The proportion of births attended by a skilled birth attendant (SBA) defined as a provider who is “trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns” [1] is an important indicator for monitoring progress toward Millennium Development Goal (MDG) 5. The international target to have 90% of births attended by skilled health personnel by 2015 remains a major challenge [1].

Worldwide, many efforts have been made to address this challenge and in the past decade a major focus has been placed on improving access to skilled birth attendance and Emergency Obstetric Care. Particularly in countries with poor infrastructure more hospitals have been built, more skilled birth attendants have been trained, and through work education and community initiatives more families have been encouraged to give birth in health facilities.

By 2008, 66% of all births globally were attended by a SBA. By 2012, the proportion is still low in the African region (49%) compared to 59%, 94% and 92% in Asia, the Americas and Europe respectively [2, 3]. The global focus on increasing uptake of and demand for facility based care to reduce maternal mortality creates an urgent need to address the quality of maternal care [4].

There is emerging evidence that when the quality of care at a health facility level is perceived to be poor, this discourages women and their families from accessing this care. Similarly, a poor quality of care or care that is ‘sub-standard’ is recognised to result in increased morbidity and mortality. To improve the quality of maternity care an understanding of what is meant by the concept of “quality of care” is important. A systematic literature review showed that there is no universally accepted definition of quality of care and the multi-faceted nature of quality is widely acknowledged. Models describe quality of care from the perspective of health care providers, managers and patients; dimensions within the health care system; using elements such as safety, effectiveness, patient-centeredness, timeliness, equity and efficiency; and through the provision of care and experience of care [5].

Although several definitions and frameworks have been developed to define quality of care, defining the quality of care in maternal and neonatal health remains a challenge due to a multitude of aspects that have to be considered. Hulton et al have highlighted the fact that in the context of maternal health and child birth, effective (safe) care, timely access and reproductive health rights are all important components of the quality of care provided [6].

Both the quality of the provision of care by the healthcare provider (birth attendant) and the quality of care as experienced by users are important. The use or uptake of services, including care at the time of childbirth is the result not only of the availability of that care but also of women’s experiences of that care [7]. Maternity audit, in a variety of forms, is now being implemented in many resource-poor countries. All essentially ask the same three questions: what was done well, what was not done well, and how can care be improved in future? [8, 9] However, provision of care may be deemed of high quality against recognised clinical standards of care but unacceptable to the woman and her family. Conversely, some aspects of care may be popular with women but may be ineffective or harmful to health.

This study aimed to explore the perceptions of maternity care from the point of view of both the mother who had received maternity care and the healthcare provider who had provided care in a rural setting in Malawi.

The study was conducted in the four hospitals of Mangochi district (Mangochi District General, St. Martins, Monkey Bay and Mulibwanji). The facilities were purposefully selected to guarantee a sufficient number of daily deliveries but also ensure a representative number of study participants. All study hospitals had quality improvement committees and conducted maternal deaths audits.

The study population included postnatal mothers aged between 16 to 36 years who had delivered in the last 7 days. We excluded mothers with poor birth outcomes such as stillbirths or neonatal deaths from focus group discussions as we considered it unethical and insensitive to group them with healthy mothers and healthy babies.

The healthcare providers included in this study were all working on the maternity wards. Data was collected by the main researcher and four trained national research assistants who understood the local language using in-depth semi-structured interviews (IDI) and focus group discussions (FGD). In order to guarantee the consistency of the interviews, all research assistants received training in qualitative data collection and used the same topic guides. Topic guides addressed the understanding of the term “quality of care”, factors contributing to good or poor quality of care and the interviewees’ perceptions and experiences of the quality of care provided or received during childbirth. 33 postnatal mothers and 10 health care providers participated in the study; a total of 16 mothers attended the two FGD, 17 mothers and 10 healthcare providers (4 midwives, 4 clinical officers and one nurse attendant) participated in IDI. All participants were chosen purposefully to ensure a varied sample of postpartum mothers and healthcare providers with different levels of experience and care roles (midwives, nurses, clinical officers).

Data was recorded, translated into English and transcribed. All data was analysed using the framework approach [10] and NVivo software version 8.0.

Both women and their caregivers were eager and willing to share their understanding of and experiences with quality of care.

Perceptions of good quality care

When asked which aspects of care were perceived to be the most important to the participants, caregivers and mothers prioritised different factors. Figure 1 summarises key factors which are arranged as representing the enabling environment, clinical care provision and as related to communication. All the caregivers listed availability of resources, such as medication, equipment and staff as the most essential components of good quality care: “Factors that affect quality of care could be how skilled the nurse is; the availability of instruments; the availability of essential drugs”.

The vast majority of mothers however, placed emphasis on the importance of a positive staff-patient relationship. This relationship was built by the mothers feeling welcomed into the labour environment and attended to in a timely manner as well as being able to ask questions, which was important to women. Being “shouted at” or being “scared” were considered to be poor quality care: “[Good quality care is] when you have been received well by the staff at the hospital, and they have helped you quickly”. It is worth noting that very few mentioned the importance of sufficient equipment and medications. In contrast, only one caregiver mentioned the importance of staff-patient relationships. Only when asked directly whether a good relationship was important, did the healthcare providers add this factor to their list of determinants. However, they also stated that ensuring a good relationship was not always feasible: “Yes, good rapport is also important, but it is not always possible”.

This study revealed that there were key differences in the perception of quality of care between mothers and caregivers. While mothers prioritised the importance of a good relationship with the caregiver, healthcare providers felt the supply of resources to be most important. We also noted a lack of awareness amongst mothers regarding what they could expect with regard to “Quality of Care”. This may be due to their lower levels of education when compared to the relatively higher educational levels of healthcare providers. These findings correlate with studies suggesting that education could be a contributing factor to the differences of opinion between mothers and caregivers [11–13]. Addressing the inequalities between mothers and caregivers by strengthening education could ensure common views on quality. It may also help to improve staff-patient relationships, a key component for improved quality care [11].

A poor client-provider relationship led to feelings of powerlessness among mothers with regard to decision making about the care they required or expected during labour and delivery. This lack of autonomy has also been highlighted in a study from Ghana [14]. Health care workers mentioned the existence of a “class” hierarchy in healthcare settings and attributed the lack of autonomy to the fact that healthcare providers ‘knew what was best’. Similar findings were reported in South Africa, where prohibiting mothers from making their own health decisions was a way for caregivers to assert a higher class authority [13].

Having autonomy is not merely an ethical principle, it is a human right. To be able to take responsible decisions about their sexual and reproductive health, individuals need to be provided with adequate information resulting in informed choice which is a key condition for quality in care [15]. In our setting, healthcare workers dominated the decision making process and patients were rarely asked for their opinion. However, a more rights based approach that involves patients and builds their capacity to take decisions would be good practice as studies have shown that giving patients decision making powers is linked to improved outcomes and satisfaction [16]. Furthermore, just as dissatisfaction is shown to have implications on whether mothers access in future, improving empowerment of patients may lead to an uptake of services [11].

Poor behaviour of healthcare providers, such as shouting at mothers, was cited as an example of poor quality care. Such experiences have been described in other studies [17–20]. A lack of identified routes but also fear to report dangerous or unethical practice underlines the importance of introducing clinical audit as an effective and cheap low-technology intervention to improve quality of care [21–24]. Encouraging hospitals to harbour non-blame environments so that staff is encouraged to reflect on clinical practice, seek appraisal and perform continual professional development may change practice and improve outcomes [14].

From the point of view of the healthcare provider, many spoke of their frustration with the inability to provide what they would consider a good quality of care because of resource constraints and lack of an enabling environment. This problem has also been mentioned in an earlier publication from Malawi [25]. Such frustrations contribute to the demotivation of the healthcare provider and are likely to have a negative impact on the provision of care. Some frustrations stemmed from differences in practice and opinions between the midwives and the more senior clinicians who were said to have the ultimate decision making power.

The fact that many of the management decisions within the hospitals are made without consultation with those who are the main care providers may explain why, for example, implementation of new policy and practice fails. Not only do proposed changes often fail to reflect the local context, they can even evoke strong adverse reactions from workers [26]. It must be stressed to future policymakers that it is crucial to consider local context and seek caregivers’ opinions before changes are imposed, if effective care is to be achieved [27].

There was a feeling that the cause of poor behaviour was ultimately linked to job demotivation. Lack of motivation was influenced by the frustration and daily struggle to provide adequate care in a poorly resourced setting; a growing feeling of non-involvement and lack of teamwork or multidisciplinary approach; and a missing engagement of policy makers with caregivers on the ground. In a non-direct culture, by blaming external factors such as a lack of resources as the reason for poor quality care, disenfranchised caregivers can externalise blame and responsibility [28].

By using a qualitative approach this study reflects the views of both healthcare providers and patients and provides us with identified components of care that are considered ‘good quality’. Although there are clear advantages of using such an approach this study does have several limitations. We did not include perceptions of policy makers and based on the purely qualitative approach some quantitative information such as measuring work pressure and identifying resource constraints would have added to a more comprehensive picture and would require further research. Additional research could include assessing perceptions of quality of care in the wider community and the role of participatory women’s groups and community outreach services regarding awareness raising on quality of care and its impact on the provision of quality care in the facilities.

This study highlights the need to create a reciprocal understanding of what quality comprises and provides information on factors to be addressed in order to strengthen the quality of maternity care. More focus needs to be placed on better communication between clients and providers. Such requires strengthening of patient rights and improving their autonomy whilst simultaneously supporting and motivating good practice through audits and the provision of opportunities for professional development.