UNREALISED POTENTIAL OF EmOC IN RESOURCE POOR SETTINGS

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Quality improvement and case fatality rate

Quality improvement of emergency obstetric care enhances the performance of EmOC and contributes to the reduction of maternal mortality. Quasi-experimental studies conducted to assess the effectiveness of EmOC demonstrated that improved EmOC provision reduced case fatality rates. Improved emergency obstetric care provision, through training physicians and midwives in recognition and management of obstetric complication, enhanced availability of essential drug and supplies, and reduced the case fatality rate from 22% to 5% at Kebbi State Referral Hospital in Nigeria (Oyesola, Shehu, Ikeh & Maru 1997:S79). Similarly, the improvement of EmOC provision at Makeni, in Sierra Leone, reduced the case fatality rate from 32 to 5% (Leigh, Kandeh, Kanu, Kuteh, Plamer, Daoh & Moseray 1997:S59). Thus, the improvement of the quality of EmOC enhances maternal health by treating obstetric complication and reducing case fatality rates.
Otchere and Binh (2007:171) attribute the dramatic decrease of the case fatality rate from 10.3% to 0% in Vietnam to the hospital’s increased capacity and better competence of staff to manage obstetric complications. The introduction of a criteria based audit and client oriented provider efficient (COPE) identified more than 200 problems of which 31% were related to clinical care and 29% related to readiness and hospital management. Strikingly, 90 % of the problems were resolved by the obstetric departments themselves (Otchere & Binh 2007:168). A 22% overall reduction of case fatality rate at the Zaria teaching Hospital in Nigeria was attributed to blood banking (Ifenne, Essien, Golji, Sabitu, Alti-Mu´azu, Mussa, Adidu & Mukaddas 1997:S42).
Santos, Diante, Baptista, Matediane, Bique and Bailey (2006:199) do not explain the reasons behind the decline in case fatality rate from 2.9% to 1.6% in Mozambique but mention that improvements in the management of haemorrhage, obstructed labour and sepsis have taken place. These interventions focussed on infrastructure development, human resource development, transportation, communication system and management. The interventions related to management were supportive supervision, logistics for supplies, equipment and drugs, record keeping, monitoring and evaluation and quality improvement techniques (Santos et al 2006:193-195). In another case, a 51% reduction of case fatality rate was recorded due to the implementation of similar interventions in South Western Bangladesh (Islam, Hossain, Islam & Haque 2005:303). Furthermore, the case fatality rate from haemorrhage decreased from 14.8% to 1.9% and case fatality rate from pre-eclampsia from 3.1% to 1.1% at a regional hospital in Ghana. The contributing factors include timely referral, ultrasound for high-risk clients, protocol adherence for hypertension management and labour induction (Srofenyoh, Ivester, Engmann, Olufolabi, Bookman & Owen 2012:20). Therefore, case fatality rate can be reduced significantly by improving the quality of EmOC provision.
Maternal death reviews and criterion-based audit improves professional practice and reduces case fatality rates. The introduction of audit and feedback in hospitals and health centres in Malawi reduced the case fatality rate from 3.7% to 1.5% between 2005 and 2007 (Kongnyuy, Leigh & Van den Broek 2008:152). Hence, quality improvement approaches reduce maternal mortality.

Quality EmOC improvement and met need

The improvement of quality EmOC provision increases the utilisation of services. Quality improvement interventions in EmOC that reduced case fatality rate also improve the met need for EmOC (Santos et al 2006:198; Islam et al 2005:302; Otchere & Binh 2007:170). The met need for EmOC increased from 11.3% to 32.8% in Mozambique after quality improvement interventions (Santos et al 2006:198). Improved reporting of complication and increased referrals are some of the factors that contributed to the increased met need (Santos et al 2006:199). The met need also increased from 11.1% to 26.6% in Bangladesh (Islam et al 2005:302). That of EmOC increased from 30% to 84% with quality improvement of EmOC in Peru (Kayongo, Esquiche, Luna, Frais, Vega-Centeno & Bailey 2006:305). In addition, the met need for EmOC increased from 16% to 87% as a result of quality improvement interventions in Vietnam. The increase in the met need for EmOC is attributed to the capacity of the hospital and competence of staff (Otchere & Binh 2007:170). The met need for EmOC increased from 15.2 % to 18.8% in Malawi after the introduction of maternal death reviews and criterion-based audit (Kongnyuy et al 2008:152). The slight increase of met needs for EmOC is explained by the absence of fully functioning basic EmOC facilities and low institutional delivery rates (Kongnyuy et al 2008:154). Hence, the met need is attributed to quality EmOC provision but improving the experience aspect of EmOC can also contribute to an improvement the met need.

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CLIENTS’ PERSPECTIVES ON QUALITY EMERGENCY OBSTETRIC CARE

Women’s understanding and perception of quality and how quality of care is defined affects their decision to seek care. Access to health services does not guarantee the use of the service by the target group as there are many barriers associated with the utilisation of services. Even, the utilisation of service does not guarantee the intended health outcomes. The concept of quality highlights the reason why women do not access services at all, access them late or suffer an avoidable adverse outcomes despite timely presentation (Schneider 2006:259). Essendi et al (2010:S360) identified various barriers that limit the uptake of formal obstetric services in Nairobi. The barriers are inability to identify danger signs, poor health decision making, unaffordable health care seeking, poor physical access, inadequately equipped health facilities and inhospitable formal providers. Therefore, understanding the perceptions on an experience of EmOC will increase the utilisation of EmOC, and guide health facilities to provide client centred EmOC.
Dogba and Fournier (2009:9) espoused that the technical aspects of quality of EmOC has not been adequately studied. The process aspect of care, one of which is the interpersonal was assessed from the clients’ perspectives by satisfaction questionnaire. Dissatisfaction influences clients’ use of health service and compliance with treatment. Client satisfaction is used as an outcome measure for the improvement of EmOC provision (Clapham, Basnet, Pathak & McCall 2004:88). However, client satisfaction can be affected by factors that are external to the health system, thereby making it difficult to measure the performance of health system. Bleich, Özaltin and Murray (2009:274) found the association between client satisfaction and client experience of care, client expectation, self-perceived health status and type of care. Rohrer, Lund and Goldfarb (2005:2) examined the different levels of satisfaction on the basis of racial differences, which obviously is external to the health system. Nevertheless, Lule, Tugumisirize and Ndekha (2000:254) assert that women’s satisfaction is attributed to many factors, which include women’s expectation of care, knowledge level about health care, previous experience from using other health facilities and their perception of the government health system.

CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 AIM OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.7 DEFINITION OF KEY CONCEPTS
1.8 RESEARCH DESIGN AND METHOD
1.9 SCOPE AND LIMITATIONS OF THE STUDY
1.10 STRUCTURE OF THE THESIS
1.11 CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 THE CONCEPT OF EMERGENCY OBSTETRIC CARE
2.3 UNREALISED POTENTIAL OF EmOC IN RESOURCE POOR SETTINGS
2.4 QUALITY OF EMERGENCY OBSTETRICS CARE SERVICES
2.5 QUALITY IMPROVEMENT OF EmOC
2.6 CLIENTS’ PERSPECTIVES ON QUALITY EMERGENCY OBSTETRIC CARE
2.7 THE PROVISION AND EXPERIENCE OF CARE MODEL
2.8 CONCLUSION
CHAPTER 3 THEORETICAL GROUNDING OF THE RESEARCH
3.1 INTRODUCTION
3.2 PARADIGM
3.3 ONTOLOGICAL, EPISTEMOLOGICAL AND METHODOLOGICAL ASSUMPTIONS OF THE STUDY
3.4 THEORETICAL ORIENTATIONS
3.5 THEORETICAL ORIENTATION OF THE STUDY
3.6 CONCLUSION
CHAPTER 4 RESEARCH DESIGN AND METHODS
4.1 INTRODUCTION
4.2 RESEARCH DESIGN
4.3 THE RESEARCH METHOD
4.4 DATA ANALYSIS
4.5 TRUSTWORTHINESS
4.7 CONCLUSION
CHAPTER 5 ANALYSIS, PRESENTATION AND DESCRIPTION OF THE RESEARCH FINDINGS
CHAPTER 6 DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS OF THE STUDY
CHAPTER 7 GUIDELINES FOR PROVISION OF CLIENT FOCUSED QUALITY EMERGENCY
OBSTETRIC CARE IN ETHIOPIAN PUBLIC HEALTH FACILITIES