Research Article: Ugandan health workers’ and mothers’ views and experiences of the quality of maternity care and the use of informal solutions: A qualitative study

Date Published: March 11, 2019

Publisher: Public Library of Science

Author(s): Susan Munabi-Babigumira, Claire Glenton, Merlin Willcox, Harriet Nabudere, Kahabi Ganka Isangula.

http://doi.org/10.1371/journal.pone.0213511

Abstract

Although the coverage of maternity services in some low and middle-income countries (LMIC) has greatly improved, the quality of maternity care remains poor, and maternal mortality rates are high. In this study, we describe the meaning and determinants of maternity care quality from the perspective of health workers and mothers in Uganda, the informal solutions used by health workers to manage their daily challenges, and we suggest ways in which maternal care quality can be improved.

We conducted a qualitative study in the Mpigi and Rukungiri districts of Uganda. Twenty-eight health workers based at selected health centres participated in structured interviews. Thirty-six mothers, half of whom had delivered at health facilities, participated in focus group discussions. Data were analysed thematically, and informed by the WHO framework on quality of care for maternal and newborn health and by Lipsky’s street level bureaucracy concept.

According to health workers, knowledge of clinical standards and processes, timeliness, and women’s choice during labour, as well as resources, physical infrastructure; collaboration with mothers, professionals and community health workers; were important aspects of good quality care. Mothers’ perceptions of good quality care were largely similar to health workers’ views, though mothers were more concerned about health workers’ interaction skills. Structural challenges sometimes led health workers to develop informal solutions such as asking mothers to purchase their own supplies with variable implications on the quality of care. While several of these informal solutions were useful in addressing bottlenecks in the health system, they sometimes placed additional burdens and personal costs on health workers, created mistrust, inequity in care and negative experiences among mothers who could not afford the extra costs.

Health system structural factors; including technical, interpersonal, resource and infrastructural factors; impede the provision and experience of good quality maternity care at health centres in Uganda. Improving the quality of care will require strategies that address these core problems in the health system structure. Such structural reforms will require political support to commit resources, skilful management and leadership that seek to change organisational behaviour and build trust through good quality, woman-centred maternity care.

Partial Text

In order to achieve universal health coverage, health services, including maternity services, need to be accessible, affordable, and of good quality [1]. Whereas the coverage of maternity services in low and middle-income countries has greatly improved over the last decade, the quality of maternity care remains poor and is linked to persistent high maternal mortality rates [2, 3]. In Uganda, deliveries in health facilities have increased from 37% in 2000 to 74% in 2016, and the number of women attending antenatal care four or more times has increased from 42% to 60% [4, 5]. However, maternal mortality rates remain high in the country, at 336 per 100,000 live births, and suboptimal quality of care has been suggested among the reasons for this occurrence [6]. Improving the quality of maternity care is therefore a policy priority for Uganda [7, 8].

Twenty eight health workers, 13 from Mpigi district and 15 from Rukungiri district, participated in this study (See Table 3). In addition to providing maternity care, fourteen respondents were managers of the facility or maternity unit. We conducted four focus group discussions (FGD) with 36 mothers. In each district, ten women that had recently delivered at a health facility and eight who did not deliver at a health facility participated in separate focus groups.

This study highlights how health workers and women in a low resource setting view and experience the quality of maternity care. Health workers had clear perceptions about the elements they believed constituted good quality maternity care. These included knowledge of clinical standards and processes, timeliness, and women’s choice during labour. Good quality maternity care also included the resources and physical infrastructure needed to provide care; as well as collaboration with professionals and community health workers, and good relationships between health workers and mothers. Mothers’ perceptions of good quality care were in many ways similar to health workers’ views; although mothers tended to focus more on health workers’ interaction skills, and on the resources and infrastructure available at health facilities and how these influenced their access to care than on health workers’ technical competence. Whereas health workers had a clear understanding of what constituted good quality maternity care, they emphasized how limited resources, poor infrastructure and lack of technical skills prevented them from providing this care. These structural challenges sometimes led health workers to develop informal solutions with variable implications on the quality of care. While several of these informal solutions were useful in addressing bottlenecks in the health system, they sometimes placed additional burdens and personal costs on health workers, created mistrust, inequity in care and negative experiences among mothers who could not afford the extra costs.

Health system structural factors; including technical, interpersonal, resource and infrastructural factors; impede the provision and experience of good quality maternity care at health centres in Uganda. The enactment of good quality care is further undermined when health workers’ relationship with mothers as well as their time and resources are further stretched by informal solutions that try to plug the bottlenecks created by a weak health system. Improving the quality of maternity care will require strategies that address the structural challenges within the health facilities, at policy and governance levels. These strategies could include reconceptualising maternity services to align available resources to key areas of need, and to improve health worker performance and behaviour through managerial mechanisms such as supervision and monitoring. Such structural reforms necessitate political support to commit resources, skilful management and leadership at all levels of the health system that seek to change organisational behaviour and build trust through good quality, woman-centred maternity care.

 

Source:

http://doi.org/10.1371/journal.pone.0213511

 

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