Utilization and quality: How the quality of care influences demand for obstetric care in Nigeria.
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ABSTRACT:
SUBMITTER: Peet ED
PROVIDER: S-EPMC6366755 | biostudies-literature | 2019
REPOSITORIES: biostudies-literature
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Utilization and quality: How the quality of care influences demand for obstetric care in Nigeria.
Peet Evan D ED Okeke Edward N EN
PloS one 20190207 2
This paper examines the association between health facility quality, subjective perceptions, and utilization of obstetric care. We draw on unique survey data from Nigeria describing the quality of care at rural primary health care facilities and the utilization of obstetric care by households in the service areas of these facilities. Constructing a quality index using the detailed survey data, we show that facility quality is positively related to perceptions of quality and utilization. Disaggre ...[more]
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Project description:BackgroundLate arrival in hospital by women experiencing pregnancy complications is an important background factor leading to maternal mortality in Nigeria. The use of effective and timely emergency obstetric care determines whether women survive or die, or become near-miss cases. Healthcare managers have the responsibility to deploy resources for implementing emergency obstetric care.ObjectivesTo determine the nature of institutional policies and frameworks for managing obstetric complications and reducing maternal deaths in Nigeria.MethodsThirty-six hospital managers, heads of obstetrics department and senior midwives were interviewed about hospital infrastructure, resources, policies and processes relating to emergency obstetric care, whilst allowing informants to discuss their thoughts and feelings. The interviews were audiotaped, transcribed and analyzed using Atlas ti 6.2software.ResultsHospital managers are aware of the seriousness of maternal mortality and the steps to improve maternal healthcare. Many reported the lack of policies and specific action-plans for maternal mortality prevention, and many did not purposely disburse budgets or resources to address the problem. Although some reported that maternal/perinatal audit take place in their hospitals, there was no substantive evidence and no records of maternal/perinatal audits were made available. Respondents decried the lack of appropriate data collection system in the hospitals for accurate monitoring of maternal mortality and identification of appropriate remediating actions.ConclusionHealthcare managers are handicapped to properly manage the healthcare system for maternal mortality prevention. Relevant training of healthcare managers would be crucial to enable the development of strategic implementation plans for the prevention of maternal mortality.
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Project description:In this perspective, Andrew Browning of the Fistula Hospital in Addis Ababa discusses a study on obstetric fistula in Ilorin, Nigeria. The study was originally published in the West African Journal of Medicine [1]. With the journal's permission, we have made a PDF of the full-text article freely available on our website (see Text S1). Obstetric fistula causes women enormous distress and social isolation in developing countries like Nigeria. What do we know about the condition?
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Project description:Obstetric Early Warning Systems (EWS) use combined clinical observations to predict increased risk of deterioration and alert health workers to institute actions likely to improve outcomes. The objective of this study was to explore the experience of health workers about the implementation of an obstetric EWS and assess its effectiveness as an alternative clinical monitoring method compared to standard practice. This mixed-method study included obstetric admissions (n = 2400) to inpatient wards between 01/08/2018 and 31/03/2019 at three Nigerian tertiary hospitals (1 intervention and two control). Outcomes assessed were the efficiency of monitoring and recording vital signs using the patient monitoring index and speed of post-EWS trigger specialist review. These were evaluated through a review of case notes before and four months after EWS was introduced. Qualitative data was collected to explore healthcare workers’ views on EWS’ acceptability and usability. EWS was correctly used in 51% (n = 307) of the women in the intervention site. Of these women, 58.6% (n = 180) were predicted to have an increased risk of deterioration, and 38.9% (n = 70) were reviewed within 1 hour. There was a significant improvement in the frequency of vital signs recording in the intervention site: observed/expected frequency improved to 0.91 from 0.57, p<0.005, but not in the control sites. Health workers reported that the EWS helped them cope with work demands while making it easier to detect and manage deteriorating patients. Nurses and doctors reported that the EWS was easy to use and that scores consistently correlated with the clinical picture of patients. Identified challenges included rotation of clinical staff, low staffing numbers and reduced availability of monitoring equipment. The implementation of EWS improved the frequency of patient monitoring, but a larger study will be required to explore the effect on health outcomes. The EWS is a feasible and acceptable tool in low-resource settings with implementation modifications. Trial registration: ISRCTN, ISRCTN15568048. Registration date; 9/09/2020- Retrospectively registered, http://www.isrctn.com/ISRCTN15568048
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Project description:BackgroundMedical ethics is not given due priority in obstetric care in many developing countries, and the extent to which patients value compliance with ethical precepts is largely unexplored.ObjectiveTo describe the expectations and experiences of obstetric patients in South East Nigeria with respect to how medical ethics principles were adhered to during their care.MethodsThis was a cross-sectional, questionnaire-based study involving parturient women followed in three tertiary hospitals in South East Nigeria.ResultsA total of 1,112 women were studied. The mean age of respondents was 29.7 ± 4.1 years. Approximately 98% had at least secondary education. Ninety-six percent considered ethical aspects of care as important. On the average, over 75% of patients expected their doctors to comply with the different principles of medical ethics and specifically, more than 76% of respondents expected their doctors to comply with ethical principles related to information and consent during their antenatal and delivery care. There was a statistically significant difference between the proportions of women who expected compliance of doctors with ethical principles and those who did not (P < 0.001). Multivariate analysis showed that increasing levels of skilled occupation (odds ratio [OR] 9.35, P < 0.001), and residence in urban areas (OR 2.41, P < 0.001) increased the likelihood of patients expecting to be informed about their medical conditions and their opinions being sought. Although the self-reported experiences of patients concerning adherence to ethical principles by doctors were encouraging, experiences fell short of expectations, as the level of expectation of patients was significantly higher than the level of observed compliance for all the principles of medical ethics.ConclusionThe level of practice of medical ethics principles by doctors during obstetric care in South East Nigeria was encouraging but still fell short of the expectations of patients. It is recommended that curriculum-based training of doctors and medical students should be implemented, and hospital policy makers should do more to promote ethical aspects of care, by providing official written guidelines for adherence to medical ethical principles during obstetric care.
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Project description:OBJECTIVE:To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices. METHODS:Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests. RESULTS:Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P?.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04). CONCLUSION:Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.
| S-EPMC7020098 | biostudies-literature
Project description:BackgroundDifferences in health care utilization across geographical areas are well documented within several countries. If the variation across areas cannot be explained by differences in medical need, it can be a sign of inefficiency or misallocation of public health care resources.MethodsIn this observational, longitudinal panel study we use regional level data covering the 21 Swedish regions (county councils) over 13 years and a random effects model to assess to what degree regional variation in outpatient physician visits is explained by observed demand factors such as health, demography and socio-economic factors.ResultsThe results show that regional mortality, as a proxy for population health, and demography do not explain regional variation in visits to primary care physicians, but explain about 50% of regional variation in visits to outpatient specialists. Adjusting for socio-economic and basic supply-side factors explains 33% of the regional variation in primary physician visits, but adds nothing to explaining the variation in specialist visits.Conclusion50-67% of regional variation remains unexplained by a large number of observable regional characteristics, indicating that omitted and possibly unobserved factors contribute substantially to the regional variation. We conclude that variations in health care utilization across regions is not very well explained by underlying medical need and demand, measured by mortality, demographic and socio-economic factors.
| S-EPMC5987462 | biostudies-literature
Project description:BackgroundMale involvement in maternal, newborn and child health contributes to better health outcomes for women and their children, especially in restrictive societies. There is evidence that when men have better understanding of women's health needs, attitudes toward utilization of maternal and child health services, of both women and men, are improved. Given the role of men as the ultimate decision makers in families in northern Nigerian society, this study assessed the determinants of men's knowledge of danger signs in pregnancy and the continuum of obstetric care, and their perceptions of the importance of antenatal care utilization and health facility delivery.MethodsThis was a cross-sectional descriptive study. Structured questionnaires with close ended questions were administered to 1627 married men who had at least one wife younger than 25 years in communities in Nigeria northern states of Kaduna and Katsina. We use crosstabulations and means to compare characteristics of study respondents in the two states, assessing statistical significance of the differences with χ2-square and Anova tests as appropriate, and logistic regressions to assess the determinants of knowledge and perceptions.ResultsKnowledge of obstetric danger signs, especially during the postpartum period, was poor overall, but respondents were relatively more knowledgeable about danger signs during pregnancy and delivery compared with the postpartum period. Most perceived that antenatal care can reduce the risk of complications. Literate men were twice more likely to have positive health-behaviour perceptions. Wealth was positively associated with the perception that women should deliver in a health facility or hospital but did not have a statistically significant effect on the perception that antenatal care can reduce the risk of complications.ConclusionsWhile knowledge of obstetric danger signs was poor, literacy and household wealth significantly influenced knowledge of obstetric danger signs and perceptions that women should deliver at a health facility. Male involvement programmes need to ensure that men are empowered to understand obstetric danger signs along the continuum of obstetric care to improve perception and utilization of maternal health services for better maternal and newborn health outcomes.
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Project description:BackgroundThe continuing burden of maternal mortality, especially in developing countries has prompted a shift in paradigm from the traditional risk assessment approach to the provision of access to emergency obstetric care services for all women who are pregnant. This study assessed the knowledge of maternity unit operatives at the primary and secondary levels of care about the concept of emergency obstetric care (EmOC) and investigated the contents of antenatal care (ANC) counseling services they delivered to clients. It also described the operatives' preferred strategies and practices for promoting safe motherhood and averting maternal mortality in South-west Nigeria.MethodsThe study population included all the 152 health workers (doctors, midwives, nurses and community health extension workers) employed in the maternity units of all the public health facilities (n = 22) offering maternity care in five cities of 2 states. Data were collected with the aid of a self-administered, semi-structured questionnaire and non-participant observation checklist. Results were presented using descriptive statistics.ResultsNinety one percent of the maternity unit staff had poor knowledge concerning the concept of EmOC, with no difference in knowledge of respondents across age groups. While consistently more than 60% of staff reported the inclusion of specific client-centered messages such as birth preparedness and warning/danger signs of pregnancy and delivery in the (ANC) delivered to clients, structured observations revealed that less than a quarter of staff actually did this. Furthermore, only 40% of staff reported counseling clients on complication readiness, but structured observations revealed that no staff did. Only 9% of staff had ever been trained in lifesaving skills (LSS). Concerning strategies for averting maternal deaths, 70% of respondents still preferred the strengthening of routine ANC services in the health facilities to the provision of access to EmOC services for all pregnant women who need it.ConclusionWe concluded that maternity unit operatives at the primary and secondary care levels in South-west Nigeria were poorly knowledgeable about the concept of emergency obstetric care services and they still prioritized the strengthening of routine antenatal care services based on the risk approach over other interventions for promoting safe motherhood despite a global current shift in paradigm. There is an urgent need to reorientate/retrain the staff in line with global best practices.
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Project description:BackgroundBecause pregnancy complications, including gestational diabetes mellitus (GDM) and hypertensive disorders in pregnancy, are risk factors for diabetes and cardiovascular disease, post-delivery follow-up is recommended.ObjectiveTo determine predictors of post-delivery primary and obstetric care utilization in women with and without medical complications.Research designFive-year retrospective cohort study using commercial and Medicaid insurance claims in Maryland.Subjects7,741 women with a complicated pregnancy (GDM, hypertensive disorders and pregestational diabetes mellitus [DM]) and 23,599 women with a comparison pregnancy.MeasuresWe compared primary and postpartum obstetric care utilization rates in the 12 months after delivery between the complicated and comparison pregnancy groups. We conducted multivariate logistic regression to assess the association between pregnancy complications, sociodemographic predictor variables and utilization of care, stratified by insurance type.ResultsWomen with a complicated pregnancy were older at delivery (p < 0.001), with higher rates of cesarean delivery (p < 0.0001) and preterm labor or delivery (p < 0.0001). Among women with Medicaid, 56.6% in the complicated group and 51.7% in the comparison group attended a primary care visit. Statistically significant predictors of receiving a primary care visit included non-Black race, older age, preeclampsia or DM, and depression. Among women with commercial health insurance, 60.0% in the complicated group and 49.5% in the comparison group attended a primary care visit. Pregnancy complication did not predict a primary care visit among women with commercial insurance.ConclusionsWomen with pregnancy complications were more likely to attend primary care visits post-delivery compared to the comparison group, but overall visit rates were low. Although Medicaid expansion has potential to increase coverage, innovative models for preventive health services after delivery are needed to target women at higher risk for chronic disease development.
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Project description:Non-pneumatic Anti-Shock Garment (NASG) is a lightweight, reusable first aid compression device that squeezes blood from the lower extremities and centralizes blood circulation to vital organs of the body. Postpartum hemorrhage followed by severe preeclampsia/eclampsia is the leading primary cause of maternal death (A reduction in extreme maternal adverse outcomes and faster recovery from shock are more likely to occur with earlier NASG intervention. The median blood loss reduced by half when the NASG was used for obstetric hemorrhage management, which was associated with significantly reduced maternal mortality among the most severe cases. To estimate the pooled prevalence of NASG utilization and its predictors in Ethiopia. Appropriate and comprehensive searches of PubMed, MEDLINE, EMBASE, Google Scholar, HINARI, and Scopus were performed. The electronic literature search was last performed on November 18/2023. All observational study designs were eligible for this SRMA. All cross sectional studies reporting the prevalence/proportion of NASG utilization for obstetric hemorrhage management among obstetric care providers and associated factors were included in this SRMA. Primary studies lacking the outcome of interest were excluded from the SRMA. The extracted Microsoft Excel spreadsheet data were imported into STATA software version 17 (STATA Corporation, Texas, USA) for analysis. A random-effects model was used to estimate the pooled prevalence of NASG utilization among obstetric care providers in Ethiopia. The Cochrane Q-test and I2 statistics were computed to assess the heterogeneity among the studies included in the SRMA. A total of 1623 articles were found by using our search strategies and seven studies comprising 2335 participants were ultimately included in the SRMA. The pooled prevalence of NASG utilization for obstetric hemorrhage in Ethiopia was 43.34% (95% CI: 35.25, 51.42%). The findings of this subgroup analysis by sample size showed that the pooled prevalence of NASG utilization for obstetric hemorrhage was greater in studies with sample sizes of less than the mean sample size (48.6%; 95% CI: 32.34, 64.86%). Receiving training (AOR = 3.88, 95% CI: 2.08-5.37), having good knowledge (AOR = 1.99, 95% CI: 1.28-3.16), positive attitude (AOR = 2.16, 95% CI: 1.62-2.75) and having available NASGs in the facility (AOR = 4.89, 95%CI: 2.88-8.32) were significantly associated with the use of NASGs for obstetric hemorrhage management. The level of NASG utilization for obstetric hemorrhage in Ethiopia is low. Receiving training, good knowledge, positive attitudes and availability of NASG were significantly associated with the utilization of NASG. Therefore, policy makers and other stakeholders should emphasize enhancing the knowledge and attitudes of obstetric care providers through continuous support and training. At the same time, they should work strictly in providing devices for all the health facilities.
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