Abstract
Objective: To describe aspects that create positive experiences for emergency obstetric care (EmOC) clients in public health facilities in Ethiopia.
Design: A qualitative contextual descriptive phenomenological design was used in this study.
Subjects and setting: In-depth interviews were conducted with women who had complications during childbirth and received EmOC in three hospitals in Addis Ababa.
Outcome measures: Content analysis was used to analyse data as it complies with the phenomenological data analysis. The data were analysed using the Atlas ti version 6.2 qualitative data analysis software.
Results: Care that is life-saving, safe, timely, responsive and given in a clean environment, where the service carers show humility, respect, equal treatment and encouragement in an effort to meet the clients’ needs and expectations, creates a good experience.
Conclusion: Clients’ experiences during the provision of EmOC influence their future decisions on whether to seek care or not. The findings of the study along with the developed guidelines will assist in the improvement of the provision and utilisation of EmOC at public health facilities in Ethiopia.
Introduction
Emergency obstetric care is a strategy that reduces maternal mortality through the treatment of obstetric emergencies in hospitals and health centres.Citation1 Various studies have revealed that emergency obstetric care (EmOC) can significantly reduce maternal mortality through the provision of lifesaving interventions for potential life-threatening obstetric complications.Citation2–4 However, the potential of EmOC in the prevention of maternal deaths is not realised in countries with a high burden of maternal mortality. In Ethiopia for example, only 10% of health facilities had fully functioning EmOC facilities. Furthermore, the functioning EmOC facility to population ratio is 0.6 per 500 000, which is significantly below the recommended 5 EmOC facilities to 500 000 population ratio.Citation5 The unmet need for EmOC is high, as also very low, 3%, of all childbirths took place in fully functioning EmOC facilities and only 3% of women who had major direct obstetric complication were treated in EmOC facilities. Thus, the failure to prevent maternal deaths emanates from a poor functional status and a low utilisation of EmOC services.
The quality of EmOC provision generally remains poor in most public health facilities in Ethiopia and other developing countries in general.Citation5–9 Nearly half, 44%, of the hospitals in Ethiopia provided poor quality EmOC as measured by direct obstetric case fatality rate and the quality of EmOC provision is low in the country.Citation5 Maternal mortality can hardly be reduced without access to EmOC services and without the ability to treat women with obstetric complications.Citation10,11 It is therefore important to improve the provision and utilisation of EmOC in order to treat the majority of obstetric complications.
The utilisation of EmOC can be improved by creating a good experience of care for clients who arrive to receive EmOC. However, the client’s view and perspective on quality of EmOC provision remain relatively unexplored. Therefore, the current study aimed at exploring and describing the clients’ views and perspectives on the quality of EmOC provision.
Theoretical framework of the study
This study used the provision and experience of care model as its theoretical framework (Figure ). The model classifies quality of care in maternity services in to two dimensions, which are provision of care and experience of care.Citation11 The model helps to explore and describe the patient’s perspectives on quality EmOC as patient experience is one of the dimensions of the model.
Figure 1: Conceptual framework for the quality of care in maternity servicesCitation12
Problem statement
Direct obstetric complications, which account for the leading causes of maternal deaths, remain untreated or poorly treated in Ethiopia as evidenced by a poor functional status and low utilisation of EmOC. Client-focused EmOC provision and the creation of a good client experience of EmOC enhances the provision and utilisation of EmOC. Yet there is sub-optimal knowledge on aspects of the experience of EmOC clients. This study therefore sought to examine the aspects that create positive experience for emergency obstetric care (EmOC) clients in public health facilities in Ethiopia.
Method
The study was conducted among women who had obstetric complications and received EmOC in three high-clientele-loaded hospitals in Ethiopia. The three hospitals, located in Addis Ababa, had a childbirth attendance of 10 977 in a year, which made it suitable for this study. An exploratory and descriptive phenomenological qualitative research design was used to enhance exploration and description of the experiences of EmOC clients at public health facilities in Ethiopia.
The target population includes women who had complications during childbirth and received EmOC at three hospitals in Addis Ababa. A purposive sampling technique was utilised to select 12 participants for the study.
A semi-structured interview questionnaire was used to collect data. The instrument was structured with open-ended questions to enhance the richness of data. Pretesting was done a week before the actual data collection to streamline the questionnaire and ensure that the research questions brought forth the required information. Two key informant interviews were conducted with patients who had direct obstetric complications and had received EmOC. In-depth interviews were held with women who had complications during childbirth and received EmOC. The interviews were conducted in the obstetric wards of the hospital.
Content analysis was used to evaluate the data as it complies with the phenomenological data analysis. The data were analysed using the Atlas ti version 6.2 qualitative data analysis software.
Ethical clearance was obtained from the Research and Ethics Committee of the Department of Health Studies at the University of South Africa (UNISA). Approval to collect data was obtained from the Addis Ababa City Government Health Bureau. The study complied with the moral principles of respect for persons, avoidance of harm, beneficence and justice.
Findings
Participants’ demographic data
The participants of the study were 12 clients who had had direct obstetric complications and received EmOC in high-clientele hospitals in Addis Ababa. Most of the participants, 67%, were in the age range between 25 and 29 years. Some 42% of the participants were pregnant for the first time, while 25% had been pregnant twice. More than half of the participants had given birth for the first time. Among the participants who were pregnant in the period prior to the study, 43% had a history of obstetric complications (Table ). However, only 7 of the 12 participants (5 participants did not respond) responded to the question concerning their history of obstetric complications.
Table 1: Demographic profile of participants (n = 12)
In-depth interviews
Five themes emerged from the analysis of the in-depth interviews. The themes were: EmOC quality as perceived by clients, EmOC that created a good experience for the clients, causes of clients’ disappointment with EmOC, barriers for use of EmOC and barriers for the provision of quality EmOC at public health facilities as perceived by clients.
The scope of this article is to describe the nature of the experience of EmOC clients in public health facilities. The client’s experiences of EmOC considered here comprise safety, availability, accessibility, interpersonal relations, physical structure, care coordination and organisation (Figure ).
Figure 2: Clients’ aspects of EmOC experience
The aspect of safety of EmOC describes care that does not bring other health problems in the course of receiving EmOC. Clients fear that compromised quality EmOC provision exposes them to diseases, as others who also are receiving care in the public health facility are not healthy: ‘When you come here for treatment, you don’t have to get another illness. Here, those who are not sick do not come …’.
Clients especially feel that they are at high risk of HIV infection during delivery. This fear compelled some clients to suggest a separate provision of EmOC for people living with HIV (PLWHA). They explained that they did not intend for the PLWHA to be stigmatised, but advocated for separate care for PLWHA in order to avoid risks of HIV infection: ‘separate care for those PLWHA…. I am not saying they should be stigmatised … .’
Cleanliness of public health facilities indicates to the client that providers care and there is a good quality EmOC. Safety of EmOC is compromised when facilities do not maintain cleanliness: ‘Quality delivery care means how the delivery is clean and all including the house/structure…. Starting from the housing structure up to instruments….’
Availability describes an EmOC in which lifesaving intervention service is rendered all the time. Clients perceived that the availability of EmOC ensures that treatment can be obtained without an appointment. In other words, care is always available: ‘You will get treated as a client without any appointment.... You will finish timely … you will get what you need….’
The aspect of accessibility of EmOC ensures that clients receive lifesaving interventions whenever they need them. Accessibility of service is made possible through having physicians on call beyond the normal working hours, to complement the skills of midwives who run shift duties: ‘They [providers who performed operations] were not there [in the public health facility] … they were called and brought by car to save my life … This is very pleasing …’; ‘when it was beyond their capacity, they called the doctor around 4 am …. He [the doctor] came and operated because my blood pressure was high … that is how I am here today …’
The health infrastructure is considered by patients as a safety issue rather than a luxury. Larger rooms are preferred to avoid congestion. Also, cleanliness of instruments is key for clients. In one of the public health facilities there was only one toilet facility; yet it was not clean, thereby raising concerns regarding exposure to diseases: ‘Many people are staying in one room … we all have bleeding … there is [offensive] smell … if you count there is about 20 beds in one room … this will expose you to diseases ….’
The interpersonal aspect within EmOC provision comprises compassionate care, emotional support, dignity and respect, information and advice. The provision of compassionate care is warmly welcoming and treating clients, with humility and respect.
The delivery service of the hospital is good…. They understand your stress…. They don’t have pride of being a doctor…. When I was in stress … it is the doctor who put my shoes on for me…. This was not so in the past … he was carrying the IV bag for me. Their care is good especially the doctors … even more, it is good for others in lower position to learn from the doctors….
Clients expect encouragement from healthcare workers, which they consider as assisting them relieve their stress. It gives strength to bear the challenges: ‘They warmly welcome you and show you a good face … but when you come for delivery care, they treat you badly like a dog ….’;
‘They were encouraging me. They say “you will be okay” … encouraging for a human being is very good thing …. They say don’t worry ….’
Clients value the information and advice they receive from care providers: ‘They also are good in information. They write. They have checked us a moment ago …’; ‘they advise you and tell you how to take care ….’
The aspects relating to care coordination and organisation describe for care both the newborn and the client; and how organised and coordinated the care provision is.
They check you regularly; they check the heartbeat of the baby ….
They did their best to save my life … when it was beyond their capacity; they called the doctor around 4 am ….
Everyone takes good care of you and [they] work together to save your life when you are under stress and a difficult situation, especially the doctors ….
Discussion
EmOC provision that ensures availability, accessibility, safety, and good interpersonal relations, well-coordinated and organised care in a good physical structure creates good experiences for EmOC clients. This finding relates to the five categories of clients’ important aspects of care reported by Regula, Miller, Mauger and Marks, which are treatment, access to care, professional interactions, follow-up care and environment of care.Citation13 The clients’ perception of quality of EmOC also complies with the six dimensions of quality as defined by IOM and WHO. The WHO dimensions of quality of care include effectiveness, efficiency, accessibility, acceptability, equity and safety.Citation14 The six dimensions or characteristics of quality of care according to IOM are safety, timeliness, effectiveness, efficiency, equitableness and being client centred. These dimensions are complementary and synergistic.Citation15
Cleanliness for clients is a safety issue rather than a luxury. Clients’ preference for a place of delivery includes consideration of the level of cleanliness of the health care environment. Environmental factors play a crucial role in causing health-care-associated diseases.Citation16 About 1.4 million people suffer from hospital-acquired infections at any given time.Citation17 Concern with the safety of EmOC provision conforms to the human and physical resource aspect of the experience of care model: that the physical infrastructure and the overall maternity wards are acceptable to all women.
Availability of EmOC enhances the utilisation of EmOC services. Opening hours and availability of doctors and midwives were among the accessibility factors that created good perceptions of access to care and quality care in their study.Citation18 Clients seek care from other providers or stay at home when they perceive a service as not available. The literature has shown that one of the reasons for home delivery in Ethiopia is unavailability of health services during nights and weekend hours.Citation19,20 The availability of providers during odd hours to provide EmOC fits with the experience of human and physical resource aspect of the model.Citation21
Compassionate care of providers, listening to clients, encouraging clients, teamwork by providers and lifesaving care created a good experience for clients. This finding was corroborated by Goberna-Tricas, Banús-Giménez and Placio-Tauste, in that women demanded that health professionals be not only technically skilled but also capable of respecting their autonomy and values as women.Citation22 They craved for health professionals to show a caring attitude and empathy.Citation22 Lifesaving interventions also created a good experience. Patients expressed their gratitude to providers as they felt they were near-miss cases and would have died were it not for the help of the providers.Citation23
Clients were relieved from fear, anxiety and stress when encouraged by providers. It gave them the strength to bear the challenges they face. Hospital maternity procedures, specifically vaginal examination and urinary catheterisation, induce fear.Citation24 This finding is corroborated by Kabakian-Khasholian, Campbell, Shediac-Rizkallah and Ghorayeb’s assertion that technical care is intimidating for women and makes them experience discomfort.Citation25
Clients’ experience of care is affected by the amount of information they receive and understand.Citation26 Clients expect clear, sufficient and good provision of information from providers and are less interested when providers give more information without them enquiring. Therefore, clear information should be communicated to the clients in a participatory way. Clients should be fully aware of what is going on and consent before receiving care. Also, informing clients about the care they are to receive ensures the safety and appropriateness of care to the client.
Integrated care refers to care for the mother and the baby. Clients not only consider the care accorded to them but also that offered to the baby. Care for the mother and the baby should not be seen as separate. Clients perceive quality EmOC and define it as the care accorded to both them and their babies. Studies found that the bond between a mother and an infant is a key feature of a woman’s entry to motherhood that can affect their experience of care.Citation22 Hence, clients look for greater possible contact with their infants following childbirth.
Care coordination refers to how the team works together to save lives. Teamwork and coordination among service providers was recognised as good practice that saves lives. Gynaecologists/obstetricians, midwives and nurses were perceived as highly skilled professionals.Citation22 Clients’ experience of care has been affected by lack of teamwork. Some clients felt neglected or ignored by a provider during the daily ward round because caesarean sections had been performed by another provider.Citation23
Conclusion
The client perspective of quality EmOC provision in public health facilities comprised safety, availability, accessibility, interpersonal relations, care organisation and coordination. EmOC provision that incorporates clients’ perspectives creates a good experience and enhances utilisation.
Limitations
The study sample was not representative of all the clients accessing EmOC in Ethiopia, and a qualitative study paradigm was utilised in the study. Therefore, the result of this study is not generalisable.
Recommendations
The findings of the study should be utilised by health workers and policy-makers to create a good experience for clients, with client-focused EmOC provision. Programmes aimed at reducing maternal mortality should ensure provision of EmOC that comprises compassionate care, emotional support, dignity and respect to create a positive experience of EmOC and thereby increase the met need for EmOC. Public health facilities should maintain cleanliness at all times and build the interpersonal skills of providers through training and coaching to provide equitable, ethical, respectful and client-friendly care.
Conflict of interest
The authors declare that they have no financial or personal relationships that may have in appropriately influenced them in writing this paper.
References
- Bailey P, Paxton A, Lobis S, et al. The availability of life-saving obstetric services in developing countries: an in-depth look at the signal functions for emergency obstetric care. Int J Gynecol Obstet. 2006;93(3):285–91.10.1016/j.ijgo.2006.01.028
- Fortney JA. Emergency obstetric care: the keystone in the arch of safe motherhood. Int J Gynecol Obstet. 2001;74:95–7.
- Paxton A, Maine D, Freedman L, et al. The evidence for emergency obstetric care. Int J Gynecol Obstet. 2005;88(2):181–93.10.1016/j.ijgo.2004.11.026
- World Health Organization. Monitoring emergency obstetric care: handbook. Geneva: WHO; 2009.
- Federal Ministry of Health. National baseline assessment for emergency obstetric and newborn care. Addis Ababa: Federal Ministry of Health; 2008.
- Paxton A, Bailey P, Lobis S, et al. Global patterns in availability of emergency obstetric care. Int J Gynecol Obstet. 2006;93(3):300–7.10.1016/j.ijgo.2006.01.030
- Leigh B, Mwale TG, Lazaro D, et al. Emergency obstetric care: how do we stand in Malawi? Int J Gynecol Obstet. 2008;101(1):107–11.10.1016/j.ijgo.2008.01.012
- Ziraba AK, Mills S, Madise N, et al. The state of emergency obstetric care services in Nairobi informal settlements and environs: results from a maternity health facility survey. BioMed Central Health Service Res. 2009;9(46):1–8.
- Gao Y, Barclay L. Availability and quality of emergency obstetric care in Shanxi province, China. Int J Gynecol Obstet. 2010;110(2):181–5.10.1016/j.ijgo.2010.05.001
- Rosenfield A, Maine D, Freedman L. Meeting MDG-5: an impossible dream? Lancet. 2006;368(9542):1133–5.10.1016/S0140-6736(06)69386-0
- Ijadunola KT, Ijadunola MY, Esimai OA, et al. New paradigm old thinking: the case for emergency obstetric care in the prevention of maternal mortality in Nigeria. BioMed Central Women’s Health. 2010;10(6):1–8.
- Hulton LA, Matthews Z, Stones RW. Applying a framework for assessing the quality of maternal health services in urban India. Soc Sci Med. 2007;64(10):2083–95.10.1016/j.socscimed.2007.01.019
- Regula CG, Miller JJ, Mauger DT, et al. Quality of care from a patient’s perspective. Arch Dermatol. 2007;143(2):1589–603.
- World Health Organization. Quality of care: a process for making strategic choices in health systems. Geneva: WHO; 2006.
- Institute of Medicine. Crossing the quality chasm: a new health system for 21st century. Washington, DC: National Academy of Sciences; 2001.
- Pittet D, Allegranzi B, Storr J, et al. ‘Clean care is safer care’: the global patient safety challenge 2005–2006. Int J Infect Dis. 2006;10:419–24.10.1016/j.ijid.2006.06.001
- World Health Organization. Patient safety in developing and transitional countries: new insights from Africa and Eastern Mediterranean. Geneva: WHO; 2011.
- Fotso JC, Mukiira C. Perceived quality of and access to care among poor urban women in Kenya and their utilization of delivery care: harnessing the potential of private clinics? Health Policy Plan. 2011;27(6):505–15.
- Shiferaw S, Spigt M, Godefrooij M, et al. Why do women prefer home births in Ethiopia? BMC Pregnancy Childbirth. 2013;13(5):1–10.
- Gebrehiwot T, Goicolea I, Edin K, et al. Making pragmatic choices: women’s experiences of delivery care in Northern Ethiopia. BioMed Central Pregnancy Childbirth. 2012;12(113):1–11.
- Hulton LA, Matthews Z, Stones RW. A framework for the evaluation of quality of care in maternity services. Southampton: University of Southampton; 2001.
- Goberna-Tricas J, Banús-Giménez MR, Palacio-Tauste AP. Satisfaction with pregnancy and birth services: the quality of maternity care services as experienced by women. Midwifery. 2011;27(6):e231–7.10.1016/j.midw.2010.10.004
- Kabali E, Gourbin C, Brouwere VD. Complications of childbirth and maternal deaths in Kinshasa hospitals: testimonies from women and their families. BioMed Central Pregnancy Childbirth. 2011;11(29):1–9.
- Foster J, Burgos, Lic., MA R, Tejada, Lic., C, et al. A community-based participatory research approach to explore community perceptions of the quality of maternal–newborn health services in the Dominican Republic. Midwifery. 2010;26(5):504–11.10.1016/j.midw.2010.06.001
- Kabakian-Khasholian T, Campbell O, Shediac-Rizkallah M, et al. Women’s experiences of maternity care: satisfaction or passivity? Soc Sci Med. 2000;51(1):103–13.
- Jansen BM, Wiegers TA. Strengths and weakness of midwifery care from the perspective of women. EB Midwifery. 2006;4(2):53–9.