ASSESSMENT QUALITY OF ANTENATAL CARE SERVICES AT DR KHALID

HEALTH CENTER IN HARGEISA SOMALILAND

A RESEARCH REPORT SUBMITTED IN PARTIAL FULFILLMENT FOR THE

AWARD OF DEGREE IN PUBLIC HEALTH AT HOPE UNIVERSITY TO THE

DEPARTMENT OF PUBLIC HEALTH

Advisor: Ahmed Ali Qalib

By:

NAWAL A/MAJID MOHAMED

RAHIMA NOUR DAUD

AISHA A/RAHMAN AHMED

AISHA AMIN EGAL

HIBO AHMED OSMAN

October 2015

i

DECLARATION

We declare that the work submitted have been our own effort leading to our award for a degree

in public health .

NAWAL A/MAJID MOHAMED Signed...............................................

RAHIMA NOUR DAUD Signed...............................................

AISHA A/RAHMAN AHMED Signed...............................................

AISHA AMIN EGAL Signed...............................................

HIBO AHMED OSMAN Signed...............................................

Date..............................2015

ii

APPROVAL

This work has been submitted in with the authority of the university supervisor.

MR. Ahmed Ali Qalib

Signed...............................................Date..................................................

iii

DEDICATION

We dedicate this research report to our beloved parents who showed us love and adequate care

since we were born up to now.

iv

ABSTRACT

Background. Pregnant women need adequate antenatal care (ANC) and delivery care for their

own health and for healthy children. Availability of such care has increased in

Hargeisa but maternal mortality remains high and variable between population groups.

Aims. The general aim of this research report is to assess the status of quality in antenatal

care services in DR Khalid MCH in Hargeisa, Somaliland. The specific aim of the research

report include the following; to measure level of client satisfaction with ANC services they

received, to describe the relationship between service provider and service receiver (client) in

ANC services and to assess providers’ perception on quality of ANC services.

Method. The method used was descriptive cross sectional study design and also the sampling

method of this study was probability based sampling method.

Main Findings. Mainly due to less than recommended use of core ANC services, overall ANC

adequacy was low in some groups, the main risk factors for not having adequate ANC were (i)

living in a rural area, (ii) low level of education, (iii) low economic status and (iv) exclusive use

of private ANC The services were utilized with the ANC services in MCH being the most

visited. Generally, people were satisfied with the service and their health needs are met.

ANC in Somaliland has not reached more than one thirds of Pregnant women, it is not reported

increases in the coverage of the recommended four ANC visits but increases in the coverage of a

first trimester ANC visit.

Conclusion. Pregnant mothers were willing to seek heath care services during pregnancy.

However, most pregnant women don’t attend for ANC services regularly mainly due to lack of

knowledge and information as well as poor quality antenatal care services in MCHs. The

pregnant women with relatives and friends as well as ANC providers share the

responsibility for a positive development.

v

ACKNOWLEDGEMENT

We feel indebted to the Almighty Allah for granting us the right state of health to be able to

produce this research paper. We say Alhamdulillah. We also indebted to a number of people who

have in diverse ways contributed to the success of this rewarding learning process.

We are extremely grateful to MR. Ahmed Ali Qalib our supervisor in this material who

dedicated all his effort and time in spite tight commitment in order to make this work success

.We are grateful for the assistance rendered to us.

Not forgotten, our appreciation to ministry of health especially the department of HIMS and

regional health office for their support during the data collection

we also thank to our lecturer Abdi Hakim Suleiman For his greet support and help to us.

We would like to express our appreciation to our lectures about their dynamic way for delivers

lessons an also their great encouragements to sustain our education. Our acknowledgement also

goes to al managerial persons and office staffs of HOPE UNIVERSITY to their co-operation

Last but not least we would like to thank our parents who have given us tremendous inspiration

and support. Without their mental, financial support We would not be able to complete our

research work. We wish to appreciate the contributions to this report of all individuals

unmentioned that Allah may reward them abundantly.

vi

ABBREVIATIONS

ANC Antenatal care

WHO World Health Organization

ICPD International Conference on Population and Development

MCH Maternal and Child Health

EDHS Ethiopian Demographic Health Survey

UNICEF United nation children's fund

UNFPA United Nation fund for population agency

HIV Human Immunodeficiency Virus

AIDS Acquired Immune Deficiency Syndrome

UNAIDS United Nations Programme on HIV and AIDS

MICS Multiple Indicator Cluster Survey

MDHS Mississippi Department Of Human Service

vii

TABLE OF CONTENTS

DECLARATION ............................................................................................................................. i

APPROVAL ................................................................................................................................... ii

DEDICATION ............................................................................................................................... iii

ABSTRACT ................................................................................................................................... iv

ACKNOWLEDGEMENT .............................................................................................................. v

ABBREVIATIONS ....................................................................................................................... vi

TABLE OF CONTENTS .............................................................................................................. vii

LIST OF FIGURES ...................................................................................................................... ix

LIST OF TABLES .......................................................................................................................... x

CHAPTER ONE ............................................................................................................................. 1

THE PROBLEM AND ITS SCOPE ............................................................................................... 1

1.1 INTRODUCTION ................................................................................................................. 1

1.2 Background of the Study ....................................................................................................... 1

1.3 STATEMENT OF THE PROBLEM .................................................................................. 4

1.4 OBJECTIVE OF STUDY ................................................................................................. 5

General objective ..................................................................................................................... 5

1.5 Research Questions ............................................................................................................... 5

1.6 Significance of the Study ...................................................................................................... 6

1.7 Scope of the Study................................................................................................................ 6

1.7.2.Geographical Scope............................................................................................................ 6

CHAPTER TWO ............................................................................................................................ 7

LITERATURE REVIEW ............................................................................................................... 7

2.0. Introduction .......................................................................................................................... 7

2.1 What is ANC? ....................................................................................................................... 7

2.2 Goals of ANC: ....................................................................................................................... 9

CHAPTER THREE ...................................................................................................................... 13

METHODOLOGY ....................................................................................................................... 13

3.0. Introduction ........................................................................................................................ 13

3.1 Study Design ....................................................................................................................... 13

3.2 Study Area &Period ............................................................................................................ 13

3.3. Population......................................................................................................................... 13

3.3.1 Source population ......................................................................................................... 13

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3.3.2 Study population ........................................................................................................... 13

3.3.3 Inclusion and exclusion criteria .................................................................................... 14

3.5.7 Sampling method .......................................................................................................... 14

3.5.8 Sample size determination and technique .................................................................... 14

3.7. Data Collection Methods ................................................................................................ 16

3.6.2 Data collection Instruments .......................................................................................... 16

3.6.1 Data Analysis ................................................................................................................ 16

3.6.1 Data Quality Assurance ................................................................................................ 17

3.6. 3. Ethical Consideration ................................................................................................. 17

3.9 validity and reliability ......................................................................................................... 17

3.10 Strength of the study ......................................................................................................... 18

3.11 Limitation of the study ...................................................................................................... 18

CHAPTER FOUR ......................................................................................................................... 19

RESULT AND DISCUSSION ..................................................................................................... 19

4.1. Result .................................................................................................................................. 19

4.2.discussion………………………………………………………………………………..40

CHAPTER5……………………………………………………………………………………...44

CONCULUTION AND RECOMMENDATION……………………………………………….44

5.0 introduction………………………………………………………………………………44

5.1 conclusion………………………………………………………………………………..44

5.3 recommendation………………………………………………………………………..45

APPENDIX 1…………………………………………………………………………………...46

REFRENCE…………………………………………………………………………………….46

APPENDIX 2 QUESTIONNAIRE……………………………………………………………48

ix

LIST OF FIGURES

figure 4.1 Educational status ......................................................................................................... 21

figure 4.2 Respondents' occupation .............................................................................................. 23

figure 4.3 how do you understood antenatal care………………………………………………..24

figure 4.5 do you ever take antenatal care service……………………………………………….25

figure 4.5 birtth place of childeren ................................................. Error! Bookmark not defined.

figure 4.6 How satisfied are youwith the ANC you have recieved ............ Error! Bookmark not

defined.

figure 4.7 Do you come MCH regular or irregular………………………………………...…..30

figure 4.8 interaction between health care provider and client………………………………..33

figure 4.9 how health care provider understood ANC………………………………………….34

figure 4.10 do you know if the client come MCH regular or irregular…………………………35

figure 4.11 length between time of visits……………………………………………………...…36

figure 4.12 information client have received…………………………………………………..37

figure 4.13 what opinion women’s have in ANC……………………………………………..38

x

LIST OF TABLES

Table 3.5.8 Sample frame ............................................................................................................. 15

Table 4.1.1 Age ,Sex,Natonality, Religion and Distance from Health facility Distribution of

respondents: .................................................................................................................................. 19

Table 4.1.2 Educational Status: .................................................................................................... 20

Table 4.1.3 Marital Status: ............................................................................................................ 21

Table 4.1.4 Occupational Status: .................................................................................................. 22

Table 4.1.5 who encourage you to come MCH………………………………………………..27

Table 4.1.6 How many visits you come MCH…………………………………………………27

Table 4.1.7 Evaluation of the time between check-up…………………………………………32

Table4.1.8 How interested are health workers to discus about your problem with

you………………………………………………………………………………………………………31

Table 4.1.9 How long is the care provider spend to check up………………………….32

Table 4.1.10 How sociable do you think are the health works…………………………….32

Table 4.1.11 Is there any challenge faced you,when you are giving ANC for

women’s……………………………………………………………………………………………….39

Table 4.1.11 Do you tell them the complication that they develop if they don use

ANC?......................................................................................................................39

Table 4.1.11 Is there any other service you give women’s?…………………………………39

1

CHAPTER ONE

THE PROBLEM AND ITS SCOPE

1.1 INTRODUCTION

1.2 Background of the Study

Antenatal care (ANC), also known as prenatal care, is the complex of interventions that a

pregnant woman receives from organized health care services.

The purpose of ANC is to prevent or identify and treat conditions that may threaten the health of

the fetus or the mother, and to help a woman approach pregnancy and birth as positive

experiences.

Antenatal Care (ANC) is the key entry point of a pregnant woman to receive broad range of

health promotion and preventive services which promote the health of the mother and the baby. .

[1]

The World Health Organization (WHO) estimates that worldwide more than 529,000 women die

every year from complications of pregnancy, childbirth and abortion, Ninety nine percent (99%)

of these deaths are from the developing countries , Less than 1% of these deaths occur in more

developed countries making maternal mortality the health indicator with the greatest disparity

between developed and developing countries. .

The situation is worst in sub-Saharan Africa where one in every 13 women dies of pregnancy

related causes compared to only one in 4,085 women in developed countries.

The Safe Motherhood Initiative of 1978 in Nairobi and 1988 in Amman stressed the need for

strategies which tackle the root causes of maternal morbidity and mortality.

International Conference on Population and Development (ICPD, Cairo, 1994) set a new agenda

to promote reproductive health. Improving essential services for pregnant women was one of the

reproductive health priorities set for decision-makers. [2]

2

The area of quality of maternity care is an important focus of research for women in health

services have been shown to increase uptake of services and reduce the number of adverse

maternal health outcomes.

The quality standard for antenatal care (ANC) require that service should be commissioned from

and coordinated across all relevant agencies encompassing that antenatal care is part of the

maternity pathway

This quality standard cover ANC of all pregnant women up to 42 week s of pregnancy in all

settings that provide routine antenatal care including primary community and hospital –base

care. The quality standard addresses routine ANC including screening test for complications of

pregnancy but it does not address the additional care needed to manage these complications if

they arise in pregnancy [for example gestational diabetes ,pre-eclampsia and venous

thromboembolism).

Roemer and Angular, (WHO, 1988), defined quality as “…proper performance (according to

Standards) of interventions that are known to be safe, that are affordable to the society in

Question, and the ability to produce an impact on mortality, morbidity, disability and

Malnutrition.” The components of quality care are well established. Clients need a choice of

services, Accurate and complete information, technically competent care and good interaction

with Providers, continuity of care and constellation of related services. These elements apply

equally to most of the components of reproductive health care. [3]

Avedis Donabedian, a physician and health services researcher at the University of Michigan,

developed the original model in 1966. The Donabedian model is a conceptual model that

provides a framework for examining health services and evaluating quality of health care.

According to the model, information about quality of care can be drawn from three categories :

the structure (health care setting), process (how health care is provided) and outcome (effect of

the health care including level of patient/client satisfaction.

(1) Structure: evidence of local services that insure antenatal care is readily and easily. Evidence

of local arrangement to encourage pregnant women to access and maintain contact with antenatal

care services.

3

(2) Process: proportion of pregnant women missing scheduled antenatal appointment that are

followed up within locally defined time scale.

Numerator: the number of women in the denominator followed up within locally defined time

scale.

Denominator: the number of pregnant women missing scheduled antenatal appointment.

OUTCOME:

Pregnant women accessing ANC who are seen for booking by 10 weeks

Pregnant women accessing ANC who are seen for booking by 20 weeks

Median gestation at booking [3]

Pregnant women assessing ANC attendance at least the recommended to have number of

antenatal appointments.

Growing demand for health care, raising costs, constrained resources, and evidence of variations

in clinical practices have increased interest in measuring and improving the quality of health care

in many countries of the world.

In the field of ANC, recent efforts have been made to sort out various influences of the

subjective dimension of quality of care.

However, the knowledge about clients' views is still very limited, especially in developing

countries.

Based on many reports from in developing countries, the health care delivery system not only

falls short of reaching the majority of the people but also its quality is often compromised.

Quality of ANC has been designated one of the four Pillars of Safe Motherhood, along with

clean and safe delivery , essential obstetric care and family planning which could 2 contribute to

reduction of maternal mortality.

It is necessary to promote a better access of all women to antenatal care in developing countries

antenatal care is still very low and the quality of those services is very insufficient in Somaliland.

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1.3 STATEMENT OF THE PROBLEM

Somaliland has one of the highest maternal mortality ratios in the world at 1,044 deaths per

100,000 live births multiple indicator cluster survey (MICS, 2006). According to MICS, 2006,

only thirty-two percent of women received antenatal care (ANC) from skilled health personnel;

whereas ANC coverage is only 26%.[4]

The reason for the priority given to ANC services is: Children are the future of the nation,

Women and Children from the majority of the population in less developed areas, The health of

mothers and infants is related, Mothers and children are particularly vulnerable to disease, Most

of the diseases that cause mortality and morbidity in children and associated with pregnancy are

preventable, and Women and children represent the least powerful members of the society

without special consideration and their needs are neither considered nor understood.

In Somaliland there are no interventions that have being conducting in this study before, there for

the reason that we are conducting this research is Somaliland have the highest maternal mortality

rate, the mothers that are dying the complications related from pregnancy, at the same time the

utilization of ANC service is not very high.

those people who are taking this service don’t know or don’t have the knowledge of the quality

of antenatal care service The research also investigates how to overcome this problem and get

ways to solve it. Since the mother and child are more vulnerable for having a disease, It is very

essential to investigate knowledge, attitude and practice towards taking ANC for pregnant

mother among community in in Hargeisa

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1.4 OBJECTIVE OF STUDY

General objective

To assess the status of quality in antenatal care services in DR Khalid MCH in Hargeisa,

Somaliland

Specific objectives

To measure level of client satisfaction with ANC services they received

To describe the relationship between service provider and service receiver (client) in

ANC services

To assess providers’ perception on quality of ANC services

1.5 Research Questions

The research will answer the following questions:

If the client was happy for ANC service they received?

What are the interaction between service provider and ANC clients?

What is the Providers perception on quality of ANC service?

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1.6 Significance of the Study

This study is very important to know how antenatal care is necessary for pregnant mother. In

this research, we hope to know more educational background of how the pregnant women’s

understood the quality of antenatal care and that will improve the utilization of antenatal care

(ANC) .

Firstly, Ministry of Health of Somaliland will benefit from this research because there were no

interventions for quality of antenatal care in all the country.

Secondly health centers will benefit from it to give mothers more health care support for

pregnancy mothers and to prevent any kind of complications that women develops

1.7 Scope of the Study.

1.7.1. Contextual scope

In this research was conducting pregnant women’s, and the health care providers. We are making

our research in DR Khalid Health Center ( 2015)

1.7.2. Geographical Scope

Hargeisa serves as the capital of Somaliland, a self-declared republic that is internationally

recognized as an autonomous region of Somalia.

Hargeisa is situated in a valley in the Galgodon (Ogo) highlands, and sits at an elevation of 1,334

m (4,377 ft). Home to rock art from the Neolithic period, the city is also a commercial hub for

precious stone-cutting, construction, retail services and importing/exporting, among other

activities.

According to Demography, Hargeisa has a population of around 750,000 residents as of 2015. It

is the 652nd largest city in the world by population size. The urban area occupies 65 square

kilometers (25 sq mi), with a population density of 11,600 inhabitants per square kilometer

(30,000/sq mi). It is primarily inhabited by people from the Somali ethnic group.

7

CHAPTER TWO

LITERATURE REVIEW

2.0. Introduction

2.1 What is ANC?

Antenatal care, the care that a woman receives during pregnancy, helps to ensure healthy

outcomes for women and newborns (WHO/UNICEF 2003). Antenatal care is a key entry point

for a pregnant woman to receive a broad range of health promotion and preventive health

services, including nutritional support and prevention and treatment of anemia; prevention,

detection and treatment of malaria, tuberculosis and sexually transmitted infections

(STIs)/HIV/AIDS (particularly prevention of HIV transmission from mother to child); and

tetanus toxoid immunization. Antenatal care is an opportunity to promote the benefits of skilled

attendance at birth and to encourage women to seek postpartum care for themselves and their

newborns. It is also an ideal time to counsel women about the benefits of child spacing. Finally,

antenatal care is an essential link in the household-to-hospital care continuum—it is an

intervention that can be provided at both the household and peripheral facility levels and helps

assure the link to higher levels of care when needed

Every year there are an estimated 200 million pregnancies in the world. Each of these

pregnancies is at risk for an adverse outcome for the woman and her infant. While risk cannot be

totally eliminated, they can be reduced through effective, and acceptable maternity care. To be

most effective, health care should begin early in pregnancy and continue at regular intervals .

Globally, UNICEF identifies women in the richest 20 percent of the population are also more

likely to receive antenatal care than poorer women, especially in the most deprived regions. [5]

In the developing world: Nearly 70% of pregnant women have at least one antenatal care visit,

and the majority of women presenting for any antenatal care have at least four visits. All age

groups show similar rates of four or more visits. Rural and uneducated women are least likely to

receive antenatal care. Women reporting at least four antenatal care visits are on average 3.3

times more likely than other women to give birth with a skilled provider. (WHO/UNICEF

2003). [2]

ANC in Africa has reached more than two thirds of pregnant women, with reported increases in

the coverage of the recommended four ANC visits and increases in the coverage of a first

8

trimester ANC visit. Multiple vertical programmes rely on ANC to deliver their interventions,

representing both a challenge and an opportunity. As a critical link in the continuum of care,

ANC offers tremendous opportunities to reach a large number of women and communities with

effective clinical and health promotion interventions. However, inequity exists, and young, rural,

poor, and less educated women may not benefit from ANC services or may drop out due to

access barriers and low quality services. [5]

In South Asia, for instance, women in the richest quintile are almost twice as likely as women in

the poorest quintile to have at least one antenatal care visit with a skilled provider (94 per cent

versus 50 per cent). Large disparities in coverage based on wealth are also found in sub-Saharan

Africa, particularly in West and Central Africa.

In the case of Ethiopia, the 2005 Ethiopian Demographic Health Survey (EDHS) showed that the

maternal mortality rate was 673 deaths per 100,000 live births, and infant mortality rate was 77

deaths per 1000 live births. . [6]

Somaliland has one of the highest maternal mortality ratios in the world at 1,044 deaths per

100,000 live births (MICS, 2006). According to MICS, 2006, only thirty-two percent of women

received antenatal care (ANC) from skilled health personnel; whereas ANC coverage is only

26%, TT coverage stands at 26.3% and pregnant women receiving Vitamin at 4-25%. Although

this is low coverage, given the Somali context, it is an opportunity to reach out with preventative

services to women.

Poverty, low levels of female literacy and lack of female empowerment are factors that correlate

strongly to poor reproductive health outcomes in different countries. . [7]

In Somaliland, matters have been worsened by chronic war and conflict over almost two

decades, lack of a functional central government, and poor access to quality reproductive health

services. Despite increases in knowledge of in reproductive health, progress in maternal health

towards MDG 5 is not on track.

The majority of deaths and disability among females of reproductive age is related to pregnancy

and childbirth. Optimal pregnancy care depends on all levels of the health system, from basic

preventive services such as vaccination and birth spacing services, to highly technical emergency

obstetric care at referral level. Assuring support to maternal survival requires an approach

9

[8]different to that for child survival, in which major improvements can be made with low cost

technology at the community level. Good obstetric care is thus crucially dependent on a well-

functioning, interlinked health care system at all levels. Despite progress in some countries, the

global number of maternal deaths per year estimated at 529,000 or one every minute during the

year 2000 has not changed significantly since the International Conference on Population and

Development (ICPD), according to recent estimates by WHO, United nation children's fund

(UNICEF) and United Nation fund for population agency (UNFPA). [2]

Millions more women survive but suffer from illness and disability related to pregnancy and

childbirth

2.2 Goals of ANC:

1. To reduce maternal mortality and morbidity rates.

2. To improve the physical and mental health of women and children.

3. To prevent, identify, and maternal and fetal abnormality that can affect pregnancy outcome.

4. To decrease financial recourses for care of mothers.

As Assessment conduct by ANPPCAN, the Level of awareness of the reproductive health rights

in the study population is very low. This is worsened by the prevailing cultural values, beliefs

and practices. This has led to increased frequencies of pregnancies among women of the

reproductive age in the study population. Pregnant mothers are willing to seek heath care

services during pregnancy. However, most pregnant women don’t attend for ANC services

regularly mainly due to lack of knowledge and information as well as poor quality antenatal care

services in MCHs .

The provision of high-quality, basic antenatal care—safe, simple, cost-effective interventions

that all women should receive—helps maintain normal pregnancies, prevent complications and

facilitate early detection and treatment of complications. The major goal of focused antenatal

care is to help women maintain normal pregnancies through:

10

First, Targeted assessment based on the woman’s individual situation to ensure normal progress

of the pregnancy and postpartum/newborn period, and to facilitate the early detection of and

special care for complications, chronic conditions and other potential problems that can affect the

mother and newborn.

Second, Individualized care to help maintain normal progress, including preventive measures,

supportive care, health messages and counseling (including empowering women and families for

appropriate and effective self-care), and birth preparedness and complication readiness planning.

As Assessment report of ANPPCAN show us, Over 95% of the interviewed women were in the

reproductive age i.e. from 15 to 49 years old. Over 90% of the interviewed women were

currently in marriage union. Around 66% of the interviewed women were housewives; in other

words, they were only engaged in other valuable household related activities such as house-

keeping, rearing and educating children, etcetera. Illiteracy was very common; nearly 80% of

the interviewed women did not attend school.

Nearly 95% of the interviewed households had women of child bearing age living in the house.

Out of this number, 89% had 1-2 women in the house.

Further, the assessment results identified that majority (83%) of the interviewed households had

children living in the house who are less than two years old.

Majority of the interviewed households had no regular income or definite income source;

whereas nearly 30% relay on remittance from the diaspora. It is evident that majority of the

interviewed households were in extreme poverty as reflected in their monthly disposable

incomes. Majority of the interviewed women (81%) indicated that they visited health facilities

when pregnant; however, the answers recorded did not elaborate whether the visit was during the

last or the immediate pregnancy. These women pointed out various basic services they received

in the health centers including blood pressure measurement, weight measurement, iron

supplementation, TT immunization, and medicine including de-worming tablets, urine test and

malaria test. Frequency of pregnancy is prevalent among interviewed women. Nearly 82% of the

interviewed women had become pregnant 1-6 times in their live while nearly 40% of them were

pregnant by the time of the survey. Among the pregnant women, majority of them visit the health

facilities or seek health care services in the first trimester of their pregnancy. A very minimum

11

number visit the health facilities in all the three trimesters. The frequency of visit also varies, and

nearly half of the respondents visit health facilities 1 – 2 times. Knowledge on the importance of

the TT immunization was reasonably good among the respondents. However, nearly 40% of the

interviewed women had no information on what TT prevents against women. The health seeking

behavior of the interviewed women varied during pregnancy with complications. Half of the

respondents noted that they to public hospitals whenever they experience complications. Use of

private clinics and traditional birth attendants are very limited. Almost all of the interviewed

mothers were able to identify at least one risk factor that the women can die during labour or at

birth; majority of them expressed high blood pressure as the as major factor that can lead to

maternal death. Knowledge of family planning was very high among the interviewed women.

However, details on the modern family planning methods were provided. More than half of the

interviewed women seek medical advice and treatment from medical doctors; less than 40%

either go to a trained midwife or a nurse. The results elaborate that majority of the people had no

confidence on the competences of the midwives and nurses or perhaps they are lacking

information what midwives and nurses can help for pregnant mothers. Nearly 70% of the

interviewed women express their willingness to give birth at a health facility and only 31%

favored to deliver at home. We know with the available literatures, that institutional delivery is

only 9% in Somaliland; however, if the access and the quality of the maternity clinics is

improved, women would be willing to deliver at maternity clinics. The survey findings indicate a

remarkable shift towards women in decision making on issues related to seeking health care

services during pregnancies. Nearly 70% of the respondents expressed that they decide by

themselves when seeking health care services.

As recommend by ANPPCAN for it ASSESEMENT ON ANTE-NATAL CARE IN AWDAL,

MAROODIJEEX, TOGDHEER & SANAAG REGIONs in Somaliland the appropriate health

education sessions on reproductive health should be designed and delivered to the community

targeting both women and men using different methods and materials. Audio-visual materials

should be used given the high level of illiteracy among the community.

The role of the trained midwives and public health nurses should be widely disseminated to the

community so that women will have more confidence in seeking advice and care from them.

Facilitate distribution of family planning commodities to health facilities so that women would

12

have an access to these services to help child spacing and reduce high frequencies in pregnancies

among women of child bearing age. Knowledge of women in family planning services is very

high. Train health care providers to enable them change their attitude in quality care provision

for them to handle clients more respectfully with confidentiality and professionalism. This will

encourage women to seek health care services from health facilities even for the stigmatized

cases like rape, abortion and teenage pregnancy.

Somaliland is differ from other countries the utilization of antenatal care is very poor at the same

time the understanding of quality of antenatal care is also very low so there were no previous

interventions of this study. [4]

13

CHAPTER THREE

METHODOLOGY

3.0. Introduction

This chapter presents the methodologies used for data collection and analysis of the research.

The chapter examined further the topics including.

research design, research population, sample and sampling procedures, research instruments,

validity and reliability, data analysis, ethical consideration and lastly limitation of the research.

3.1 Study Design

The study design was descriptive cross sectional study design because this type of study

describes the prevalence of the problem in relation to place, person and time

3.2 Study Area &Period

The study was conducted in Dr Khalid MCH, Ga’anLibah District, Hargeisa Somaliland. The

study period was conducted from March to September 2015.

3.3. Population

3.3.1 Source population

The source population of the study was All adult female patients in the MCH during the study

period.

The health professionals providing Health Care services in the Dr. khalid MCH during the Study

period

3.3.2 Study population

The study population was include:

All Pregnant women who were came for antenatal care service to health institution both

multipara and Primigravida during data collection period.

Health professionals providing antenatal services in Dr. Khalid MCH during data collection

period.

14

3.3.3 Inclusion and exclusion criteria

.3.3.4.1 Inclusion criteria

-All pregnant mothers who use ANC service in Dr. Khalid MCH.

-Care providers who involved in direct care of ANC

- Care providers who worked in the institution for > 3 months

3.3.5.2 Exclusion criteria

- All female clients who are not pregnant

- All other clients who are not using ANC service

- All other staffs that are not care providers

- care providers who worked in the MCH < 3 months

3.5.7 Sampling method

The sampling method of this study was probability based sampling method specifically non-

proportional allocation stratified method because of the target population will be categorized into

groups(strata) who have the same characteristics.

3.5.8 Sample size determination and technique

131 sample populations was selected from the source population; the study unit was selected

based on their characteristics by using Non proportional stratified sampling method.

The sample size was calculated by using the following formula

n = Z2 pq/d2

Where:

n = sample size

z= confidence level or accuracy = 95% =1.96

15

d= marginal error 5% = 0.05

p-proportion of success, 50% = 0.5

q- proportion of failure, q = 1-p = 0.5

n = (1.96)2 0.5 X 0.5/(0.05) 2

n = 384

If the population is less than 10 000 , the sample size will be minimized by using the correction

formula

Fn = n/1+n/N

N= number of population, if N = 200

Than

Fn = 384/1+384/200

=384/584/200

=384x200/584

=7680/584 =131

Sample size is 131

Table 3.5.8 Sample frame

Dr Khalid MCH Target population Simple size

Pregnant women’s 170 120

health care provider 30 11

Total Population 200 131

16

3.7. Data Collection Methods

The collection data gathering of this research was two forms namely, primary data and secondary

data. The collection of primary data involved the use of questionnaires to gather information

from the chosen respondents and use of interview guide from key selected respondents. The

secondary data involved review of official documents such as files, memos, annual and quarterly

reports.

3.6.2 Data collection Instruments

Client Interview: Data was collected by interviewing clients using a structured questionnaire to

assess their satisfaction to actual ANC service. The questionnaire was comprised of socio-

demographic characteristics, and quality related variables.

After reviewing of relevant literatures from previous similar studies and other materials;

questionnaire that could address the objectives of the study where gathered and adapted . The

questionnaire was prepared in English and translated in to Somali language for the respondent.

Provider interview: In the case of the providers; the self-administered questionnaire where

distribute to all ANC providers in the facility where the study was conducted. All providers are

expected to respond to the questionnaire.

The data collected were used analyzed by using statistical package for social science (spss) and

Tables, charts, graphs and percentages were used to interpret, analyze and present the data in

appropriate way.

3.6.1 Data Analysis

Quantitative and qualitative methods of data analysis where used for the research. The reasons

for selected quantitative and qualitative methods of data analysis includes, it’s easy way of

summarizing a bulk of data, its appropriateness to analyze data with many variables, and lastly

its easy way to analyze a data collected through questionnaires.

17

3.6.1 Data Quality Assurance

Quality control measure where employed during collection. The data collectors was given

training for one day on the study instrument and data collection procedure. The principal

investigator was supervise the data collecting process prior to actual data collection.

Questionnaires were pre-tasted 5% of similar population but not including the sample size. This

could help to identify problems that have to address both the questionnaire and data collectors.

Every day, filled questionnaire where review and checked for completeness, illegible answers

and missed information

3.6. 3. Ethical Consideration

Social researchers where ethical. In the collection of their data, in the process of analyzing the

data and in the dissemination of findings, they expected to respect the rights and dignity of

those who are participating in the research project; avoid any harm to the participants arising

from their involvement in the research; and operate with honesty and integrity. Therefore these

studies have done according to ethical consideration and guided by the following principles:-i)

the interest of participants were protected this means both participants and researcher do not

come any physical and psychological harm as a result of the research. The researcher kept the

information confidential that might have an adverse impact on the participants. ii) Researcher

avoided deception or misrepresentation: - to be honest and open, used code of conduct to provide

fair and unbiased analysis of findings, and avoided any kind of dishonesty or misrepresentation

while dealing with informative or the subject. iii) Participants were informed consent:

participants were voluntary and had sufficient information about the research to arrive at a

seasoned judgment about whether or not they want to participate

3.9 validity and reliability

Reliability

For actual data collection, the Questionnaires where checked for their accuracy and increase

data quality assurance pretesting where also done among non study participant before the actual

data collection.

18

Validity

Per-test where conducted to check validity of the instrument and the collected data will be

checked for completeness, accuracy clarity and consistency. Any errors, ambiguity or

incompleteness where identified and corrected validity and quality of instrument important to

evaluate is worth

3.10 Strength of the study

Non professional Female interviewers where used for exit interview to minimize interviewer bias

and increase respondent rate.

3.11 Limitation of the study

Limitation

The main constraints that we faced during this research whenever we tried to find information

from MCH we find no pregnant women to interview them or if the pregnant women are in MCH

they were reluctant to give us necessary information that we need it.

Secondly, we didn’t found any research or study of antenatal care which was done previously,

we contacted both Ministry of health and Ministry planning but we found no record about ANC

in Somaliland.

ANC Client will come to health facility periodically; the researcher will not find clients whose

appointment is not during the data collection period .this may influence the finding of the study.

19

CHAPTER FOUR

RESULT AND DISCUSSION

4.1. Result

This chapter we were discussed deeply and widely analysis and discussion of data, that we have

been collected in the field through interview schedule, this research focused on the study of

quality assessment of antenatal care among the women in DH Khalid MCH.

The results of this study were analyzed using statistical software, namely IBM SPSS Statistics.

The information obtained was presented in frequency tables, pie graphs and bar charts for all

variables in order to determine the distribution of variables.

Table 4.1.1 Demographic information

4.1.1.Age 2.Sex 3. Nationality4. Religion 5. Distance from Health facility Distribution of

respondent

Age Distribution Frequency Percent

Valid less than

20years 20 15%

20-30 85 65%

31-40 26 20%

Total 131 100%

What is your Sex?

Valid Female 131 100%

Nationality

Valid Ethiopia 5 4%

Somalia 126 96%

Total 131 100%

Religion

Valid Islam 131 100%

Distance from your residence to Health facility

Valid Very close 19 15%

Close 34 26%

average 28 21%

long 25 19%

very long 25 19%

Total 131 100%

20

According to Table 4.1.1 above shows the findings of the Age ,Sex, Religion and Distance from

Health facility Distribution of respondents for the age distribution 64.9% of the respondents are

between the age of 20 to 30, while 19.8% of the interviewed were 31 to 40. finally 15.3 % of the

participants were less than 20 years. On the other hand the sex of the respondents were women's

include Multipara and Premagravida and their nationality was Somalia about 126 (96 % ) and

the rest in Ethiopia. The respondent's religion was 100% are belief in Islamic religion.

Finally Distance from residence to Health facility was differently some of the are closely or very

closely while others was far apart as the table describes.

6. Educational Status of Mothers

Table 4.1.2 Educational Status:

Education Status Frequency Percent (%)

Valid Illiterate 77 58.8

Primary 28 21.4

Secondary 13 9.9

University 13 9.9

Total 131 100

The above table 4.1.2 describes that seventy seven (58.8%) of the respondents were illiterate ,

twenty eight (21.4%) were primary while the secondary and university level have the same

percentage which is thirteen (9.9%) each.

21

figure 4.1 Educational status

7. Martial Status of Mothers

Table 4.1.3 Marital Status

Marital Status Frequency Percent (%)

Valid Divorced 2 1.5

Married 129 98.5

Total 131 100.0

As the above table 4.1.3 indicates that one hundred twenty nine (98.5%) of the participants were

married while the rest two ( 1.5%) were divorced .

22

8. Occupation Status of Mothers

Table 4.1.4 Occupational Status

Occupation Frequency Percent (%)

Valid House wife 108 82.4

Private employee 1 .8

Daily labor 6 4.6

Student 14 10.7

Merchant 1 .8

Government Employee 1 .8

Total 131 100.0

As the above table 4.1.4 and figure 4.2 below shows the distribution of the mothers' occupation

was as follows : the most of them was one hundred eight ( 82.4%)were house wife and least of

them include private employee, merchant and government employee was one (0.8%) each.

23

figure 4.2 Respondents' occupation

24

9. How do you understood ANC?

Figure 4.3 How do you understood ANC

The above figure 4.3 describes the question related to ANC service how they

understood they mentioned that 4.167 is very bad ,9.167 said not bad while 47.f were

said very good and 9.167 were missed

25

10. Do you ever take ANC service?

Figure 4.4 Do you ever take ANC service

A large portion of participants seventy five (62.5%) stated that their antenatal care

service were not met. Where, forty five of the participants (37.5%) atenatal care service

were met. Where, eleven of the participants(9.167) where missed.

26

11 Birth Place of the Children

The Figure below shows that ninety five (79.2 %) of the children were born at home and

nineteen( 15.8%) born at Hospital where, the 6 ( 5%) born at MCH

Figure 4.5 Birth place of children

27

12.Who encourage you to come MCH?

Table 4.1.5

As the table 4.1.5describes womens encouragement fore coming MCH therefore, the

data collected from the respondents shows that 36.6% encouraged by health care,

29.8% encouraged by her self, 18.3% encouraged by her husband while the rest was

encouraged different source like media, community and her family.

13. How many visits you come MCH?

Table 4.1.6

As the above table 4.1.6 shows the health care center specifically MCH how the

mother (client) visit was the 61.1% come visit three, 27.5 come the MCH in visit two

and 3.1 come visit one

28

14. How satisfied are you with The ANC you have received?

Figure 4.6 how satisfied are you with the ANC you have received?

As the figure above indicates the clients satisfaction with the ANC was the major

respondents that 41.67% were satisfied while 29.17% of them were average satisfied,

25.83% were highly satisfied and the rest of them 3.33% were not satisfied .

29

15. How would you evaluate the time between check up?

Table 4.1.7

As the above table 4.1.7 shows that the time between check up were the major

respondents were responded 51.1% were average

30

16. do you come MCH regular or irrigular?

Figure 4.7

The above figure 4.6 shows the regularities or irregularities for coming MCH health

centre therefore the 48.33% come irregular while only 10% come regular

31

17. How interested are health workers to discuss about your problem with you?

Table 4.1.8

As the above table 4.1.8 shows the that the interest of health workers to discuss

abourt the clients problem they responded 45.0% interested,44.3 highly interested

while 2.3% where not interested How deeply health providers listen to you

32

18 How long is the time care provider spend to check up?

Table 4.1.9

19. How sociable do you think are the health workers?

4.1.10

The above table 4.19 shows time care provider spend to check up therefore it took long

as responded the participants 44.33%

The above table 4.1.10 shows that health care providers how they are sociable the

majority of responded 44.3 % are sociable

33

20 How strongly the interection between client and you?

Figure 4.8 Strongly the interaction between client and you

There was a strong interaction between service provider and client service in ANC

as the figure 4.7 describes 57.5% and 35% both of them mentioned the strong

interection between them

34

21.

Figure 4.9 How health care provider understood the antenatal care

As the above figure shows that the health care providers understood ANC service very good

53.33 .

35

22.

Figure 4.10

As the above figure indicates that the provider know if the mother come MCH regularly or do

not

36

23

Figure 4.11 in your opinion what is the time between visits?

The above figure 4.10 shows the opinion of provider for the mothers visit in health center so they

are closely to gather as the figure explains

37

24

Figure 4.12 in your opinion,how much information client had received?

This figure 4.11 above shows how much information client had received, about 81.82% of the

provider said that the clients got enough information while only 18.8 did not get enough

information the rest and last portion are the client.

38

25 What opinion that women’s have in antenatal care ?

As the above figure 4.11 indicates the opinion that women’s have in ANC the participant said

54.55% understood good while 45.45 said very good and the rest are client.

39

Table 4.1.11 Challenging for giving ANC care service

Is there any challenged for giving ANC

for Women's Frequency Percent

Valid Yes 11 8.4

Missing System 120 91.6

Total 131 100.0

is there any other service you give

women's

Valid Yes 11 8.4

Missing System 120 91.6

Total 131 100.0

The above table describes three questions about women's giving ANC challenges,

complications and other service to give women's during their pregnancy stage, the table shows

that almost same responded answer that was YES because the respondents was healthy workers.

Do you tell them the complication that

they developed if they don't use ANC

Valid Yes 11 8.4

Missing System 120 91.6

Total 131 100.0

40

4.2. Discussion

The results revealed Dr Khalid Health Center in Hargeisa Somaliland had inadequate

number of skilled personnel to attend to pregnant women at the antenatal clinic.

The number was inadequate compared to the number of women reporting for

ANC per day and considering the required services and counseling to be

provided.

This had an implication on the quality of the services delivered because one nurse was

attending to about fifty women and close the ANC clinic at around twelve o’clock

midday. The situation in Hargeisa is in agreement with the national situation in Somaliland

where other studies in Ethiopia have identified low staff levels in most government health

facilities to provide required services. [12]. .

Lack of proper infrastructure for providing ANC compared to the standards

was identified at the health centre.

Antenatal women had to wait for the services outside on the ground due to lack of proper

structure. The findings concur with another study , where findings reveled that there was no

proper structures for providing ANC in most government hospitals in Istanbul which hindered

most women from reporting for ANC especially in rainy season. . [13]. The finding entails

lack of readiness to provide ANC at the facility. There was also severe shortage of material

resources for providing ANC identified at the Health Centre where as in our study revealed that

clients have a proper waiting area for their service.

The study further revealed that the majority of women in Hargeisa attended antenatal clinic for

both their first and last born child pregnancy. There was no significant difference between ANC

attendance during first and last born pregnancy. Similarly there was no relationship

between maternal age at marriage, parity and level of education. However there

41

was significant relationship between school attendance and antenatal attendance although the

CI was wide indicating a weak association.

This finding is consistent with the MDHS which reported high ANC attendance in

Malawi since the year 2000 [3]. In the MDHS 2004 the other socio- demographic

characteristics like age, parity, and marital status were also not associated with ANC

attendance, except for school attendance which was strongly associated to ANC

attendance. Despite high antenatal attendance in this study, most women started

ANC late in second and third trimester contrary to WHO recommendation of initiation of

antenatal care before sixteen weeks. [9]. Late starting was due to cultural reasons and a

mere laugh from friends. This finding is similar to findings in a study done by

Matekwe- Phoya) where most rural pregnant women in Malawi started antenatal care late within

second trimester and one of the reason was cultural.

Late initiation has also been identified in most sub-Saharan African countries where

most women present for antenatal care services in the second trimester and a relatively

substantial proportion in the third trimester.

The clinical implication of late initiation of ANC is the missed opportunity for early

intervention for a large proportion of pregnant women in Hargeisa. This implies

that messages regarding the importance of early initiation of ANC have not made any significant

impact in the area.

In addition the finding could be due to illiteracy as most women did not go to school, negative

staff attitudes which have been highlighted in the qualitative findings and lack of knowledge on

the importance of ANC. Women in the study made more than the required four targeted visits

required in ANC.

The finding implies that more visits made added more workload and wasted the already scarce

resources as the other visits had no impact at all.

However more than necessary visits by women may be due to lack of women orientation as the

staff providing ANC was not oriented as well. The study findings further revealed the skilled the

staffs at Dr Khalid Health Center was not oriented on ANC, the new approach proved

to have an impact on maternal

mortality. The staff providing ANC concentrated on examinations proven to have less impact

on maternal health like weighing, auscultation of the fetal heart and palpation of the fundus.

42

Other important examination like HIV, urine and VDRL testing were not done to lack of

reagents. This implied identification of pre-existing health conditions that may affect

outcome of pregnancies such as HIV, anemia, and other sexually transmitted

infections were not offered.

Such missed opportunities should be regarded as indicators of poor quality.

However the finding could be due to lack of staff orientation on ANC, and lack

of resources. Inadequate staff training or lack of refresher courses to upgrade staff skills

on maternal health have also been reported in some studies.

Study findings revealed that health education on HIV, diet and family planning

was given to most women during both first and last born pregnancies.

However other important information like danger signs, afterbirth complications, and plan

for delivery which are emphasized in FANC were not given to some of the antenatal women.

This result concurs a finding in another study on quality where most health workers in public

facilities did not dwell much on educating women on topics like danger signs and birth plan

during pregnancy. [11]

Findings also revealed that there was no proper referral system of antenatal women with

complications to the next facility. Most antenatal mothers with complications with

hired vehicles which had to be called in times of need and there were a lot of delays when was

called. Similar to the finding, delays in referring complicated cases from health facility to

another facility in most developing countries due to inadequate transport. [10] This implied

that emergencies and complicated pregnancies were good time.

In Somaliland, most maternal deaths are due to the three delays. The findings in this study

revealed that Dr Khalid Health Center was experiencing these three delays; that is delay in

seeking care ( cultural beliefs in initiation of ANC ), delay in reaching appropriate

care (due to ineffective referral in times of complications) and delay in receiving

care (due to inadequate skilled personnel in emergency obstetric care, inadequate

supplies and equipment ). The delays resulted in delivering poor quality of ANC.

43

CHAPTER FIVE

CONCLUSIONS AND RECOMMENDATIONS

5.0 Introduction

The result our study was very precisely concerns the objectives of the study and clearly

expresses all most all the factors which direct or indirect related assessment quality of antenatal

care among the pregnant women in DR Khalid MCH

5.1 Conclusion

Pregnant mothers were willing to seek heath care services during pregnancy. However, most

pregnant women don’t attend for ANC services regularly mainly due to lack of knowledge and

information as well as poor quality antenatal care services in MCHs.

ANC in Somaliland has not reached more than one thirds of Pregnant women, it is not reported

increases in the coverage of the recommended four ANC visits but increases in the coverage of a

first trimester ANC visit, because Somaliland have only three visits.

As a critical link in the continuum of care, ANC offers incredible opportunities to reach a large

number of women and communities with effective clinical and health promotion interventions.

However, inequity exists, and young, rural, poor, and less educated women may not benefit

from ANC services or may drop out because in Somaliland there is some believes in the culture

they believe if the women goes to the MCH the providers will make that women sterile or the

service that MCH gives is family planning only .

at the same time they believe that the immunization is HIV virus that the health care provider

inject the mother

44

5.3 Recommendations

The following recommendations are recommended to Ministry of health, Ministry of Education,

Ministry of planning, International NGOs and Local NGOs and any other organization who

interest humanitarian intervention

strengthen ANC should focus on universal coverage by addressing financial and cultural

barriers to reaching vulnerable groups, quality improvement to increase women's

satisfaction and reduce drop out, and integration of programmes to maximize the contact

between the woman and the health services.

Similarly, awareness campaigns should be organized as part of the child health days

campaigns or separate reproductive health campaigns should be organized to address the

prevailing misinformation and misconceptions that prevent women to access and utilize

available reproductive health care services.

Training must be given to the traditional midwife in order to minimize mother mortality

rate and also complication of the delivery

The role of the trained midwives and public health nurses should be widely disseminated

to the community so that women will have more confidence in seeking advice and care

from them. Facilitate distribution of family planning commodities to health facilities so

that women would have an access to these services to help child spacing and reduce high

frequencies in pregnancies among women of child bearing age.

Train health care providers to enable them change their attitude in quality care provision

for them to handle clients more respectfully with confidentiality and professionalism.

This will encourage women to seek health care services from health facilities even for the

stigmatized cases like rape, abortion and teenage pregnancies.

To improve the antenatal care Develop linkages with other programmes, especially

traditionally vertical interventions, such as malaria and HIV

To reduce barriers to accessing care and reach out to women not accessing care the

Ministry of health must give awareness to the community

45

APPENDIX

REFERENCES

1. Aonsection3_2 Opportunities for Africa’s Newborns Usiad Child health research project

in 1999 reducing prenatal and neonatal mortality al L

2. AbouZahr, C & Wardlaw, T . Maternal Mortality in 2000: Estimates by WHO, UNICEF

& UNFPA: Department of Reproductive health Research World Health Organization,

Geneva; 2004 [accessed 3 July 2006] Available from:

http://www.who.int/whomatmortestimates2000.pdf.

3. Authors. Roemer and Angular, (WHO, 1988)Quality assurance in primary health care

4. Anppcansomaliland.org/ANC%20REPORT%20final.doc Unicef Antenatal Care in

Kosovo QUALITY AND ACCESS

5. AntenAtAl cAre Presented by: Dr.Hani Mohammed Ibrahim MBBS, PGDip.Research

Fellow at RCRU.Fellow Student at GFMER .Obs & Gynae Resident at MCH

6. . Hall, J.J. & Taylor, R. 2003. Health for all beyond 2000: the demise of the Alma-Ata

Declaration and primary health care in developing countries. Medical Journal of

Australia. Vol 178. No.1.17-20.

7. Anppcansomaliland.org/ANC%20REPORT%20final.doc Unicef Antenatal Care in

Kosovo QUALITY AND ACCESS

8. Somaliland Millennium Development Goals (MDGs) 2010. goal fiveimproving maternal

health

9. Peaboy J, Gertler PJ, Leibowits A. The effects of structure and Process of Medical

Care on Birth outcomes in Jamaica. Health Policy. 1998; 43: 1-13.

10. . Rose M. Assessing quality and availability of maternal health services: Results

from Kenya; 2001 [Accessed 24 November 2006]. Available from:

file://C:Documents and Settings/User/Desktop/ Assessing the quality and availability of

maternal health services.

46

11. World Health Organization Consultation on Maternal and Prenatal Infections. 28

November-2 December Report. WHO/MCH/91.10.WHO: Geneva, Switzerland; 1988

12.

.

47

APPENDIX III QUESTIONNAIRE FOR CARE PROVIDERS

Hope university with co-corporate Kampala university

Department of Public Health

Information Sheet

Hello Madam we are working for degree research project we are studying the quality of antenatal

care service in Dr Khalid MCH in Hargeisa, Marodijeex region, the capital city of Somaliland.

In our study we interview clients who are visiting the health institutions as well as service

provider on the same issues. Your information and genuine response is extremely important to

have a good understanding of the existing level of quality of antenatal care services in MCH.

Your name will not be asked and unique identification is not required. You participation will

contribute improving the provision of quality of antenatal care service in DR Khalid MCH

Do you want to participate? Yes------ No-------

Interview Date-----------------------------------

48

1.2. Questionnaire for Exit Interview of clients to assess quality of antenatal care Services

in DR Khalid MCH

Part I. QUESTIONNAIRE ON SOCIO-DEMOGRAPHIC CHARACTERSTICS

1.1 How old are you?

A)less then 20 B. 20-30 C. 30-40

D.40-49

1.2 What is your sex?

A. Male B. Female

1.3 Educational status

A. illiterate

b. Primary school c. Secondary school d. University

1.4 What is your marital status?

A. Single B. Married

C. Divorced/Separated D. Widowed

1.5. What is your occupation?

A. House wife E. Private Employee

B. Government Employee F. Daily labor

C. Student G. Unemployed

D. Merchant H. Other (specify)

1.6 To which nationality/ethnic group/ do you belong? __________________.

1.7 What is your religion? __________________.

49

1.8 the distance from your residence to health facility?

A. Very long B. long

C. close D. very close

Part II: Questionnaire on Client satisfaction

2.1 How do you understand antenatal care?

A. good B. Very good

C. Not Bad D. Very bad

2.2 . Do you ever take antenatal care service?

A. yes B. No

2.3 Where was the birth place of your children?

A. Hospital B. MCH

C. Home

2.4 Who encourage you to come MCH ? ________________.

2.5 How many visits you come MCH?

A. Visit one B. visit two

C. Visit three

2.6 How satisfied are you with the antenatal care you have received?

A. Highly satisfied B. Satisfied

C. Averagely satisfied D. Not satisfied

2.7 How would you evaluate the time between check-up?

A. Too long B. long

C. Average D. Short

2.8 How much information did you received about your health?

50

A. As much as I need B. Enough information

C. Not enough information

2.9 Do you come MCH regular or irregular?

A. Regular B. Irregular

C. When I feel pain D. Every time

Part III. Questionnaire on Interaction between care provider & ANC client

3.1 How respectful are the health workers?

A. Highly respectful B. Respectful

C. Average D. Not respectful

3.2 How interested are health workers to discus about your problem with you?

A. Highly interested B. Interested

C . Average D. Not interested

3.3 How deeply health providers listen to you?

A. Deeply listen B. Listen

C. Average D not listen

3.4 How sociable do you think are the health workers?

A. Highly sociable B. Sociable

D. Poorly sociable

3.5 How strongly the interaction between client and you?

A. Very strong B. strong

C. Not strong

3.6 How the health care provider understood the ANC health service ?

51

A. Very good B. good

C. not bad D. bad

Part IV Questionnaire on Providers Perception on ANC

4.1 In your opinion, what is the length time between visits?

A. Too long B. long

C. Short D. Too short

4.2 How long waiting time before seen by a care provider?

A. Very long B. long

C .Average D .Short

4.3How are you antenatal care provided sociable with client?

A. Highly sociable B. sociable

C. Poorly sociable

4.4 How are you thinking that women who attended ANC were satisfied?

A. Highly satisfied B. Satisfied

C. Averagely satisfied D. Not satisfied

4.5 What opinion that women’s have in ANC ?

A. Very good B. Good

C. Not bad D. Bad

4.6 Is there any challenge for giving antenatal care for women’s ?

A. no B. yes

4.7 do you tell them the complications that they develop if they don’t use ANC ?

52

A. No B. No

4. Is there any other service you give women’s ?

A. Yes B. No

4.9 Do you encourage women’s to take antenatal service?

A. Yes B. No

Thank you