofmatcraal care tbey received during their most recent pregnancy 
SD D N A SA 
Mean ±SD n(%) n (%) n(%) n(%) n(%) 
Lociatics and supplies domain 
35. You pay for the medications that you get at the health facility 2.28 ± 1.17 151(29.04) 209(40.19) 47(9.04) 9207.69) 21(4.04) 
36. You buy your medication outside the health facility 2.66 ± 1.22 103(19.81) 171(32.88) 73(14.04) 147(28.27) 26(5) 
37. You have to walk a long distance in order to get the medicines that 2.46 ± 1.48 187(35.96) 151(29.04) 10(1.92) 101(19.42) 71(13.65) 
are available at the health facility 
PaiD management domain 
38. Measures to reduce pain during labour are effective 3.14± 1.18 65(12.5) 108(20.77) 60(11.54) 262(50.38) 25(4.81) 
CUents' satisfaction domain 
39. You are satisfied with treatment outcome for yourself 4.05 * 0.73 6( 1.15) 22(4.23) 23(4.42) 358(68.85) 111(21.35) 
40. You are satisfied with treatment outcome for your baby 4.11 *0.72 5(0.96) 15(2.88) 33(6.35) 330(63.46) 137(26.35) 
41. You are generally satisfied with treatment received at health facility 4.03 ± 0.73 3(0.58) 20(3.85) 52(10) 327(62.88) 118(22.69) 
42. You are satisfied with healthcare providers' attitude 3.63 ± 0.93 7(1.35) 78(15) 80(15.38) 288(55.38) 67(12.88) 
43. You are satisfied with education received on condition 4.03 * 0.69 2(0.38) 24(4.62) 33(6.35) 360(69.23) 101(19.42) 
44. You are satisfied with inter-personal communication (between 3.68* 0.91 6(1.15) 71(\3.65) 77(14.81) 296(56.92) 70(13.46) 
heaJthcare provider and clients) 
45. You are satisfied with review information received from healthcare 3.91 * 0.69 2(0.38) 33(6.35) 39(7.5) 381(73.27) 65(12.5) 
providers 
Outcomes domain 
46. No injury to mother 4.3 * 0.75 4(0.77) 9(1.73) 40(7.69) 241(46.35) 226(43.46) 
47. Live birth achieved 4.43 * 0.68 3(0.58) 3(0.58) 30(5.77) 216(41.54) 268(51.54) 
N-frequency, %=percentage, SD= Strongly disagree, D=Disagree, N= Neutral, A = Agree, SA = Strongly agree 
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Table 28 shows the best-rated and worst-rated indicators under each domain. Under the 
health facility domain, the best-rated indicator was spaciousness of facilities to 
accommodate all clients (3.53) while the worst-rated was availability of seats (2.89). 
Adequacy of urinals (3.35) and cleanest and neatness of toilets (2.91) were respectively the 
best and the worst rated indicators under amenities domain. 
In respect of the environment domain, its airy and fresh characteristics (4.08) was the best-
rated indicator whilst its cleanness was the worst rated. Privacy in the examination room 
(4.14) and the consulting room (4.11) came first and last respectively under the privacy 
domain. 
Women rated adequate information and education on the pregnancy (4.13) as the best 
indicator in the interpersonal relationship domain. The worst-rated indicator under the 
same domain was home visitation after delivery at the facility (1.99). The best-rated 
indicator under the human resource domain was ability on the part of service providers to 
provide needed services to clients (3.79). The worst-rated indicator in the domain was 
sufficiency of doctors on duty (2.55). As regards the safety domain, the best-rated 
indicator was adequacy of measures put in place to ensure clients' safety (3.92). The 
worst-rated indicator was the feeling that the environment of the health facility was safe 
(that is, it was free from dangerous animals and hazards) with a mean score of 3.91. Health 
facilities having all services needed (3.79) was the foremost indicator under range of 
services domain. The least-rated indicator was the inadequacy of specialist and experts to 
provide needed services at the facility (3.48) 
BUying one's medication outside the facility (2.66) was the best-rated indicator under the 
domain of logistics and supplies (2.66). The worst-rated indicator was paying for 
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medication at facility (2.26). In respect of clients' satisfaction domain, the best-rated 
indicator was satisfaction with treatment outcome for baby (4.11). The worst-rated 
indicator was satisfaction with providers' attitude (3.63). Achievement of live birth (4.43) 
was the better-rated of the two indicators under the outcome domain. 
Table 28: Best and Worst-rated indicators under domains of quality of maternal care 
Domains Best-rated indicator Worst-rated indicator 
I. Health Facility Spacious to accommodate Facility has seats (2.89± 1.29) 
clients (3.53±l.07) 
2. Amenities Adequacy of urinals (3.35) Toilet is clean and neat 2.91 
3. Environment Airy and fresh environment Clean environment (4.0S±O.68) 
(4.08±O.72) 
4. Privacy Privacy in examination room Privacy in consulting room 
(4.14±O.89) (4.01±O.96) 
5. Interpersonal Adequate information and Post-delivery home visitation 
Relationship education on pregnancy (4.13) (1.99) 
6. Human Resource Service providers have the Adequacy of doctors on duty 
ability to provide needed (2.55) 
services to you (3.79) 
7. Safety Adequate of measures put in I feel the environment of the 
place to ensure clients' safety health facility is safe (e.g. from 
(3.92) dangerous animals) (3.91) 
8. Range of Services Facility has all services needed Facility has adequate 
(3.79) specialists/experts to provide 
needed services (3.91) 
9. Health Insurance Facility accepts health Non-discrimination between 
insurance (4.77) insured and non-insured clients 
at facility (3.48) 
10. Logistics and Supplies You buy your medication You pay for medication at the 
outside the facility 2.66) facility (2.28) 
11. Pain Management Effectiveness of measures to 
reduce pain during labour 
(3.14) 
12. Clients' Satisfaction Satisfaction with treatment Satisfaction with providers' 
outcome for baby (4.11) attitude (3.63) 
13. Outcome Live birth achieved (4.43) No injury to mother (4.3) 
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Table 29 shows the six best-rated and six worst-rated indicators of quality of maternal care 
women received during the most pregnancy. The overall best-rated of the 47 indicators 
was acceptance of health insurance by health facility (4.77), which belonged to the health 
insurance domain. The 5 indicators that followed in descending order of rating were 
achievement of life birth (4.43). no injury to mother (4.3). privacy in examination room 
(4.14), satisfaction with treatment outcome for baby (4.11) and airy and fresh environment 
(4.08). 
The overall worst-rated indicator of quality of maternal care women received during their 
most recent pregnancy was home visitation after delivery at health facility (1.99). The 
other 5 poorly rated indicators in descending order were payment for medication at the 
health facility (2.28), rich clients being offered faster and better treatment (2.32), feeling 
discriminated against at any time for not coming from a rich background (2.46), walking 
long distances for medicines available at the facility (2.46) and sufficiency of doctors on 
duty (2.46). 
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Table 29: Overall six best-rated and six worst-rated indicators of quality of maternal 
care women received 
Overall six best-rated indicators Overall six worst-rated indicators 
1. Acceptance of health insurance by facility Home visitation after delivery (1.99). 
(4.77) 
2 Life birth achievement (4.43) 2. Payment for medication bought at 
facility (2.28) 
3 No injury to mother (4.3) 3. Rich clients offered faster and better 
treatment (2.32) 
4 Privacy in examination room (4.14) 4. Feeling discriminated against for not 
having rich background (2.33) 
5 Satisfaction with treatment outcome (4.11) 5. Walking long distances for medicines 
available at facility (2.46) 
6 Airy and fresh environment (4.08) 6. Insufficiency of doctors on duty (2.55) 
6.5 Women's rating oftbe quality of care domains 
In addition to examining women's rating of each of the 47 items that were used to assess 
quality of maternal care, the study assessed and compared women's rating of the quality of 
maternal care domains. To do this, the mean quality of care score was obtained for each 
domain by adding the 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 categorized into three scales, where a mean score of 0 -2 meant low 
quality; a mean score of 2.1 - 3.9 meant moderate quality; and a mean score of 4-5 
meant high quality. The results are shown in Table 30. Across the 13 domains under which 
quality of maternal care was assessed, the two worst rated domains were pain management 
and amenities with average scores of 3.14 ± 1.18 and 3.20 ± l.l8 respecti vely. 
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Specifically, about 12.31% (64/520) and 18.3% (95/520) of the respondents, respectively 
rated quality of "pain management domain" and "amenities domains" as low. However, 
the outcome domain was identified to be the best rated domain with an average score of 
4.26 ± 0.57. The proportion of respondents who rated the outcome domain as low was 
only 0.8% (4/520). Overall, 72% of the respondents rated the quality of maternal care they 
received during their most recent pregnancy as high while 27% rated the quality of care as 
moderate. Only 0.6 % (3) of the respondents rated the overall quality of care as low as 
shown in Table 30. 
Table 30: Percentage distribution of women's rating of the quality of care domains 
Domains Mean ± SD Low, n(%) Moderate, n(%) High, n(%) 
Health facility 3.24 ± 0.94 103 (19.81) 227 (43.65) 190 (36.54) 
Amenities 3.20 ± 0.94 95 (18.27) 161 (30.96) 264 (50.77) 
Environment 4.07 ± 0.61 7 (1.35) 44 (8.46) 469 (90.19) 
Privacy 4.07 ± 0.80 34 (6.54) 45 (8.65) 441 (84.81) 
Interpersonal relationship 3.64 ± 0.45 9 (1.73) 156 (30) 355 (68.27) 
Human resource domain 3.31 ± 0.65 49 (9.42) 231 (44.42) 240 (46.15) 
Safety domain 3.91 ± 0.70 23 (4.42) 52 (10) 445 (85.58) 
Range of services domain 3.60 ± 0.77 38 (7.31) 125 (24.04) 357 (68.65) 
Health insurance services domain 3.70 ± 0.75 23 (4.42) 186 (35.77) 311 (59.81) 
Logistics and supplies domain 3.30 ± 0.75 45 (8.65) 239 (45.96) 236 (45.38) 
Pain management domain 3.14±1.18 64(12.31) 179(34.42) 277(53.27) 
Clients' satisfaction domain 3.92 ± 0.56 14 (2.69) 80 (15.38) 426 (81.92) 
Outcomes domain 4.26 ± 0.57 4 (0.77) 42 (8.08) 474 (91.15) 
Overall 3.64±0.32 3(0.58) 142(27.31) 375(72.12) 
6.6 Rating of quality of maternal care by respondents' background characteristics 
Tables 31a and 31 b show the percentage distribution of the levels of quality of maternal 
care women received during their most recent pregnancy by background characteristics. 
From the table, more women aged 37-49 years (81%) rated the quality of maternal care 
they received during the most pregnancy as high than women aged 26-36 years (73%) and 
women aged 15-25 years (68%). Comparatively, more women with five or more 
deliveries (80.5%) rated the quality of matemal care they received in their most recent 
pregnancy as high than those who have had no deliveries (65.38%), 1-2 deliveries 
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(72.55%), and 3-4 deliveries (70.07%). More women from Tamale Metropolis (80.00%) 
rated quality of maternal care they received during their most recent pregnancy as high 
compared to those from Sagnarigu (73.88%), Kumbungu (55.56%) and Savelugu 
(78.46%) districts. More women from urban communities (77.27%) rated quality of 
maternal care high compared to those from rural communities (67.06%). 
Regarding educational levels of the respondents, more women with secondary level of 
education (82.46%) rated quality of maternal care they received during their most recent 
pregnancy as high than those with no formal education (67.37%), primary (73.77%) and 
tertiary (76.06%) levels of education. Comparatively, more women who were separated, 
widowed, or divorced (100.00%) rated quality of maternal care they received during their 
most recent pregnancy as high than those who were married, cohabiting and single 
(61.54%). More women who were traditionalists (100%) rated the quality of maternal care 
they received during their most recent pregnancy high compared to those who were 
Christians (78.95%) and Muslims (71.21%). In terms of tribes, more Kusaasi women rated 
quality of maternal care they received during their most recent pregnancy as high than 
Bimoba (75.00%), Dagomba (72.27%), and Mamprusi (50.00%) women. 
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Table 31a: Level of quality of maternal care by respondents' background 
characteristics 
OveraD Quality of Maternal care 
Low,n(%) Moderate, D(%) High,D(%) 
Age 
15 -25 1(0.62) 51(31.68) 109(67.7) 
26-36 1(0.34) 80(26.94) 216(72.73) 
37 -49 1(1.61) 11(17.74) 50(80.65) 
Number of times pregnant 
1-2 1(0.38) 72(27.69) 187(71.92) 
3-4 1(0.51) 56(28.28) 141(71.21 ) 
5+ 1(1.61) 14(22.58) 47(75.81) 
Number of deliveries 
0 0(0) 9(34.62) 17(65.38) 
1-2 2(0.65) 82(26.8) 222(72.55) 
3-4 0(0) 44(29.93) 103(70.07) 
5+ 1(2.44) 7(17.07) 33(80.49) 
District 
Tamale Metro 0(0) 26(20) 104(80) 
Sagnarigu 1(0.75) 34(25.37) 99(73.88) 
Kumbungu 2(1.59) 54(42.86) 70(55.56) 
Savelugu 0(0) 28(21.54) 102(78.46) 
Residence type 
Urban 1(0.38) 59(22.35) 204(77.27) 
Rural 2(0.78) 82(32.16) 171(67.06) 
Educational level 
None 2(0.85) 75(31.78) 159(67.37) 
Primary 0(0) 41(26.28) 115(73.72) 
Secondary 0(0) 10(17.54) 47(82.46) 
Tertiary 1(1.41) 16(22.54) 54(76.06) 
Marital status 
Single 0(0) 5(38.46) 8(61.54) 
Married/Cohabiting 3(0.6) 137(27.29) 362(72.11) 
SeparatedIW idowedlDivorced 0(0) 0(0) 
Religion 5(100) 
Traditional 0(0) 0(0) 
Christianity 1(100) 0(0) 
Islam 12(21.05) 45(78.95) 3(0.65) 
Tribe 130(28.14) 329(71.21) 
Dagomba 3(0.66) 
Mamprusi 124(27.07) 331(72.27) 0(0) 
Bimoba 10(50) 10(50) 0(0) 
Kusaasi 7(25) 21(75) 0(0) 1(7.14) 13(92.86) 
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Table 31 b: Level of quality of maternal care by respond  en ts' background characteristics 
OveraU QuaUty of Maternal care . 0 
Low, a(%) Moderate, n(%) High, n( Yo) 
Occupation 
Farmer 1(1.52) 21(31.82) 
44(66.67) 
120(73.17) 
Trader 1(0.61) 43(26.22) 
1(0.58) 51(29.82) 119(69.59) Housewife 
0(0) 10(21.28) 37(78.72) Civil 
Student 0(0) 4(22.22) 
14(77.78) 
Artisan 0(0) 13(24.07) 
41(75.93) 
Health decision maker 
Self 1(0.57) 53(30.29) 
121(69.14) 
Mother-in-Iawl co-wives 0(0) 11(29.73) 26(70.27) 
Husband 2(0.65) 78(25.32) 228(74.03) 
Facility type 
Government 1(0.21) 125(25.99) 355(73.8) 
Private 2(5.13) 17(43.59) 20(51.28) 
Distance to nearest health facility 
< 30 mins walk 0(0) 53(29.78) 125(70.22) 
30 mins - I hour walk 0(0) 43(23.5) 140(76.5) 
1.1 - 2 hours walk 2(1.79) 30(26.79) 80(71.43) 
> 2 hours walk 1(2.13) 16(34.04) 26(63.83) 
Means of transportation 
Walking 1(0.42) 69(28.99) 168(70.59) 
BicyclelMotor cycleffricycle 2(0.98) 54(26.34) 149(72.68) 
Car 0(0) 19(24.68) 58(75.32) 
Number of ANC Visits 
None 1(3.7) 7(25.93) 19(70.37) 
I 0(0) 8(30.77) 18(69.23) 
2 0(0) 14(25) 42(75) 
3 0(0) 38(27.14) 102(72.86) 
4+ 2(0.74) 75(27.68) 194(71.59) 
6.7 Chapter summary 
This chapter presented results from the main survey on women's assessment of the quality 
of care they received during their most recent pregnancy in the Northern Region. Overall, 
72% of the respondents rated the quality of maternal care they received during their most 
recent pregnancy 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 of 
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 worst rated 
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domain among all the 13 domains was the Pain management domain, 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. In the next chapter. these 
results are discussed. 
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CHAPTER SEVEN 
DISCUSSION 
7.1 Introduction 
This chapter discusses results that were presented in chapters four, five and six. The results 
are discussed in relation to Donabedian' s(1966) quality of healthcare model, which 
provided a framework for evaluating the quality of maternal care. The chapter highlights 
areas that researchers who are interested in maternal care studies can focus on for further 
research and then makes recommendations for implementation of health policies and 
programmes. The discussion is divided into four sections. The first section discusses what 
quality of maternal care means and how it should be assessed. The second section presents 
a contextual discussion of the findings from the development and validation process of the 
quality of care assessment tool. The third section discusses results from women's rating of 
the quality of maternal care services they received during their most recent pregnancy in 
the Northern Region. The final part of this chapter looks at the study's strengths and 
limitations. 
7.2 Summary and discussion of findings on women's and healthcare providers' 
perspectives on quality of maternal care 
A central objective of this study was to examine women's and maternal care providers' 
understanding of what constitutes quality maternal care and how quality of maternal care 
should be measured in Ghana. Qualitative findings suggested that in terms of what 
constitutes quality maternal care during the antenatal period (ANC), both women and 
healthcare providers agreed that time and patience on the part of care providers to listen to 
clients, availability of equipment, provision of medicines, and protection of mother and 
unborn baby's wen-being were important markers of quality care. Most women interpreted 
quality ANC to mean healthcare providers having the patience to listen to clients' health 
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problems and provide treatment for their health needs. Women and healthcare providers 
also discussed quality in terms of education on general management of pregnancy and 
regular check-ups and monitoring by the midwives. Furthermore, results suggested that 
most participants explained quality of care during labour and delivery to mean the ability 
of the care regime to prevent and manage complications as well as ensure the mother's and 
baby's safety during labour and delivery. Quality care during the postnatal period was also 
discussed in terms of access to appropriate and timely immunization and access to 
appropriate general check-ups to ensure babies' welfare. 
[n relation to how quality of maternal care should be measured, findings revealed thirteen 
domains or aspects of maternal care that participants said were important for the 
assessment. 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. The other domains were quality of the 
human resource/workforce, non-discriminatory provision of maternal care services, range 
of services and inter-personal relationship, clients' privacy, pain management and clients' 
involvement in the care decision-making process, mother and baby's safety, outcome of 
pregnancy and clients' satisfaction with the care processes and outcomes. However, 
healthcare providers viewed mother and baby's safety and the outcome of pregnancy to be 
the two most important components of quality of care, while the majority of the women 
agreed that inter-personal relationship and range of services were the most important. 
Many of the fmdings reported above are consistent with those of previous studies 
conducted in Ghana and other parts of the world. For instance, on access to quality 
antenatal care, the fmdings confirm those of Pervin et al. (2012) in Bangladesh that 
suggested that good quality antenatal care services lead to lower neonatal and maternal 
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mortality rates. Similarly, fmdings in this study elucidated that non-clinical services such 
as information and education during antenatal care, inter-personal relationship and clients' 
privacy are crucial to the success of ANC. This revelation is in consonance with Kumbani 
et al. (2012) in Malawi, who showed that women reported complications and poor quality 
of care because they were not provided with adequate information during pregnancy. The 
findings of this study further corroborate those of earlier studies by the Quality 
Commission (2008) in the UK (Kingston et al., 2011), Canada and the USA (Mac Dorman 
et aI., 2016). These studies have indicated that providing adequate information, being 
treated with respect, and having a therapeutic relationship with healthcare workers are all 
critical factors for ensuring high quality ANC. Additionally, the current fmdings confirm 
those reported earlier by Afulani (2015) in Ghana that pregnant women demanded 
education on risks of pregnancy complications as part of the antenatal care services they 
required from healthcare providers. 
The finding that good labour process and safe delivery denote quality maternal care 
services is also consistent with results from a number of previous studies (Care Quality 
Commission, 2018; Pervin et aI., 2012; Diamond-Brown, 2016). Globally, safe delivery is 
a major concern not to only expectant mothers but to researchers and healthcare policy-
makers as well. Several instances of maltreatment of women during delivery have been 
recorded (Bohren et al., 2015). Typical cases are those in north-eastern Tanzania, where up 
to 28% of women reported cases of unsafe labour process (Kruk et aI., 2014). Moyer et aI. 
(2014) and Yakubu et al. (2014) found similar cases of maltreatment of pregnant women 
before and during delivery in northern Ghana. Aside maltreatment in the labour and 
delivery processes, a study by Sharma (2017) found poor quality of maternal care during 
delivery where women were being cared for by unqualified birth attendants coupled with 
malfeasance as informal payments influenced the quality of maternal care women 
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received. However, these events are often overlooked because quality of care has often 
focused on the health providers' perspectives and health outcomes with little attention 
given to the clients' perspectives (Tripathi et al., 2015). 
Gabrysch and Campbell (2009) disclosed that access to skilled birth attendance has the 
potential to reduce obstetric complications and maternal and neonatal deaths compared 
with women who give birth outside health facilities with no skilled assistance. However, a 
study in Eastern Region of Ghana on women's childbirth experiences by Adugu (2018) 
found that women may not patronize the services of skilled birth attendants in health 
facilities because of poor labour and delivery services they received. This earlier finding 
may explain why, in the view of the participants in this study, good labour process and 
safe delivery should be important components of quality maternal care in Ghana. 
Many participants also explained quality maternal care to mean having access to good 
postnatal care services. The services women receive after delivery and beyond are of 
paramount importance to themselves and their new-born babies (WHO, 2018). With 
reference to the views expressed by the participants, immunization and general child 
welfare services for their babies are among the components of quality maternal care. 
World Health Organisation recommends that mothers who have just been delivered should 
receive postnatal care within the first 24 hours. Newly-born babies are to be cared for 
within 2-3 days after birth and between days 7 andl4 as well as six weeks after birth. It is 
mandatory that during this period, the health status of the mother and the infant are 
assessed (WHO, 2018). Indeed, immunization of children, as a component of postnatal 
care, has been responsible for averting about 24% of the 10 million deaths that occur 
annually among children less than five years old (Sarker et aI., 2016). Friberg et aI. (2010) 
have linked over half of mortalities which occur a day after delivery to lack of quality 
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postnatal care. This assertion is supported by studies elsewhere (Montagu et al, 2017, 
Friberg et al, 2010, Black et ai, 2010, Bryce and Requejo, 2010, UNICEF, 2009). This 
assertion perhaps explains why many women and healthcare providers argued that the 
components of quality maternal care must include timely access to relevant immunisation 
for newborns. 
The findings also reflect earlier results by Black et al. (2010) that the components of 
quality postnatal care must include adequate warnlth, adequate nutrition, optimal feeding, 
better hygiene and early treatment of infections. Postnatal care is another key intervention 
measure for reducing child deaths caused by diarrhoea, pneumonia and malaria (Puente et 
aJ., 2016). However, documented evidence shows that access to quality postnatal care and 
other heaIthcare services is greatly influenced by the calibre of healthcare workers (Say et 
aI., 2009; Pitchforth et aI., 2010; Nesbitt et al., 2011; Graham & Varghese, 2012). A study 
in Australia by Forster et aI. (2006) found that shortage of qualified staffing was a major 
factor inhibiting the provision of quality postnatal care. This contention may also explain 
why participants in this study emphasized the importance of not only having sufficient 
numbers of healthcare workers but also that these healthcare workers must be qualified 
and properly trained with the appropriate mix of technical and inter-personal skills. 
Another finding of this study that require discussion relates to the distribution of the 13 
domains of quality that participants reported. Generally, most of these domains fell within 
the process aspects of care as shown earlier in the Donabedian (1966) conceptual model. 
According to the Donabedian (1966) conceptual model, quality of care comprised 
structural, process and outcome elements. In this study, the structural dimension of quality 
is related to availability and provision of medicines and equipment while the outcome 
component is related to only mother's and baby's safety during delivery. This skew may 
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relate to experiences, preferences, perceptions, priorities, values, beliefs and attitudes at 
the community and personal levels. Clients' perceived care processes as more important 
than structure probably because of the tendency of poor care processes to undernline their 
dignity. 
Nevertheless, all the components identified by participants do have potential to impacts on 
quality of maternal care. For instance, patience on the part of healthc are providers to listen 
to clients offers the potential benefits of enhancing voluntary compliance rather than 
regimentation. particularization rather than generalization/stereotyping and boosting the 
client's self-respectlself-esteem rather than demoralization/ mortification. It is thus 
essential for maternal care providers to cultivate and sustain rapport and exchange of 
experiences with their clients irrespective of the disparities in their educational levels and 
economic statuses. Similarly, availability and provision of medicines and equipment may 
be associated with benefits such as effective diagnosis and treatments of cases that need 
special attention. aversion of self-medication, drug abuse and patronage of fake/sub-
standard medicines. Other potential benefits include enhanced affordability of maternal 
care. Indeed, the need for adequate medication and equipment probably came out because 
Northern Region is one of the poorly resourced regions in the country in terms of 
healthcare delivery (GHS, 2017). As noted in the 2016 Northern Regional Ghana Health 
Service Annual Report, most health facilities in the region lack the needed medication and 
equipment to effectively provide maternal care services. 
Education on general management of pregnancy is also likely to benefit maternal care 
through improVed diets for mothers and babies and the avoidance of harmful medications 
and concoctions. Education also increases awareness among pregnant women of the need 
for adequate and timely rest and the danger of high workloads, stress, anxiety and other 
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negative psychological conditions. Also, regular check-ups and the monitoring of the 
unborn baby's growth could promote positive outcomes of pregnancy. Early and regular 
check-ups and monitoring particularly offer added benefits in respect of economic cost to 
the household and the community at large through diversion of human resources from 
economic activities to the care of an unhealthy mother and baby. In respect of access to 
appropriate and timely immunization, the benefits include prevention of childhood 
diseases (such as measles and poliomyelitis), protection of babies from the long-time 
effects of morbidity (such as stunting, mental retardation, paralysis and emotional 
dysfunction). Similarly, prevention and management of complications during labour and 
delivery are strongly correlated with the mother's and baby's safety during labour. 
Further. the two main domains that women identified as most critical for assessing quality 
of maternal care are inter-personal relationship and good diagnosis and treatment. This 
finding suggests that women are perhaps more concerned with the process dimension of 
care than either structure or outcome of the healthcare system. On the contrary, healthcare 
providers seem to be more concerned with the outcome domain (on the basis of their 
identification of outcome of pregnancy as the most important indicator of quality care). 
The disparity in areas of focus may derive from differential experiences. Clients, for 
instance, are less likely to be aware and concerned about the challenges related to the 
acquisition, operation and servicing/maintenance of the requisite equipment and logistics 
for maternal care, which, in healthcare providers' view, have serious effects on the 
outcome of pregnancy. Additionally, providers ostensibly perceive a strong correlation 
between their effectiveness/performance, professional ratings, personal reputation, social 
acceptance ratings and prestige on one hand and the outcomes of cases they handle on the 
other hand. On the contrary, clients are more likely to be interested in the display of 
empathy, respect, dignity etiquette and tact that lessen their maternity- related agonies. 
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This tendency could provide a justification of clients' perception of inter-personal 
relationship as the foremost indicator for assessing quality of maternal care. Women's 
views of inter-personal relationship as the most important indicator could also be 
explained in a culturally-grounded sense. Among the Dagombas, cordial reception by a 
bealthcare provider is perceived to be more prudent than the most expensive medication 
devoid of compassion. 
7.3 Summary and discussion offindiogs on the Development and Validation of 
Quality Maternal Care assessment tool 
One of the key knowledge gaps that this study addressed relates to the lack of appropriate 
validated tools for assessing quality of maternal care in low-income settings like Ghana. 
Consequently, this study aimed to develop and validate a tool for assessing quality of 
maternal care. Results presented in Chapter Five showed that the 55 experts who were 
surveyed to evaluate the appropriateness and validity of the 57-item tool rated all the items 
of the construct 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 pre-testing of the tool and further reliability testing of the items in the 
tool using item discrimination indices, only 47 items had acceptable item discrimination 
indices. These items were therefore included in the final tool. 
Several aspects of the tool development and validation process deserve further discussion. 
First, the procedures for the development and validation of the tool were consistent with 
existing literature (Haddad et aI., 1998; McCowan & McCowan, 1999; Van Duong et aI., 
2004; Abuya et ai, 2015; Sheferawet aI., 2016; Melo et aI., 2017; Carpente, 2018, 
Kyriazos, & Stalikas, 2018). Second, the heterogeneity of the expects in respect of age, 
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sex, years of working experience, and type of profession facilitated access to varied 
experiences. knowledge and perceptions about maternal care. This benefit, I believe, 
ensured that a valid and reliable tool was produced. In particular, the fact that the majority 
of the expert panel were females who may themselves have experienced pregnancy and 
maternal care services in health facilities offered access to data on personal rather than 
existential experiences. This access helped to enhance the tool validity and credibility. 
Third. the processes of elimination and substitution of indicators facilitated the production 
of a more dynamic, feasible and comprehensive tool rooted in local circumstances of 
maternal care and tailored towards local priorities. Finally, the processes adopted to 
develop and validate the tool and the findings, clearly support a need for the adoption of a 
multi-stakeholder approach to defining and assessing quality of maternal care. The 
participatory approach used in this study helped to mitigate the influences of prejudices, 
biases and misconceptions associated with differential characteristics such as sex, age, 
profession, place of work, number of working years and type of community. 
7.4 Summary and discussion of Findings on quality of maternal care in Northern 
Region 
The central objective of this study was to assess the quality of care women received during 
their most recent pregnancy in Northern Region. Findings presented in Chapter Six 
showed that, overall, 72% of the respondents rated the quality of maternal care they 
received during their most recent pregnancy as high with 27% and 0.6% rating the quality 
of care as moderate and low respectively. The highest- best 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 worst rated domain among all the 13 domains was pain management, 
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which had an average rating score of 3.14:1: 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. 
Several aspects of these results deserve further discussion. First, the results in obtaining 
women's overall assessment of the quality of maternal care in the four selected districts in 
Northern Region of Ghana are consistent with those of some previous studies (Butawa et 
aI., (2010; WHO, 2014; Kambala et aI., 2015; Madaj. et al., 207; Brizuela, et al., 2019). 
Kambala et a1. (2015) specifically found in Malawi, pregnant women and nursing mothers 
highly rated quality of maternal care services in health facilities with an overall mean 
score of9/10 with the rating based on their interpersonal relations with healthcare workers, 
settings of the consultation rooms and nursing care services. 
In Kenya, Oyugi et al. (2018) found that women gave high ratings to the conduct of health 
workers but were indifferent about the physical facilities and resources in the hospitals. 
They specifically rated high quick service delivery, good management of complications 
and clean hospital environment. Consistent with findings in the current study, the rating 
reported by Oyugi et al. (2018) varies according to women's socio-demographic 
characteristics. Mumtaz et al. (2019) have also found in Afghanistan that, the basic socio-
demographic characteristics of women such as education, economic status, location, level 
of self-sufficiency and ownership of means of transport were key determinants of 
women's varied assessment of quality of maternal care services. Indeed, the finding that 
women's background characteristics affected their varied assessment of quality of 
maternal care services is consistent with the conceptual framework of this study presented 
in Chapter 2. where it was hypothesized that women's socio-demographic, socio-
economic, obstetric and community-level factors could affect their valuation of the quality 
of care they received. 
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The finding that the outcome domain was the highest best-rated domain is not surprising 
given that the nature of the outcome of every pregnancy generally reflects the result of 
maternal care. This finding is consistent with the results of other studies (d'Arobruoso et 
aI., 2005; Cham et al., 2009; Srivastava et al., 2015; Kendall, 2015; Tripathi et al., 2015). 
Findings also indicated that the two worst-rated domains of care were pain management 
and amenities. In relation to pain management, it is generally acknowledged that period 
between labour and childbirth is one of pain for most women. Consequently, it has been 
recommended that health facilities should choose between a variety of pharmacological 
and non-pharmacological options for the management and relief of pain (WHO, 2018). 
Non-pharmacological pain-relief options including manual techniques (such as massaging 
or application of warm packs) are recommended for healthy pregnant women who request 
relief of pain during labour, depending on their own preferences. WHO (2017) has 
therefore emphasized the need for member-countries to update their national lists of 
medicines to include those for management and relief of pain during labour. That pain 
management was poorly rated in this study is consistent with the findings in Machira, & 
Palamuleni's (2018) study in Malawi, where one of the ways healthcare workers 
maltreated pregnant women was denying them pain reliefs during and after labour. In 
Ghana. Amu and Nyarko (2019) found that in Ketu South District of the Volta Region, 
most of the women reported being given infusion by midwives to manage their pain after 
delivery. This strategy was deemed to be unsatisfactory as the pain did not lessen. 
It is also not surprising that women rated amenities poorly. The reason is that Northern 
Regions is one of the poorest regions in the country and also fares poorly with regard to 
most health indicators in Ghana (GSS/GHS, 2014). There is also inadequate provision of 
both human and material resources (GHS, 2017). In a region that has recorded persistent 
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inadequacy of health professionals, where the doctor to patent ratio is one to 51, 000 
(GHS, 2017), it will surely have challenges providing basic amenities especially in 
inaccessible areas of the region. This contention is confirmed by Dickson and Amu (2017) 
who revealed that Northern Region is one of the regions in the northern sector with the 
least probability of pregnant women having access to skilled personnel-assisted delivery. 
This deprivation potentially explains why the women rated amenities poorly and it is likely 
to be the case given that the Ghana Health Service Report (2016) acknowledged that 
Northern Region was poorly resourced in terms of personnel. 
The findings here, however. do lend support to recommendations by World Health 
Organisation (2018) that health facilities should improve their physical infrastructure, 
basic amenities and cons urn abies in order to be able to provide quality maternal care 
services to their clients. As a study by Symon et al. (2018) indicated, poor provision of 
health facilities in Scotland contributed to the poor quality of maternal care that women 
received. In addition, a study in 10 low-income countries including Nigeria found that 
poor infrastructure and provision of resources and amenities were linked to the poor 
quality of maternal care that women received in health facilities. Indeed, other studies have 
found that the non-availability of equipment and supplies hinders quality of healthcare in 
general and that of maternal care in particular. Dovlo (2003), for instance, linked the 
exodus of healthcare workers from sub-Saharan Africa to the inadequacy of resources and 
amenities such as equipment and medical supplies. In Ethiopia, Kea (2018) postulated that 
non-availability of medical supplies and equipment tended to retard the motivation and 
performance of healthcare workers. Finally, 72% of the respondents rated the quality of 
maternal care they received during their most recent pregnancy as high. This finding is 
encouraging although there is space for further improvement. Taken together, the findings 
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here point to a need for more attention to be paid to aspects of maternal care that were 
poorly rated by clients. 
7.5 Strengths and contribution of the Study to knowledge 
Quality of maternal care is an important detenninant of improved pregnancy outcomes but 
few empirical studies have examined how women rate the quality of maternal care services 
they receive at health facilities. Within this premise, this study assessed the quality of 
maternal care in the Northern Region of Ghana. Being one of the few studies to have 
focused on the assessment of quality of maternal care services, this study has made 
important contributions to knowledge. 
I. This study has added to the available literature on the quality of maternal care 
services women received in Northern Region. It has particularly provided 
additional knowledge on which aspects of care women deem to be important in 
both the definition and assessment of quality of care. This knowledge is critical for 
policy making, service delivery as well as future research on quality assessment in 
Ghana or similar contexts. 
2. The results of the study have also given a deeper insight into which aspects of care 
that needs quality improvement. The study revealed that the two worst-rated 
domains of care were pain management and amenities. This insight is a major 
contribution to knowledge in this field not only in terms of which aspects of care 
require quality improvements but it also opens new opportunities for further 
research to fully understand the range of factors that affect the quality of maternal 
care and how and why women rated these aspects of maternal care quality as low. 
3. Furthermore, the tool that has been developed and validated is a vital resource for 
future researchers. Before this study, such a tool did not exist, at least in the 
Ghanaian context. The 13 domains and 47 items that have been identified and 
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captured in this tool will particularly serve as important pointers to future 
researchers in tenns of what to look at for when undertaking assessment of quality 
of maternal care services. In addition. the methodological approach used to develop 
and validate the tool itself is an important contribution. In particular, integration of 
women's, healthcare providers' and experts' perspectives in the development and 
validation of the tool highlighted the necessity of adopting a multi-stakeholder 
approach to defining and assessing quality of maternal care in order to avoid and! 
or minimise prejudices, biases and misconceptions. 
7.6 Limitations of the study 
Despite the strengths and contribution of this study to knowledge. there are a number of 
limitations. 
I. The design of the study was cross-sectional; hence it was not possible to study and 
understand how women's rating of the quality of care may change with time. 
2. A retrospective self-reported method for assessing quality of care was used in this 
study. The retrospective nature of the assessment could have resulted in some 
recall biases as some respondents may have forgotten their experiences in relation 
to aspects of the care they received. A more participatory assessment approach 
whereby an independent researcher or team of experts participate in the care 
process of each respondent and observe and document the presence or otherwise of 
some of the indicators of quality would have contributed to strengthening the 
objectivity of the assessment. However, resource and time-constraints made it 
impossible to adopt an assessment approach. Future research may consider this 
approach. 
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3. Finally, while the processes used to develop and validate the quality of maternal 
care assessment tool followed standard procedures in literature, it is possible that 
some aspects of care quality may not have been captured or the indicators used 
may not have been appropriate. 
7.7 Chapter summary 
This chapter discussed the results that were presented in Chapters Four, Five and Six. The 
discussions highlighted important issues related to the quality of care that women receive 
in health facilities during pregnancy and childbirth, which have implications for policy, 
practice and research. In the next chapter, specific conclusions are drawn and 
recommendations made. 
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CHAPTER EIGHT 
CONCLUSION 
8.1 Conclusion 
The quality of maternal care women receive during pregnancy has attracted global 
attention. However, tools and empirical studies on quality of maternal care women 
actually 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 the clinical care aspect of quality without considering clients' perspective. This 
study aimed to fill these knowledge gaps by developing and validating an assessment tool 
and using same to assess the quality of maternal care in four districts in Northern Region 
of Ghana. 
To achieve the objectives of the study, a sequential mixed method, cross-sectional 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 care. 
This component of the design helped to identify key indicators that were deemed relevant 
for assessing the quality of maternal care. The second phase of the design built on the first 
and involved the development and validation of a quality of care assessment tool. The final 
phase involved administering the maternal care quality assessment tool to women in a 
survey to assess quality of maternal care they received during their most recent pregnancy. 
Findings, which have been presented in Chapters 4, 5, and 6 and discussed in Chapter 7 
revealed that women, healthcare providers and experts identified a total of 13 domains and 
47 indicators that must be considered in assessing quality of care. Overall, the majority of 
women (72%) rated the overall quality of maternal care they received during their most 
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recent pregnancy as high. The highest best-rated domain was the outcome of care domain. 
The worst rated care domain was pain management. 
Taken together. several conclusions could be drawn from this study: 
I. The first two objectives set out to defme quality of maternal care and how it should 
be assessed by women and their service providers. The study revealed that good 
antenatal, delivery and postnatal services were identified by both women and their 
providers as constituting good quality maternal care. Even though thirteen domains 
were identified by both women and providers as important in measuring quality of 
maternal care, women emphasized interpersonal relationship as a critical domain in 
measuring quality of maternal care while their providers placed more emphasis on 
pregnancy outcome. The implications of these findings are that women's 
perspectives of quality of maternal care are not too different from those of 
providers. Therefore, the quality of ANC, delivery and PNC must be enhanced. 
The scope of inter-personal relationship, which was valued by women, must be 
enhanced in health facilities in delivering healthcare services. 
2. Objective three sought to develop and validate a tool for measuring quality of 
maternal care from both women and providers and this was successfully done with 
55 maternal healthcare experts who rated the 57 item tool to be above a content 
validity ratio of 0.06, which was deemed the benchmark. The findings indicated 
that women's expectations of quality maternal care were consistent with those of 
maternal care experts after some modifications were made. 
3. The last objective was to assess the quality of care women received using the 
developed tool. The findings show that the majority of the women (72%) rated the 
quality of care they received during their last pregnancy as high. The findings 
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further reveal that the worst rated indicators included pain management during 
labour, home visitation, preferential treatment and adequacy of doctors on duty. 
The implication of this finding is that, even though the majority of women highly 
rated the services they received, more efforts and improvements are needed to meet 
the expectations of the close to 30% who did not rate the quality they received 
highly 
8.2 Recommendations 
The following strategies are recommended for implementation by the specific groups of 
stakeholders to enhance the quality of maternal care in Northern Region. These 
recommendations are directed towards improving the quality of the maternal care system 
as well as research. 
8.2.1 Recommendations policy and practice 
I. Ghana Health Service should ensure that counselling centres are made available in each 
facility to enable pregnant women and postnatal mothers to access such services for 
managing stress-related issues, tensions, anxiety and various psychological-related 
problems. Additionally, the need for in-service training to improve the communication 
skills of providers is critical for enhancing the inter-personal communication between 
providers and clients to enable women access the right information when they need it. 
2. Home visitation was rated the poorest of all the quality of care indicators during the 
postnatal period. While the scope of home visitation by midwives and trained nurses 
certainly could be limited by shortages of birth and staff resources, Ghana Health Service 
should consider involving community health volunteers in outreach programmes to 
implement a home visitation strategy. 
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3. Discrimination and feeling discriminated against for not being rich was another issue 
that many women expressed concern about. Rich clients were said to be offered faster and 
better treatments. It is recommended that Ghana Health Service ensures that 'a tirst come, 
first served policy' is implemented to reduce agitations against both perceived and real 
discrimination in favour of rich clients. Where practicable, an individual appointment 
booking system should be implemented, especially in urban centres, to avoid congestion. 
4. It is recommended to Ghana Health Service to train more providers to address the 
doctor-patient and midwives-patient ratio gaps and put incentives in place to attract more 
health workers to the region. Two main forms of packages may be used: monetory and 
non-monetary incentives. Monetary packages may include out-station allowance, domestic 
staff allowance. extra duty allowance and vehicle acquisition and running maintenance 
allowances. Non-monetary packages may include free or subsidized accommodation, 
promotion or career advancement and professional capacity building opportunities targeted 
at healthcare providers who accept to serve in deprived rural locations. 
5. To address other quality issues including inadequacy of specialists, the Ministry of 
Health and Ghana Health Service should consider implementing a specialist/consultant's 
outreach programme in deprived facilities on designated occasions. A staff exchange 
system on a short-term basis could also be implemented. This strategy could help facilitate 
learning through access to diverse professional experiences. 
8.2.2 Recommendations for further research 
1. This study has identified that although the majority of women rated the overall quality 
of care high not only is there space for further improvement but also there is need for 
more attention to be focused on the aspects of maternal care that women rated poorly. In 
this regard, the study recommends that research institutions such as the universities should 
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carry out research to understand the nature of care under these domains and why women 
rate these care domains poorly. Also, there is need for broader research to document and 
generate evidence on different quality of care improvement strategies. 
2. The tool that has been developed from this research should be used by other researchers 
and students to assess the quality of maternal care within Ghana or in another African 
country to test the reliability and validity of the instrument. 
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APPENDICES 
Appendix A: Consent Form Information Sheet for Participants 
Introduction 
Good day. My name is , and I work for Victoria Sharon Lisa Mwnuni. a 
PhD candidate at the school of public health, University of Ghana. She is doing a study on 
quality maternal health care in northern Ghana regarding what constitute quality, how it 
should be assessed and assessing the quality of perinatal care. I am going to give you some 
information and invite you to be a part of this research. You do not have to decide today 
whether or not you will participate in the research. Before you decide. you can talk to 
anyone you feel comfortable with about the research. This consent form may contain 
words that you do not understand. Please ask me to stop as we go through the information 
and I will take time to explain. If you have questions later, you can ask me or another 
researcher. 
Purpose of the research 
The purpose of this study is first to assess both woman and health workers views on 
quality of maternal health care, how it should be measured which would then infonn the 
development of a tool to assess quality of maternal health care. 
Type of Research Intervention 
This research will involve your participation in an interview that will take 45 to 60 
minutes. 
Participant Selection 
You are being invited to take part in this research because we feel that your experience 
during ANC or labour or postnatal care is vital to this research 
Voluntary Participation 
Your participation in this research is entirely voluntary. It is your choice whether to 
participate or not. If you choose not to participate, it will have no bearing on your job or 
on any work-related reports. You may change your mind later and stop participating even 
if you agreed earlier. Your refusal to participate will not affect the care you will receive 
Procedures 
We will be asking you questions on what should constitute quality of maternal health care, 
how it should be assessed. We are inviting you to take part in this research project. If you 
accept, you will be asked to participate in an interview with [name of interviewer] or 
myself. During the interview, I or another interviewer will sit down with you in a private, 
comfortable place at the [location]. If it is better for you, the interview can take place in 
your home or a friend's home. If you do not wish to answer any of the questions during the 
interview, you may say so and the interviewer will move on to the next question. No one 
else but the interviewer will be present, unless you would like someone else to be there. 
The information recorded is confidential, and no one else except Victoria Sharon Lisa 
Mumuni, who is the principal investigator, Prof Augustine Ankomah, and Dr. John 
Kuuurnuori Ganle who are the supervisors of the candidate. 
Duration 
The research project will last for 1 year in total. This interview will be conducted once and 
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will last 45 to 60 minutes. We will not contact you further after this interview. 
Risks 
We are asking you to share with us some very personal and confidential information, and 
you may feel uncomfortable talking about some of the topics. You do not have to answer 
any question or take part in the discussion/interview/survey if you don't wish to do so, and 
that is also fme. You do not have to give us any reason for not responding to any question, 
or for refusing to take part in the interview 
Benefits 
There will be no direct benefit to you, but your participation will help us understand how 
quality maternal health should be measured and the quality of maternal health care in 
northern region. 
Reimbursements 
You will not be provided any incentive to take part in the research. However, we will give 
you GH¢5.00 for your time, and travel expenses. 
Confidentiality 
The research being done may draw attention from other people in your local community 
and if you participate you may be asked questions by other people in the community. We 
will not be sharing information about you to anyone outside of the research team. The 
information that we collect from this research project will be kept private. Any 
information about you will have a number on it instead of your name. Only the researchers 
will know what your number is and we will lock that information up with a lock and key. 
It will not be shared with or given to anyone. 
Sharing the Results 
Nothing that you tell us today will be shared with anybody outside the research team, and 
nothing will be attributed to you by name. The knowledge that we get from this research 
will be shared with you and your community before it is made widely available to the 
public. There will also be meetings in the community and these will be announced. 
Following the meetings, we will publish the results so that other interested people may 
learn from the research. 
Right to Refuse or Withdraw 
You do not have to take part in this research if you do not wish to do so, and choosing to 
participate will not affect your job or job-related evaluations in any way. You may stop 
participating in the interview at any time that you wish without your job being affected. I 
will give you an opportunity at the end of the interview to review your remarks, and you 
can ask to modify or remove portions of those, if you do not agree with my notes or if I did 
not understand you correctly. 
Who to Contact 
If you have any questions, you can ask them now or later. If you wish to ask questions 
later, you may contact any of the following: Victoria Lisa Mumuni on 0543391135. This 
proposal has been reviewed and approved by Ghana Health Service Ethics Review 
Committee, which is a committee whose task it is to make sure that research participants 
are protected from harm. If you wish to find about more about the IRB, contact Ms 
Hannah Frimpong, Research & Development Division, Ghana Health Service, P. O. Box 
MB 190, Accra. Tel: -0302681109,0302679323. 
21S 
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You can ask me any more questions about any part of the research study, if you wish to. 
Do you have any questions? 
Certificate of Consent 
I have been invited to participate in a research interview about what quality of maternal 
health care should be and how it should be assessed. 
(This section is mandatory) 
I have read the foregoing infonnation, or it has been read to me in a language I understand. 
I have had the opportunity to ask questions about it and any questions I have been asked 
have been answered to my satisfaction. I also agree that the interview should be recorded. I 
consent voluntarily to be a participant in this study 
Print Name of Participant Signature of Participant 
________ Date ____________  
Day/month/year Ifilliterate 
I have witnessed the accurate reading of the consent form to the potential participant, and 
the individual has Yhad the  opportunity to ask questions. I confinn that the individual has EJ'freel
Print name of witness _____  Signature of witness Date 
Day/month/year 
Thumb print of participant 
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Appendix B: Content Validity of Tool for Measuring Quality of Maternal Health 
Care 
Information Sheet for Content Validity 
Introduction 
Good day. My name is , and I work for Victoria Sharon Lisa Mumuni, a 
PhD candidate at the school of public health, University of Ghana. She is doing a study on 
quality maternal health care in northern Ghana regarding what constitute quality, how it should 
be assessed and assessing the quality of perinatal care. I am going to give you some 
information and invite you to be a part of this research. You do not have to decide today 
whether or not you will participate in the research. Before you decide, you can talk to anyone 
you feel comfortable with about the research. A qualitative study was conducted with women 
and analysed to produce the quality of care measuring tool below. You are being invited as an 
expert in this area to validate the instrument. Please ask me to stop as we go through the 
information and I will take time to explain. If you have questions later, you can ask me or 
another researcher. 
Purpose of the research 
The purpose of this study is first to assess both woman and health workers views on 
quality of maternal health care, how it should be measured which would then inform the 
development of a tool to assess quality of maternal health care. 
You are please reminded as an expert in maternal health care delivery to critically 
evaluate the content of the proposed tool for measuring quality of maternal healthcare in 
Ghana. 
Type of Research Intervention 
This research will involve your participation in an interview that will take 15 to 20 minutes. 
Participant Selection 
You are being invited to take part in this research because of your experience in maternal 
health care service 
Voluntary Participation 
Your participation in this research is entirely voluntary. It is your choice whether to participate 
or not. If you choose not to participate, it will have no bearing on your job or on any work-
rela~ed reports. You may change your mind later and stop participating even if you agreed 
earher. 
Procedures 
We will give you a set of questions that was developed from a qualitative study conducted 
among ANC, labour and p.ostnatal ~omen in Selected health facilities in Northern region of 
Ghan~ on w~t should be ~cluded 10 tool for measuring the quality of maternal health care. 
The 1Oformatlon recorded IS confidential, and no one else except Victoria Sharon Lisa 
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University of Ghana, http://ugspace.ug.edu.gh
Mumuni, who is the principal investigator, Prof Augustine Ankomah, Dr Amos Laar and Dr 
John Kuuumuori Ganle who are the supervisors of the candidate. 
Duration 
The research project will last for 1 year in total. This interview will be conducted once and will 
last 15 to 20 minutes. We will not contact you further after this interview. 
Risks 
We are asking you to share with us some very personal and confidential information, and you 
may feel uncomfortable talking about some of the topics. You do not have to answer any 
question or take part in the discussion/interview/survey if you don't wish to do so, and that is 
also fine. You do not have to give us any reason for not responding to any question, or for 
refusing to take part in the interview 
Benefits 
There will be no direct benefit to you, but your participation will help us understand how 
quality maternal health should be measured in Ghana and more specifically, the quality of 
maternal health care in northern region. 
Reimbursements 
You will not be provided any incentive to take part in the research. 
Confidentiality 
We will not be sharing information about you to anyone outside of the research team. The 
information that we collect from this research project will be kept private. Any information 
about you will have a number on it instead of your name. Only the researchers will know what 
your number is and we will lock that information up with a lock and key. It will not be shared 
with or given to anyone. 
Sharing the Results 
Nothing that you tell us today will be shared with anybody outside the research team, and 
nothing will be attributed to you by name. 
Right to Refuse or Withdraw 
You do not have to take part in this research if you do not wish to do so, and choosing to 
participate will not affect your job or job-related evaluations in any way. You may stop 
participating in the interview at any time that you wish without your job being affected. I will 
give you an opportunity at the end of the interview to review your remarks, and you can ask to 
modify or remove portions of those, if you do not agree with my notes or if I did not 
understand you correctly. 
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Who to Contact 
If you have any questions, you can ask them now or later. If you wish to ask questions later, 
you may contact any of the following: Victoria Lisa Mumuni on 0201403848. This proposal 
has been reviewed and approved by Ghana Health Service Ethics Review Committee, which is 
a committee whose task it is to make sure that research participants are protected from harm. 
If you wish to find about more about the IRB, contact Ms Hannah Frimpong, Research & 
Development Division, Ghana Health Service, P. O. Box MB 190, Accra. Tel: -0302681109, 
0302679323. 
You can ask me any more questions about any part of the research study, if you wish to. Do 
you have any questions? 
Certificate of Consent 
I have been invited to participate in a research interview about what quality of maternal health 
care should be and how it should be assessed. 
(This section is mandatory) 
I have read the foregoing information and understand its content. I have had the opportunity to 
ask questions about it and any questions I have been asked questions and answered to my 
satisfaction. I also agree that the interview should be recorded. I consent voluntarily to be a 
participant in this study 
Print Name ofParticipant,_ _______  
Signature of Participant _________  
Date ___________  
Day/month/year 
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Appendix C: Interview Guide for Midwives and Doctors 
A. Perceived decision-making process and expectations for women to attend ANCldeliver 
at a facility/attend postnatalDPlease take a moment to think about your work on the 
ANCllabor and delivery ward/postnatal and your patients. 
I. In your opinion, why do women seek care at facilities for [ANC, Labour, Postnatal]? 
2. In your opinion, how is the decision made for women to seek care at facilities [ANC, 
o Labour, Postnatal]? 
3. In your opinion, what do patients expect when they seek care at the facility for [ANC, 
o Labour, Postnatal]? Explore factors such as. 
a. Structural factors: Infrastructure, interpersonal relation, health workforce 
b. Process factors: safety, effective, patient centred ness, timeliness of service 
c. Outcome factors: comfort, satisfaction 
4. What do you think patients NEED when they seek care at the facility for [ANC, Labour, 
Postnatal]? Please explain. 
a. Structural factors: Infrastructure, interpersonal relation, health workforce 
b. Process factors: safety, effective, patient centreciness, timeliness of service 
c. Outcome factors: comfort, satisfaction 
B. Dimension and Tenets Quality Maternal Care 
Now I would like to ask your opinion on the dimension that should be included when 
measuring quality of maternal care during labor and delivery. 
5. What is quality of maternal health care? 
6. How should quality of maternal health care be measured? Probe on dimensions 
a. Providers Perspective 
b. Clients perspective 
7. What items should be considered when designing a measurement tool to assess quality 
of Dmaternal health? 
a. Structural factors: Infrastructure, interpersonal relation, health workforce 
b. Process factors: safety, effective, patient centredness, timeliness of service 
c. Outcome factors: comfort, satisfaction 
8. Which of these dimensions do you consider very important? Please explain. 
9. In your opinion, what could be done to improve the quality of maternal health for 
women Dduring ANC, labor and delivery, postnatal? 
C. Perceived factors that influence quality of maternal health care in the facilities 
10. In your opinion, what are the factors that influence quality of maternal health care? 
Probe: 
a Related to supplies (availability of medication, equipment) 
b. Related to health provider staffmg (number of staff, attitude towards patients) 
c. Related to patient load (number of patients, overcrowding) 
d. Related to your health facility (policies, infrastructure, services) 
II. In your opinion, what could be done to improve maternal health care? 
72 
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Appendix D: Focus Discussion Guide for Women 
A. Perceived decision-making process and expectations for women to attend ANC/deliver 
at a facility/attend postnatalOPlease take a moment to think about your work on the 
ANCllabor and delivery ward/postnatal and your patients. 
1.10 your opinion, why do women seek care at facilities for [ANC, Labour, Postnatal]? 
2. 10 your opinion, how is the decision made for women to seek care at facilities [ANC, 
OLabour, Postnatal]? 
3. In your opinion, what do patients expect when they seek care at the facility for [ANC, 
J Labour, Postnatal]? Explore are such. 
a. Structural factors: Infrastructure, interpersonal relation, health workforce 
b. Process factors: safety, effective, patient centredness, timeliness of service 
c. Outcome factors: comfort, satisfaction 
4. What do you think. patients NEED when they seek care at the facility for [ANC, Labour, 
Postnatal]? Please explain. 
a. Structural factors: Infrastructure, interpersonal relation, health workforce 
b. Process factors: safety, effective, patient centredness, timeliness of service 
c. Outcome factors: comfort, satisfaction 
B. Dimension and Tenets Quality Maternal Care 
Now I would like to ask your opinion on the dimension should be included when 
measuring quality of maternal care during labor and delivery. 
S. What is quality of maternal health care? 
6. How should quality of maternal health care be measured? Probe on dimensions 
a. Providers Perspective 
b. Clients perspective 
7. What items should be considered when designs a measurement tool to assess quality of 
Omaternal health? 
a. Structural factors: Infrastructure, interpersonal relation, health workforce 
b. Process factors: safety, effective, patient centredness, timeliness of service 
c. Outcome factors: comfort, satisfaction 
8. Which of these dimensions do you consider very important? Please explain. 
9.10 your opinion, what could be done to improve the quality of maternal health for 
women Oduring ANC, labor and delivery, postnatal? 
C. Perceived factors that influence quality of maternal health care in the facilities 
10. In your opinion, what are the factors that influence quality of maternal health care? 
Probe: 
a. Related to supplies (availability of medication, equipment) 
b. Related to health provider staffing (number of staff, attitude towards patients) 
c. Related to patient load (number of patients, overcrowding) 
d. Related to your health facility (policies, infrastructure, services) 
II. 10 your opinion, what could be done to improve maternal health care? 
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Appendix E: Tool for experts in maternal heaIthcare provision 
Socio-demographic Data of experts 
Age ................................................. .. 
Sex .................................................. .. 
Profession ........................................... .. 
Place of Work ....................................... . 
Number of year working in place ................. . 
Please indicate the degree to which you agree that the following items should be included 
in a tool for measuring quality of matem al health Care 
No Health facility Strongly disagree Undecided Agree Strongly 
disagree Ae:ree 
1 A vailability of health 
facility 
2 Proximity of health 
facility to clients 
3 Health facility being 
spacious to accommodate I 
all clients i 
4 A vailability of adequate ! 
seats 
5 A vailability of adequate 
bed 
Amenities 
6 Availability of adequate 
number of urinals for 
I 
clients I 
7 Availability of adequate 
number of toilets for 
clients I 
8 Toilet is clean and neat 
9 -- - .. Urinal is clean and neat 
-
Environment -
10 Theenvrronmentwithin --f---- ----
the health facility is clean 
11 The envrronment is airy -.----
and fresh 
Privacy 
12 There is privacy in the 
consulting room 
13 There is privacy in the 
examination room of the 
facility 
14 Health providers respect 
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~---- -, 
the privacy of patients 1 -----I ---"----,-~ 
Interpersonal relationship - ---"1 
15 Health care worker 
explained procedure well 
to patients " ~-"-
16 Health care provider treats 
patients with respect .--------..-------"-- ~ ~ 
17 Health care provider 
requested for consent 
before clinical procedure 
----1---- "-
18 Health provider answers 
patients questions 
satisfactorily -
19 Health provider involves 
patient or partner in 
decision-making 
-~ - ---
Human resource ""--
20 Midwives on duty are 
adequate and attend to 
different clients at the 
•• 
same time ~_I _____- f-- --
21 Adequate doctors on duty 1--- ~ t-~-- - -----
22 Availability of health 
assistants to attend to 
clients 
23 Availability of medical 
records staff to facilitate 
fast retrieval of medical 
records 
24 Health care provided to 
patients in a timely ! 
manner without delay 
25 Ability of service 
providers to provide all 
services 
26 Health providers being 
polite to clients i L 
Saf~j" 
27 Measures put in place to --T 
ensure patients safety 
28 The environment in the 
health facility should be 
safe 
Rani e of Services 
29 Availability of all services 
clients required 
30 Availability of expert for 
services in the health 
; facility 
i~ll All service delivery POints 
223 
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-- --
located within the health 
facility ------_._- ---- ---1 
Health Insurance -----,-- --, ~.------- .~--- ---
32 Facility accepting national 
health insurance . 
33 Non-discrimination 
between insured and non-
insured clients -
34 Insurance covering all 
services provided to client ---··----~--I 
Logistics and supplies -~---------.------
35 Availability of prescribed 
medications in the health I 
I 
facility I 
36 A vailabiJity of diagnostic I 
test (Laboratory, 
I 
ultrasound) in the health 
facility - _._--
37 Measures taken to relieve 
pain to patient during 
labour I 
~ -. ---~-- ..~ - ... ~-.- ~- - --1-----
38 Measures to reduce pain 
during labour is effective 
~~ 1---- ~~-.~--~- -----~--
39 Infonning patient on 
nature of pain 
Satisfaction/wellbeing 
40 Client satisfied about 
treatment outcome for self --
41 Client satisfied with 
treatment outcome for 
baby I 
42 General satisfaction about 
treatment received at I 
health facility 
-~-~--
43 Satisfaction about health 
care providers attitude 
44 Satisfaction about -l 
education received on 
condition I 
-- ----._-----
45 ----Satisfaction about --~~-·-~I 
interpersonal 
communication between I 
health care provider and 
clients 
46 Satisfaction about review 
infonnation received from 
health care providers 
Outcome 
47 Maternal health outcome 
satisfactory 
224 
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'1 ··outcomeol"Woy 
. ··N<>in;ury to baby and 
: roodlet 
so Live birth achieved 
51 Overall rating health 
facility 
52. In your opinion, do you think there is/are other important indicator(s) to measure 
quality of maternal care that probably was not included in this developed tool? 
D No 
D Yes 53. If your response to question 52 is a "Yes", please indicate clearly which 
indicator(s) you think could be added to the tool to measure quality of maternal healthcare. 
a.  
............................................................................................................. 
b . 
............................................................................................................. 
c.  
................ ............................................................................................  
d . 
.............................................................................................................. 
e . 
.............................................................................................................. 
f.  
............................................................................................................. 
g. ........................................................................................................ . 
Slightly Moderately Very satisfied with 
satisfied satisfied the content of the 
developed tool 
225 
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Appendix F: Survey questionnaire for women 
226 
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Appendix G: Quality of Maternal HealthCare (Final Tool) 
SD D N A SA 
Domains and items 
Health Facility Domain 
1. Proximity of health facility to clients (less than 5km) 
2. Health facility is spacious to accommodate all clients 
3. Health facility has seats 
Amenities Domain 
4. Health facility has adequate urinals for clients 
5. Toilet is clean and neat 
6. Urinal is clean and neat 
Environment Domain 
7. The environment in health facility is clean 
8. The environment is ail)' and fresh 
Privacy Domain 
9. There is privacy in the consulting room 
10. There is privacy in the examination room 
11. Healthcare providers respect clients' privacy 
Inter-personal relationship domain 
12. Healthcare worker provided adequate information and education on 
your pregnancy 
13. Healthcare worker explained procedures to you 
14. Healthcare provider treated you with respect 
15. Healthcare provider requested your consent before clinical 
procedures 
16. Health provider answered your questions satisfactorily 
17. Health provider involved you or partner in your care decision-
making 
18. You have home visitation after the delivery at the health facility 
19. You felt discriminated against at any point in time in the health 
facility because you do not come from a rich background 
20. Women who are richer are treated much faster and better in the 
health facility than poor women 
21. Healthcare providers are polite to clients 
SO= Strongly disagree, D=Oisagree, N= Neutral, A = Agree, SA = Strongly agree 
227 
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SO 0 N A SA 
Domains and items 
Human resource domain 
22. Midwives on duty were adequate and attending to different clients at 
the same time 
23. Doctors on duty were enough 
24. Healthcare providers are readily available to assist clients 
25. Medical records staff are readily available to facilitate fast retrieval of 
medical records 
26. Healthcare provided to you in a timely manner without delay (within 1 
hour) 
27. Service providers can provide needed services to you 
Safety domain 
28. Adequate measures put in place to ensure patients' safety 
29. I feel the environment in the health facility is safe (e.g. free from 
dangerous animals and hazards) 
Range of services domain 
30. Health facility has all services I needed 
31. Health facility has adequate specialists/experts to provide services I 
need in the health facility 
32. Health facility has an effective referral system in place 
Health insurance domain 
33. Health facility accepts health insurance 
34. There is discrimination between insured and non-insured clients at 
health facility 
SD= Strongly disagree, O-Disagree, N- Neutral, A - Agree, SA = Strongly agree 
228 
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SD DNA SA 
Domains and items 
Logistics and supplies domain 
35. You pay for the medications that you get at the health facility 
36. You buy your medication outside the health facility 
37. You have to walk for long distance in order to get the medicines 
that are available at the health facility 
Pain management domain 
38. Measures to reduce pain during labour are effective 
Clients' satisfaction domain 
39. You are satisfied about treatment outcome for yourself 
40. You are satisfied with treatment outcome for your baby 
41. You are generally satisfied with treatment received at health 
facility 
42. You are satisfied with healthcare providers' attitude 
43. You are satisfied with education received on condition 
44. You are satisfaction with inter-personal communication between 
healthcare provider and clients 
45. You are satisfied with review information received from 
healthcare providers 
Outcomes domain 
46. No injury to mother 
47. Live birth achieved 
SD= Strongly disagree, D=Disagree, N= Neutral, A = Agree. SA = Strongly agree 
229 
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Appendix H: Ghana Health Service Ethical Clearance Form 
O. ..... H.;.id;S.;.;~ 
P. O. Bo. MB 190 
Accra 
r.l. • ]))-J01-68I1{)9 
Fa + lJJ..J0J-68$4U 
£_I:~"II'<JRI 
Victoria Sharon-Lisa Mumuni 
School of Public Heallh 
U/liversity of Ghana 
Leaon. P. O. Box 3994 
Accra-Ghana 
The Ghana Hcalll, Service [Ihies Revi .... Comm,IIee has revic"ed mal Biven approv.1 for Ihe implOlllenlllllon of 
your Study Protocol. 
~R~UiiibCr-1 ~HS-EltC: Olllll1Oto 
Projec:1 Titl. -- QualilY of P""parlum Care in Northem Ohana 
Approval Dale 14" March. 2017 __. ._ ..  _. __ -------1 
Expirv Date 13'" March. 2018 
LG~·Hc::S.:::.F.~.R:!:C::..D::::ec=is!::io:::.n __L .!A.!l.p~prrll::.:,~·ed=-____ ._ _. _ ________________. ..... 
T~ia .pprov.I requires Ih. rollowine from rh. PrindpalloveotillAlor 
• ~ubmi.sion of yearly pro8R" report oflhe srudy to !he Ethie» Review Commiu.., (ERC) 
• Ren.".l ofetl.ical appro,a! ifth. sludy luis for more than 12 monlha. 
• Reportina of all .erious adverse evenls related 10 this study to rhe ERC within three daYI verbally and 
seven days in writil1g. 
• Subnll ..i on of a final repan after completloa of the study 
• Informilltl ERC ir.ludy CIII1nol he implomenled or ill discontinued and reasons why 
• Infonnlnillhe ERC and )'Our 'p""""r ("here applicable) before any publication oflbe research ftndinas. 
PI.- note thai allY modiOcalion oflhe study "ilhonl ERC appronl oflhe amendmeiil'is invalid. 
The ERC may observe or cause 10 be observed procedures and records of Ihe study during and after 
implementalim. 
Klndl} quote Ihe protocol idenlification numher in all futu.., correspondence in relation to this approved protocol 
SIGNED ... sl~:o.-.~ ... : .................. . 
DR. CYNTHIA BANNERMAN 
(GHS-ERC CHAIRPERSON) 
Ce; The Director. Roseateb '" Oew~l Division. Ghana Health Service, Accra 
230 
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Quality of Maternal Health Care In Northern Region of GhlJ/l. 
P.,.10'22 
RECORD ID 
Record ID 
J $t category does this facility belong? o government 
o private 
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Quality of Maternal Health Care In Northern Region of Ghana 
Page 2 of 22 
Section lA: Identification For Clients 
~ Name of Interviewee 
i----------------------
i COMPOUND NAME/ID 
DATE OF INTERVIEW 
NAMES OF FIELD-WORKERS ooo 
 Sadla 
Joyce 
o  Ramatu Ibrahim 
. NAME OF DISTRICT o Tamale Metro 
NAME OF DISTRICT o Sagnarigu 
1i --------------------NAME OF DISTRICT o Kumbungu 
NAME OF DISTRICT o Savelugu 
'j~ME OF SUB-DISTRICT 
l! .-.-. ----------------------------------o-- -----------------------------rnSTRICT CLASSIFICAn ON urban o rural 
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Quality of Matemlll Health Care in Northern Region of Ghllna 
,.30f22 
Section IB: Background Characteristics of Respondents 
How old are you now? 
«Complete years» 
What Is the highest level of school you attended? o No Formal education 
oo  Primary Middle/JSS 
oo  Secondary/SSS , Tertiary/Higher 0 Vocational 
I-------------------------------------
! What Is the highest level of school you attended? 
(other (specify)) 
I What is your religion? o Traditional 
i o Christianity 
Olstam 
What is your religion? 
(other (specify)) 
Ihat is your Tribe? oo  Dagomba Mamprusl 
oo  Bimoba Kusaasi 
What is your Tribe? 
(other (specify)) 
What is your marital status now? 
oo  Never married Married 
oo  Living together Divorced 
oo  Widowed Separated 
I Mlat is your marital status now? 
I'Ihat is your main occupation? 
oo  Farmer o Trader o Housewife o Civil servant/Public Servant o Student Artisan 
What is your main occupation? 
(other (speCify» 
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'age 4 of 22 
~~-. - -----------------------------------makes decision on type of health care members of 0 Self 
this household seek? o0  Father/inlaw o Mother/inlaw o Husband Co-wife 
o Grandparents 
1-------------------------------------------------------------------------------
: Have you ever been pregnant 0 yes 
Ono 
o don't know 
Number of pregnancies 
I. ..., o f delweoilesl 
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Quality of Maternal Health Care In Northern RegJoII or (imma 
PBlJe5of11 
Section lC: Access to Maternal Health Care 
To what extent do you sometimes worry about how you aa  Do not have to worry at all ~ave to transport yourself to the health facility a I worry some of the times a I worry most of the times I worry all of the times 
What is the distance from your house to the health aa  < 30 mins walk fdtY? a 30 mlns - 1 hour walk a 1 - 2 hours walk a 2 - 3 hours walk > 3 hours walk 
i What is usually the mode of transportation to the aa  By walking J 'lealth facility a By bicycle a By motorcycle a  By Tricycle (motor) By car 
I What Is the time spent at the health facility before 
aa  < 30 mins , seen by a doctor/midwife a 30 mins - 1 hour a 1· 2 hours 2 - 3 hours 
a> 3 hours 
I15  the sanitation at the health facility hygienic a one (where one(l) is low and five(5) Is high o two 
j oo  three four 
o five 
Availability of health facility o yes 
oO no don't know 
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fitientJal Quality of Matem,1 Health Care In Northern Region of Ghana 
page 6 of 22 
Section ld Quality Of Maternal Health Care 
Are there measures to reduce pain during labour o yes 
Ono 
o don't know 
Food was provided by the facility when I was on o yes 
admission Ono 
If any Item on this page does not apply to you then leave the Item blank. In the following 
section, evaluate the number of times you carried out maternal health care; (l) being low to 
(S)"belng high. . eM!" r .,,@'tl1 C 
strongly disagree disagree neura agree strongly agree 
Proximity of health facility to 0 0 0 0 0 
clients (less than Skm) 
Health facility being spacious to 0 0 0 o 0 
accommodate all clients 
Availability of adequate seats 0 0 0 o 0 
agree strongly agree 
Availability of adequate urinals 0 0 0 o 0 
for clients 
Availability of toilets facilities 0 0 0 o 0 
separated for males and females 
Toilet is clean and neat 0 0 0 o 0 
Urinal is clean and neat 0 0 0 o 0 
..,~ ~ or. 
environment .': ~ ~~,"jR_ 
strongly disagree disagree neural 
The environment in health o 0 o 
facility is clean 
The environment is airy and o o o o o 
fresh 
strongly disagree disagree neural agree strongly agree 
There is privacy in the consulting 0 o o 
room o o 
There is privacy in the o o o o 
examination room of the facility o 
Health providers respect the o o o 
pnvacy of patients o o 
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I'age 70(11 
Health care worker provided 0 0 0 
adequate information and 
education on my pregnancy 
0 
Health care worker explained 0 0 0 0 
procedure to you 
Health care provider treated you 0 0 0 0 0 
with respect 
Health care provider requested 0 0 0 0 0 
for consent before clinical 
procedure 
Health provider answered your 0 0 0 0 0 
questions satisfactorily 
Health provider involved you or 0 0 0 0 0 
partner In decision-making 
You have home visitation after 0 0 0 0 0 
the delivery at the health facility 
You feel discriminated at any 0 0 0 0 0 
point in time In the health facility 
because you do not come from a 
rich background 
Women who are richer than you 0 0 0 0 0 
are treated much faster and 
better In the health facility than 
poor women 
agree 
Midwives on duty are adequate 0 0 0 0 
and attending to different clients 
at the same time 
More doctors on duty 0 0 0 0 0 
Availability of people or health 0 0 0 0 0 
assistants to assist clients 
Availability of medical records 0 0 0 0 0 
staff to facilitate fast retrieval of 
medical records 
Health care provided to you in a 0 0 0 0 
timely manner without delay 0 
(within 1 hour) 
Ability of service providers to 0 0 
provide needed services 0 0 0 
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,..80'22 
Health providers are polite to o o o o o 
dients 
strongly disagree disagree neura,Il··algree--stfOllln£I!J!I 
Measure put in place to ensure o o 000 
patient safety 
I feel the environment in the o o o o o 
health facility is safe (e.g free 
from dangerous animals and 
hazards) 
Availability of needed service 0 0 0 0 0 
clients required 
Availability of expert for services 0 0 0 0 0 
in the health facility 
Health facility have effective 0 0 0 0 0 
referral systems in place 
All service delivery points 0 0 0 0 0 
located within the health facility 
Health Insurance ::1?t:i'§iR~F·W' iH 
strongly disagree ( disagree neural 
Facility accepting national health o 0 o 
Insurance 
Non-discrimination between o o o o 
insured and non-insured Clients o 
Insurance covering all services o o o 
provided to client o o 
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Page90f22 
Istles and supplies 
strongly disagree disagree neural agree 
strongly agree 
0 
Availability of prescribed 0 0 0 0 
medications in the health facility 
Availability of diagnostic test 0 0 0 0 0 
(Laboratory, ultrasound) in the 
health facility 
You get all your medication 0 0 0 0 0 
~ithin the health facility 
You pay for the medications that 0 0 0 0 0 
you get at the health facility 
You buy your medication outside 0 0 0 0 0 
tl1e healthy facility 
You have to walk for long 0 0 0 0 0 
distance in order to get the 
medicines that are available at 
the health facility 
Health facility uses manual 0 0 0 0 0 
retrieval of records 
Health facility uses 0 0 0 0 0 
computerized systems for 
retrieval of records 
following section, much that you agree with the statements 
) being low and ( 
agree 
Measures to reduce pain during 0 0 0 
labour are effective 
klforming patient on nature of 0 0 0 0 0 
pain 
Food provided by the facility 0 0 0 0 0 
was good 
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iiim:3i Page 100(22 
Client satisfied about treatment 0 0 0 
outcome for self 
C~ent satisfied with treatment 0 0 0 0 0 
outcome for baby 
General satisfaction about 0 0 0 0 0 
treatment received at health 
facility 
Satisfaction about health care 0 0 0 0 0 
providers attitude 
Satisfaction about education 0 0 0 0 0 
received on condition 
Satisfaction about interpersonal 0 0 0 0 0 
communication between health 
care provider and clients 
Satisfaction about review 0 0 0 0 0 
information received from health 
care providers 
Outcome ""' ..... .:~~ '.~ 
strongly disagree disagree neura agree strongly agree 
Maternal health outcome 0 0 0 0 0 
satisfactory 
Health outcome of baby 0 0 0 0 0 
satisfactory 
No injury to mother 0 0 0 0 0 
Live birth achieved 0 0 0 0 0 
Overall rating of health facility 0 0 0 0 0 
ReSults of the Interview o COMPLETE INTERVIEW 
o INCOMPLETE REFUSED 
o INCOMPLETE TO BE COMPLETED LATER 
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Quality of Niltema/ Health Care In Northem Region of Ghanll 
Pagell of22 
SECTION 2A: IDENTIFICATION - For Health Staff Only 
Name of District o tamale metro 
oo  sagnarigu o savelugu kumbungu 
Name of community where health facility is located 
What type of health facility is this? oOC HPS o Health Centre Polyclinic 
o Hospital 
Date of facility assessment 
For the purpose of this study, the availability or presence of infrastructure, equipment and 
drugs must be observed (or seen) by the study team. If an element Is not observed by the 
team, It should be counted as not available. Exceptions to this rule, should be noted as 
ents under specific questions (In this case, It Is specified to whom the question should 
ked). Conti e study? 
How many minutes does it take to travel by vehicle to 
the nearest higher facility? (If there is no higher 
level facility. answer zero) (enquire from facility 
staff) 
Is telephone services available in this facility? (a o yes 
functional land line or mobile phone) Ono 
Is there a functional and accessible emergency o yes 
transportation in this facility? (Consider Ono 
Observation. If not ask facility staff) 
What is the available mode of transport? 
Does the facility have constant water supply? o yes 
Ono 
What is the main type of water supply 
oo  Piped o Well/Bore Hole o Rain collection River 
o Tanker 
Do cli~nts have access to a working toilet facility? 
'~ulre from facility staff) o yes Ono 
~ ~he facility have separate washrooms or toilet 
IIcHities for clients and staff workers?(enquire o yes 
hm facility staff) Ono 
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page 12 of 21 
I 
I ~s the facility have separate toilet for men and o yes 
women? Ono 
Which major source of power Is available at this 
oo  National Grid facility? Generators 
o Solar 
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QUlll/ty of /ififtemlll Heilith Care in Northern Region of Ghllnll 
Page 13 of 22 
Section 28 - Staffing 
I for the purpose of this study, the team must 0 e ture, equipment and 
drugs are available. If an element is not seen by the team, It should be counted as not 
~lable. '* • ' 
What Is the number of full time Doctors working in 
the facility? (enquire from facility staff) 
What is the number of Part Time Doctors working at 
the facility? (enquire from facility staff) 
What is the number of full time Physician Assistants 
currently working in the facility? (enquire from 
facility staff) 
What is the number of part time Physician Assistants 
currently working in the faCility? (enquire from 
facility staff) 
State clearly the number of midwives currently 
working in this facility? (enquire from facility 
staff) 
State clearly the number of professional nurses 
currently work.ing at this facility? (enquire from 
facility staff) 
State number of (health care assistance clinical) 
nurses currently working at this facility? (enquire 
from facility staff) 
State number of (health care assistance clinical) 
enrolle~ nursing assistants currently working at 
I thiS faCility? (enquire from facility staff) 
What is the number of community health nurses 
cu~~ntly employed at this facility? (enquire from 
faCIlity staff) 
What is the number of laboratory technicians 
currently working at this facility? (enquire from 
faclHty staff) 
Did. ~he district health administration visit this o yes 
faCIlity to supervise activities in the last three Ono 
completed months? (enquire from facility staff) 
State number of times visits were made? (enquire 
from facility staff) 
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QuaRry of Matern.' Health Care In Northern Region of G""". 
PlHJe 14 of22 
section 2C - ANC/PNC 
0;, weekly basis, how many days do pregnant women have 
access to antenatal services at this facility? 
(enquire from facility staff) 
On weekly basis, how many days do clients have access 
to postnatal services at this facility? (enquire 
from facility staff) 
Do ANC/PNC clients have access to waiting seats? oo  None o Yes but not enough Yes enough 
Does the facility have test kits for checking Malaria o yes 
in pregnant women? Ono 
Does the facility have test kits for checking o yes 
Hepatitis B in pregnant women? Ono 
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Quality of Maternal Health Care In Northern Region of Ghana 
Page15of11 
Section 20 - General OPO Service 
;es the facility have General OPD services? (enquire o yes 
from facility staff) Ono 
On weekly basis, how many days do pregnant women have 
access to malaria services at this facility? 
lenquire from facility staff) 
Do clients have access to waiting seats? oo  None Yes but not enough 
o Yes enough 
I Does the facility have a private and obscured place o yes 
used for examination of pregnant women? (enquire Ono 
from facility staff) o dont't know 
Does the facility have a private and obscured place, o yes 
where other clients cannot hear or see while Ono 
I examination Is ongoing? (enquire from facility staff) o don't know 
Which of these equipment is available in the facility o Clinical thermometer 
today? oo  Rapid Diagnostic Test Kit (several) Disposable syringes and needles 
oo  Stethoscope Disposable gloves 
o Canulas 
(Multiple responses allowed) 
Which of these delivery equipment Is available in o Paediatric ventilation bag and masks 
I this facility today? o Adult ventilation bag and masks 
o Filled Oxygen cylinders with Flow Metres 
o Blood Fridges 
o Blood transfusion sets 
(Multiple responses allowed) 
Which of these newborn equipment is available in the o Bag and mask for newborn resuscitation 
facility today? o Suction Equipment (mucuous extractor and suctiol 
machine) 
o Adult weighing scale 
o Paediatric weighing scale 
(Multiple responses allowed) 
Do Newly born babies get timely check up and o yes 
assessment at the facility? Ono 
Do Clients get distribution of mosquito nets from the o yes 
facility? Ono 
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Quality o( Maternal Health CMe In Notthem Region of Gh8na 
".160'22 
section 2E· Laboratory 
ooes the facility have a functioning laboratory? o yes 
Ono 
What about the presence of laboratory technician at o yes 
the facility? Ono 
Which lab tests or scans do clients receive in the o ROn - Wet mount 
facility? (enquire lab technician) 
oOHB o  Random Blood Sugar o Full blood Count o Blood Grouping and Matching Urine analysis 
o Renal/Kidney Function test 
OX-ray 
(Multiple responses allowed) 
15 blood in stock in this facility today? o yes 
Ono 
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QUllllty of NatemlJl Health Care In Northern Region of Ghana 
Page J7 of 22 
Section 2F - Pharmacy/essential drugs 
Do you have drugs in this facility? o yes 
Ono 
;e there drugs in this facility purposely to augment o yes 
labor? Ono 
Mention types of drugs you have to augment labor? 
Does this facility accept National Health Insurance? o yes 
Ono 
Does the insurance cover all the drugs you have o yes 
mentioned? Ono 
What about the presence of anti-malarial drugs for o yes 
pregnant women? Ono 
Does the facility use computerised record keeping o yes 
JtStems7(enquire from facility staff) Ono 
Does the facility have ambulance services?(enquire o yes 
from facility staff) Ono 
What type of emergency transportation services are 
available? 
Does the Health facility have effective and trusted o yes 
patient complaint and resolution mechanism in place? Ono 
(enquire from facility staff) 
Is the facility safe or protected from the following? o Rodents 
(TIck where appropriate) o Reptiles 
o Floods 
o Exposed Electrical Wires 
Review monthly records of how many pregnant women o yes 
were seen by trained professionals Ono 
How many patients (pregnant women) visit this 
facility a month 
How many deliveries have you had for the past one 
month 
~s the health facility provide catering services to 
clients on admission? o yes Ono 
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Quality 01 Uatemal Health Care In Notthem Region of Ghana 
,..180111 
Section 2G: Quality of Maternal Health Care-Facility 
Are there measures to reduce pain when clients are in o yes 
labOur? oOn o don't know 
Does this facility provide food for clients in o yes 
admission? Ono o don't know 
If any item on this page does not apply to you then leave the item blank. In the following 
section, evaluate the number of times you carried out maternal health care; (1) being low to 
!} being high. .lib _. $ 
strongly disagree disagree neural agree strongly agree 
Proximity of health facility to 000 0 o 
clients (less than 5km) 
Health facility being spacious to o o o o o 
accommodate all clients 
Availability of adequate seats o o o o o 
strongly disagree disagree neural agree strongly agree 
Availability of adequate urinals 0 o 0 0 0 
for clients 
Availability of toilets facilities 0 o 0 0 0 
separated for males and females 
Toilet is clean and neat 0 o 0 0 0 
Urinal is clean and neat 0 o 0 0 0 
The environment in health o 0 
facility is clean 
The environment is airy and o o 0 
fresh 0 0 
strongly disagree disagree neural agree strongly agree 
There is privacy in the consulting 0 
room o o o o 
There is privacy in the o o 
examination room of the facility o o o 
H~alth providers respect the o o 
privacy of patients o o o 
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Page 19 of 22 
Iiealth care provider provide 0 0 
adequate information and 
education on pregnancies 
0 
Health care workers explain 0 0 0 0 
procedures to be taken to clients 
Health care workers provide 0 0 0 0 0 
treatment to clients with respect 
Health care provider request for 0 0 0 0 0 
consent before clinical 
rea1~~';Jr~~ider answer clients 0 0 0 0 0 
questions satisfactorily 
Health provider involve clients or 0 0 0 0 0 
their partner in decision-making 
Health provider do home 0 0 0 0 0 
visitation after the delivery at 
the health facility 
Health care provider 0 0 0 0 0 
discriminate against clients at 
any point in time in the health 
facility because of a client's 
financial background 
Women who are richer than their o o o o o 
counterparts are treated much 
faster and better in the health 
facility than poor women 
strongly dIsagree disagree neural agree strongly agree 
Midwives on duty are adequate o o o o o 
and attending to different clients 
at the same time 
They are more doctors on duty o o o o o 
Availability of people or health o o o o o 
asSistants to assist clients 
Availability of medical records o o o o o 
staff to facilitate fast retrieval of 
medical records 
Health care services are o o o 
provided in a timely manner o o 
WIthout delay (within 1 hour) in 
this facility 
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0 0 
Ability of service providers to 0 0 0 
provide needed services 
0 0 0 0 0 Health providers are polite to 
dients 
~afety :J. 
strongly disagree disagree neural agree strongly agree 
Measure put in place to ensure o o o o o 
patient safety 
I feel the environment in the o o o o o 
health facility is safe (e.g free 
from dangerous animals and 
hazards) 
Range of Services 
strongly disagree disagree neural agree strongly agree 
Availability of needed service o o o o - 0 
dients required 
Availability of expert for services o o o o o 
in the health facility 
Health facility have effective o o o o o 
referral systems in place 
All service delivery points o o o o o 
located within the health facility 
Health Insurance 
strongly disagree disagree neural agree strongly agree 
Facility accepting national health o o o o 0 
insurance 
Non-discrimination between o o o o o 
insured and non-insured clients 
Insurance covering all services o o o o o 
provided to client 
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Page 2l 0122 
Lc!glstlcs and supplies 
strongly disagree disagree 
Availability of prescribed 0 0 
medications in the health facility 
Availability of diagnostic test 0 0 0 0 0 
(Laboratory, ultrasound) in the 
health facility 
All medications are within the 0 0 0 0 0 
health facility 
Clients pay for the medications 0 0 0 0 0 
they get at the health facility 
Clients buy medication outside 0 0 0 0 0 
the healthy facility 
Clients walk for long distance in 0 0 0 0 0 
order to get the medicines that 
are available at the health 
facility 
Health facility uses manual 0 0 0 0 0 
retrieval of records 
Health facility uses 0 0 0 0 0 
computerized systems for 
retrieval of records 
in the following section, evaluate how much that you agree with the state.. men. t. s presented "=" with (1) being low and (5) being high. ___ _ ":fMW\-. _.<  
strongly disagree disagree neural agree strongly agree 
Measures to reduce pain during 0 0 0 0 0 
labour are effective 
Inform patients on nature of pain 0 0 0 0 0 
Health facility provide food for 0 0 0 0 0 
admitted clients all the time 
Food provided by this facility is 0 0 0 0 0 
good 
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Clients are general satisfied with 0 0 0 
treatment outcome for them 
Clients are satisfied with 0 0 0 0 0 
treatment outcomes for babies 
There is general satisfaction 0 0 0 0 0 
about treatment received at 
health facility 
Clients are satisfaction with 0 0 0 0 0 
health care providers attitude 
Clients are satisfied with 0 0 0 0 0 
education received on their 
condition 
Clients are satisfaction about 0 0 0 0 0 
interpersonal communication 
between health care provider 
and clients 
Clients are satisfaction about 0 0 0 0 0 
review information received 
from health care providers 
Outcome A,.::,/2I 
strongly disagree disagree 
Over all this health facility o o o 
performs very well 
Results of the interview 
oo  COMPLETE INTERVIEW o INCOMPLETE REFUSED INCOMPLETE TO BE COMPLETED LATER 
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