Our study demonstrated that there were major deficiencies in the quality of MNH services in both the study facilities. Overall, the service providers in these facilities failed to follow about half of the standard activities of MNH care. In the case of maternal care, the quality was low for ANC and PNC; moderate for NVD, CS and complication management in both the facilities. In the DH, the quality of blood transfusion was high but that of infection prevention and sick newborn care were moderate and low respectively.
The QoC scores for both ANC and PNC were unacceptably low in each DH and MCWC. For both of these services, the QoC scores for ‘rapid initial evaluation’, ‘cordial and respectful receiving’, ‘history-taking’, ‘physical examination’ and ‘individualized care’ were far from satisfactory. Quality was surprisingly low for ‘birth planning’ component in ANC and for ‘neonatal management’ component in PNC. Providers in both the facilities rarely advised on ‘proper breastfeeding technique’ and informed about ‘maternal and neonatal danger signs’. A separate study in Bangladesh, using standard operation procedures of the Directorate General of Health Services [13], documented relatively high quality of ANC service compared to our study. However, that study was conducted in primary health facilities, and the variations in findings might be due to difference in the context.
Lack of refresher training and inadequate human resources might have contributed to the poor quality of care in secondary facilities [10]. Since the quality of ANC influences pregnancy outcomes [16] and a high burden of maternal and neonatal mortality exists during the postnatal period [17], standard QoC needs to be maintained. In addition to increasing human resource, special orientation programmes and refresher training for the service providers with emphasis on the low scoring areas might be useful for improving the quality of ANC and PNC.
Although the service providers in both the facilities of our study could perform more than half and three-fourths of the total standard activities while providing NVD and CS delivery services respectively, there is still considerable room for further improvement of the quality of these services. Providers in these facilities performed poorly in providing newborn care immediately after NVD and CS delivery. For NVD, the quality fell due to poor performance in ‘rapid initial assessment’ and ‘physical examination’. More than one-third of the activities in ‘active management of the third stage of labor’ that needed to be addressed properly for prevention of PPH, was not performed [18]. The QoC scores for using partograph in both the facilities were extremely poor. Similar findings were also documented in a previous study [12]. The care providers might not be in a position to use the labor-monitoring tool due to lack of training and high patient-load [19]. Our study found that clients were inadequately counseled on indications, risks, and benefits of CS. Another study revealed that there was skepticism among clients about the service providers’ justification of CS in Bangladesh [20]. To improve the situation, adequate training should be provided to human resources with emphasis on clinical assessment and monitoring. Advocacy program needs to be endorsed to motivate the service providers for using labour monitoring tool like partograph in order to observe progress in labour and foetal condition and make decision for appropriate intervention.
Standards of quality must be maintained while managing maternal and newborn complications to reduce the risk of serious complications and avert death. We found that the service providers completed most of the activities in general management of maternal complications and diagnosis of specific causes. However, the quality of management of specific conditions, such as pre-eclampsia/eclampsia and incomplete abortion was deficient. Poor quality of PPH management is a serious concern as it is the single-most important cause of maternal mortality [21]. Most prevalent causes of neonatal deaths included prematurity, birth complications (birth asphyxia and trauma) and sepsis [22]. Our findings on poor QoC in identifying specific newborn complications and lacking in providing appropriate care are similar to those from another study in Bangladesh [23]. We also documented substantially low performance in appropriate diagnosis of preterm and low-birth-weight neonates. Quality of diagnosis and referral for neonatal sepsis and jaundice were low mainly due to care providers’ poor practice to recognize the signs/symptoms of these complications. The current low qualities of sick newborn care service at these district-level facilities in Bangladesh need to be improved through special training program of the service providers. While assessing BT service, we found that standards in receiving the clients and assessing the blood donor for fitness were not maintained properly and that may enhance the risk of getting infected by intravenously transmitted diseases among the patients. Intermittent advocacy program and refresher training of the service providers may help overcome these inadequacies.
Although overall QoC scores for prevention of infection was better in the MCWC, component-wise analysis revealed that the quality of the ‘use of antiseptics in labor room’; ‘availability of the antiseptics, disinfectants, and other supplies’; and ‘collection of soiled linen’ was inadequate in both the study facilities. These shortcomings, along with the low score for sterilization processes in DH, increase the risk of hospital-acquired infection of mothers and newborns. The main cause of hospital-acquired infection is the substandard practice for prevention of infection and simple strategies, such as hand washing which can reduce this burden significantly [24]. As prevention of infection is a broad issue; the support staff of the hospitals, along with the care providers, should be appropriately trained to ensure proper sterility. Behavior change education, monitoring and supportive supervision of the staff may improve the situation [25].
One limitation of our study is that we did not correlate the QoC with availability of human resources, functioning equipment, logistics and supplies. However, the poor quality of primary MNH care in the study facilities is likely to be due to inadequate human resource and high patient load that had been documented in our another paper [26] developed from the same study. This also has been confirmed by the service providers while sharing the study findings with them. In addition to training of the existing manpower, they suggested to ensure availability of adequate human resources to practice the QoC protocols for various MNH care services. Another limitation of the study is not considering the delay in providing services at health facilities. Further qualitative studies are needed to explore the impact of delay in providing services on quality of MNH services. In this study, we observed the patients for QoC only during the morning and shifts. Not observing services at the night shift does not likely to affect the findings as the services are scanty is public facilities during that period. Only one month observation time period was another limitation in capturing adequate number of infrequent services (such as complication management, infection prevention and BT). This short observation period also did not allow us to mitigate the seasonal dips. Above all, we did not apply weights for different activities of various MNH services, as there is no standard available in the literature.
Substandard QoC in the public health sector in Bangladesh might have contributed to the recent lack of progress in health indicators [4]. The Government has developed national healthcare standards on QoC [27] but these are yet to be implemented and lack many important technical details. There is a need to develop a contextualized facility-specific quality monitoring tool of MNH service by reviewing SBM-R and other existing methods through expert consultation. Self-implementation of the newly-developed quality assessment tool can be a way of improving the QoC, and, for that purpose, training activities and motivation programs for service providers should be undertaken.