UTILIZATION OF DONABEDIAN THEORY OF EVALUATION OF QUALITY CARE AMONG MOTHERS' MANAGE

1.1 Introduction

Donabedian model health care quality assessment measures the difference between expected and actual performance to identify gaps in the health care system, which would serve as a starting point for quality improvement activities. Health care quality can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes (Gaynor, 2007; Schuster et al., 2005). Widely used in studies of health care quality, links health care services with desired health outcomes and focuses upon the gap between current versus desired practices (Counte, 2007; Crow et al., 2002; Poon et al., 2010).

As a prelude to other parts of this study, this chapter will discuss the background upon which this study was initiated, the statement of problems that led to this study, the Aim and Objectives of the study. Others are Significance of the study, Scope of work, Research hypothesis and questions, Limitations of the Study and Definition of technical terms.

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1.2 Background of Study

Maternal health care is the care a woman receives during conception, delivery, and post- delivery, it is crucial for the survival and well-being of mother and child. It comprises a broad range of services like family planning, prenatal, intrapartum, and postpartum care with the focus of minimizing maternal death and disability (Franny, 2013). The quality of care received during pregnancy and the place of delivery are great determinants of maternal and child morbidity and mortality. Improving and sustaining the quality of care in healthcare institutions has been an area of concerns and recurrent issue over the year. The client’s expression of satisfaction with the quality of health care can provide insightful feedback for healthcare providers, managers and policy makers to direct quality improvement efforts in a right direction (Beattie, Lauder, Atherton, Murphy 2014). Quality assessment is an important aspect of quality assurance which focus on identification of barriers and challenges in a system and not just bad performers (Tobin-West and Anastasia 2016).

Donabedian model was developed in 1966 for assessing healthcare services and to evaluate quality of health care. The model was revised in 1988 and provides information about quality of care using three categories which are structure, process, and outcomes. Structure describes the context in which care is delivered, including hospital buildings, staff, financing, and equipment. Process involves the transactions between patients and healthcare professionals throughout the delivery of healthcare. Outcomes refers to the effects of healthcare on the health status of client and client satisfaction. Since then other quality of care frameworks, including the World Health Organization (WHO) recommended Quality of Care Framework and the Bamako Initiative etc. have been developed but the Donabedian Model continues to be the dominant framework for assessing the quality of health care up till today (Lawson and Yazdany 2012). In 2013, World Health Organization and Partnership for Maternal, Newborn, and Child Health used Donabedian model to develop key indicators for quality in Maternal, Newborn, and Child Health care.

Yearly, about 500,000 women and girls die due to complications arising from pregnancy, labour and or the 6 weeks post- delivery. Majority of these mortality happen in less developed countries (United Nations Millennium Development Goals 2009), making the process of delivery one of the most dreaded journeys for women of child bearing age. This is worrying some as statistical findings showed that the extent of maternal mortality in low and middle income countries resulting from pregnancy and childbirth is on the increase (United Nations Children Fund (UNICEF) Nigeria, 2014).

Similarly, the risk of death from conception and child delivery in Nigeria is ratio 1 to 13.On daily basis, about 2,300 under-five year old children and 145 women in their reproductive years die in Nigeria. With these figures, Nigeria was rated the second largest country contributing to the under–five and maternal death in the world. Many of these deaths could be prevented but for Nigeria’s coverage and quality of health care services that continue to fall short of expectation for women and children. According to United Nations International Children Fund (UNICEF), Nigeria (2014) report, less than 20% of health facilities in the country provide emergency obstetric care (Eoc) and about 35% of deliveries are taken by health professionals.

Improving the quality of obstetric care in facilities has recently been identified as a neglected and essential approach to reducing maternal deaths and enabling developing countries to achieve Sustainable Development Goal 3 (SDG 3) which is good health and well- being especially for women (Van den Broek and Graham 2009). Postpartum hemorrhage is the most frequent cause of maternal deaths globally and in developing countries, accounting for 25% of maternal deaths. Next are hypertensive disorders in pregnancy (PE/E) at 15%, sepsis (8%) and obstructed labor (7%).2 Effective interventions exist for screening, preventing and treating obstetric and newborn complications, and they can be readily provided by skilled providers in facilities. However, achieving both high quality and coverage of these interventions is essential in order to reduce maternal and newborn deaths globally. International evidence suggests that the most important factor in reducing maternal and early neonatal mortality is the attendance of a skilled birth provider and provision of quality care (USAID/MCHIP 2013).

Therefore, in Nigeria where the research was carried out, the activities that was conducted is to utilize the Donabedian Theory of Evaluation of Quality Care among Mothers' Manage in Primary Health Care.

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1.3 Statement of Problems

Investigation revealed that the quality of care received during pregnancy and the place of delivery are great determinants of maternal and child morbidity and mortality (United States Agency for International Development (USAID), 2013).Worldwide significant number of women and girls yearly (almost half a million) die as a result of complications during conception, delivery or 6 weeks post childbirth. Majority of these deaths happen in underdeveloped nations (United Nations Millennium Development Goals, 2009). The risk of death from conception and delivery is in Nigeria is 1 in 13, many of these deaths could have been averted with good coverage and quality maternal and child health care (United Nations International Children Fund (UNICEF), 2014).

Increased mothers and newborn death and morbidity has been linked to poor quality of healthcare services (USAID, 2013), and has been evident by increased death rates that inadequate availability of reproductive health services is an important challenge in Nigeria (WHO Nigeria, 2014). Although progress has been made in increasing the coverage of several key reproductive, maternal, newborn and child health interventions over the past two decades, there has been limited progress in improving maternal and paediatric outcomes because of a major gap between coverage and the quality of care provided in health facilities (WHO, UNICEF, 2014).

Hence, the need to evaluate the maternal and child healthcare services in healthcare facilities in Ile-Ife for quality care to achieve Sustainable Development Goal 3 (SDG 3) which is good health and well-being.

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1.4 Aim and Objectives of Study

The aim of the study is to utilize the Donabedian Theory in the Evaluation of Quality Care among Mothers' Manage in Enugu Primary Health Care. In achieving this aim, the following specific objectives were laid out as follows:

1. To assess the structure of maternal and child healthcare services in Primary and Secondary health facilities;
2. To determine the process of maternal and child healthcare services in Primary and Secondary health facilities;
3. To assess the client’s satisfaction (outcome) with the maternal and child healthcare services in primary and secondary health facilities; and
4. To determine the categories of staff rendering maternal and child healthcare services in Enugu PHC based on Donabedian model.

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1.5 Research Questions

The study came up with research questions so as to be able to ascertain the above stated objectives. The specific research questions for the study are stated below as follows:

• What are the categories of staff rendering maternal and child healthcare services in Enugu PHC based on Donabedian model?
• What is the structure of maternal and child healthcare services in Primary and Secondary health facilities?
• What is the process of maternal and child healthcare services in Primary and Secondary health facilities?
• What is the client’s satisfaction (outcome) with the maternal and child healthcare services in primary and secondary health facilities?

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1.6 Research Hypothesis

In order to pursue the objective of this study, the following generalized statements have been designed to guide and aids in obtaining the result for the experiment to be conducted. For this work, the null hypothesis will be represented with H0 while the alternative hypothesis will be represented with hypothesis H1.

Hypothesis One

• H0: There is no significant difference between the structure of Maternal and Child Healthcare services in Enugu Primary Health Care
• H1: There is a significant difference between the structure of Maternal and Child Healthcare services in Enugu Primary Health Care

Hypothesis Two

• H0: There is no significant difference between the process of Maternal and Child Healthcare Services in Enugu Primary Health Care
• H1: There is a significant difference between the process of Maternal and Child Healthcare Services in Enugu Primary Health Care

Hypothesis Three

• H0: There is no significant difference between the client’s satisfactions (outcome) with Maternal and Child healthcare services in Enugu Primary Health Care
• H1: There is a significant difference between the client’s satisfactions (outcome) with Maternal and Child healthcare services in Enugu Primary Health Care

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1.7 Significance of Study

The following are the relevance of this study:

1. The findings from this study might help with recommendations to improve the quality of maternal and child healthcare services thereby reducing maternal and child mortality and achieve Sustainable Development Goal 3 (SDGs) which is Good health and well- being.
2. The findings may assist the Federal Ministry of Health in adopting strategies to improve the quality of maternal and child healthcare services through collaboration between stake holders.
3. The findings may be useful in National Health Planning and Budgeting to improve the structure of healthcare facilities, training and retraining of staff, supervision, and provision of supplies and transportation for prompt referrals in healthcare facilities.
4. The findings may provide useful information on areas of partnering with local and international agencies for complementary role in maternal and child healthcare services.
5. The outcome of the study may be used to further challenge health professionals to identify factors influencing quality of maternal and child health care services in Nigeria and need for improvement.
6. The findings may add to the existing body of knowledge and would assist in achieving the desired goal of quality maternal and child healthcare services in Nigeria.

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1.8 Scope of Study

The scope of the research is focused on the Utilization of Donabedian Theory of Evaluation of Quality Care among Mothers' Manage in Primary Health Care in Enugu Primary Health Care of Enugu State.

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1.9 Limitations of the Study

During the course of this study, many things militated against its completion, some of which are:

1. Time Constraint: The time frame given to accomplish this project was very short due to school academic calendar and it was carried out under pressure which made the researcher not to implement some necessary features.
2. Research material: availability of research material is a major setback to the scope of the study.
3. Frequent power failure: This made the researcher append more money on fuel to ensure sustainable power.
4. Financial Constraint: Insufficient fund tends to impede the efficiency of the researcher in sourcing for the relevant materials, literature or information and in the process of data collection (internet, questionnaire and interview).

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1.10 Operational Definition of Terms

Quality of Care: Care rendered to women during pregnancy, childbirth, and post-delivery in healthcare facilities based on Donabedian Model of quality care, this include the structure, process and outcome of Maternal and Child Health Care services.

Maternal and Child Healthcare: This is the care rendered to a pregnant woman from the time of conception to the delivery of the baby and care of the baby from birth to 2year in healthcare facilities.

Health Professionals: These are Midwives, Nurses, Community Health officers and Community Health Extension workers that provides Maternal and Child Healthcare services in healthcare facilities by the virtue of their training or qualifications.

Nursing Mothers: Women with babies 0-1year old who have received care during conception, delivery of the baby, after delivery, family planning, immunizations, care of the baby and attends immunization clinic at the time of the study in selected health facilities

Healthcare Facilities: These are Primary Healthcare Centers (PHCs) and Secondary health facilities.

Donabedian Model: This is the conceptual model of quality care developed by Avedis Donabedian in 1966, reviewed in 1980 and 1988. The model was developed to assess quality of care in clinical practice; it has three categories in which information could be gathered for evaluating quality of healthcare services which are structure, process and outcome.