Both women and their caregivers were eager and willing to share their understanding of and experiences with quality of care.
Defining “Quality of Care”
Individual interpretations of the term “Quality of Care” were sought in each interview. Gaining an understanding of each participant’s interpretation of this term was important for getting an insight to their beliefs regarding care and the factors of care most important to them. The definitions of quality of care given by mothers differed from those of caregivers. For mothers, quality was related more to personal requirements: “it is when I have soap and clean my clothes”. In comparison, the healthcare staff defined quality in relation to their practice: “Quality of care to me…it means giving care in terms of nursing or clinical services to the pregnant woman, or a woman who has just delivered; in the right way, at the right time, with the right resources, to the right woman”.
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”.
Perceptions of barriers to good quality care
Lack of autonomy
Throughout the interviews participants identified lack of autonomy in the way care was given as a key barrier. This applied both to mothers making decisions regarding their own care, and to caregivers who felt they were never involved in policymaking regarding strategies to improve care. The mothers frequently commented that they did not understand the reasons why they had been given certain treatment, and their consent had often not been sought. An example of this poor communication between healthcare providers and mothers was reported by a mother who had an emergency hysterectomy. She was not informed about the details of the procedure nor that she would not be able to conceive again. “I was bleeding so they told me that they would operate…they did not tell me what the operation was for. I found out that my baby was dead after…they did not tell me, they told my mother. I don’t know what happened, I want another baby…I do not know if this will happen”.
Strained relationships and poor communication between mothers and caregivers
All the mothers interviewed expressed respect for the healthcare workers on the maternity ward. Midwives in particular were held in high regard, and their knowledge and experience gave mothers confidence. In terms of educational achievement, the healthcare providers at the four study hospitals could often speak fluent English and were relatively well educated compared to the mothers, many of whom were illiterate. However, coupled with this respect, there was a sense of fear and a belief that if a patient disagreed with, or angered a midwife, this could result in poor labour outcomes. This was illustrated by one mother who attributed the death of her sister to failure to comply to midwives advice: “My sister was four months pregnant. She was not feeling ok and came here [the hospital] for help. She didn’t listen to what the nurses were telling her to do and so they didn’t help her. She died with the baby inside her.”
Shouting by both mothers and caregivers on the labour ward was stated as an important factor for a strained relationship between the two. Patients admitted to screaming due to labour pain, but did not like caregivers to shout back at them. One participant spoke of a healthcare provider, all mothers hoped to avoid. “…we have heard [from other mothers] that she shouts a lot. This is not good…when you are in pain and somebody shouts at you, you feel like its cruelty.” Another mother gave an example of poor staff attitude and inadequate communication “You are in crying pain, but sometimes a nurse doesn’t come to help because she is busy on the mobile [phone]…if she does come she shouts at you for screaming”. Interviewed mothers considered this behaviour as wrong: “It is not good for patients to be shouted at”. They reflected that such experiences could negatively impact future health seeking behaviour of pregnant mothers.
Caregivers reported that the pressure of their jobs could result in “being stressed” and in “a bad attitude” towards patients. “Sometimes you might not answer her questions and shout at her to be quiet. Maybe I have acted that way…you are busy and frustrated and the resources are not there”.
Lack of decision making power
When healthcare providers were discussing the types of poor care practices observed on their maternity wards, none of them was able to identify an official route to report negative incidents to higher authorities. This was demoralizing for staff who were eager to ensure best care for patients but felt that other team members were being negligent. “I feel [one colleague] is incompetent…his school said he was ‘un-trainable’…he often wants to wait…we end up having to delay. One woman…he was not comfortable taking her to theatre so we had to refer her. I was told she passed away, I was furious. [If I reported him] I feel, due to low staff, they would just move him to another hospital”. Feeling unable to formally report “incompetent” colleagues resulted in a feeling of powerlessness amongst the healthcare providers.
Midwives perceived their “lack of authority” as demoralising. When discussing midwifery training in Malawi, it emerged that many midwives felt they had a more thorough maternity training than those supervising them such as clinical officers or who, however, had the ultimate decision making powers in emergency cases. Not only did midwives feel undermined by this, but some midwives felt that, at times, patients suffered poor outcomes as a result of senior staff not agreeing with a midwife’s management plan. “Sometimes you call for a clinician…they have not been with the mother…and your opinions [on management] collide. The midwife has spent more time in school, but the clinician has the final say…there is nothing you can do. It is frustrating as you only want the mother to benefit.”
Likewise, healthcare providers reported a lack of feeling involved in management or policy decisions taken by hospital managers and policy makers. All caregivers who participated in the interviews enquired how the results of this study would be disseminated. They were keen to understand the views of the mothers and learn how they could improve the quality of their care giving. Many were keen to be more involved in decision making processes in the health system. The majority felt that decisions were often made without consulting them, and therefore they also assumed that effective solutions were never put into practice. “…we have NGOs who come and undertake studies into maternity care…the results are given to higher authorities. The people high up are busy people and so results and ideas to improve do not reach us on the labour ward. We don’t get invited to presentations or meetings, but it is us who are supposed to bring about the changes. In this way I think the research may be wasted and little done”.