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Assessment of Antenatal Maternity

Service Quality at Mafikeng
Provincial Hospital, South
Munyaradzi Mushunje
Alternation: Interdisciplinary Journal for the Study of the Arts and Humanities in Southern Africa

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Assessment of Antenatal Maternity Service
Quality at Mafikeng Provincial Hospital,
South Africa

Munyaradzi Mushunje
Sam Lubbe
Jan Meyer

Abstract
The purpose of this study was to assess antenatal maternity service quality
among patients at Mafikeng Provincial Hospital (MPH) in the North – West
Province. Quantitative research using a SERVQUAL based questionnaire was
carried out to determine the expectations and perceptions of antenatal patients
on MPH antenatal service quality. Correlation were used to determine the
relationship of expectations and perceptions on service quality. A total of 70
questionnaires were successfully completed. The results of the study showed
that antenatal patients have high expectations of MPH antenatal service quality
and patients generally had positive perceptions on the quality of service they
receive. Mixed responses were however obtained in areas involving clinic
operating times and the ability of maternity staff to perform work right the first
time. Findings of this research study were used to draw conclusions on
antenatal care service quality.

Keywords: Antenatal, maternity, public service, quality of service,

SERVQUAL

Introduction
Public sector organisations in South Africa have come under pressure to
deliver quality service and improve on efficiency. In today's global

Alternation Special Edition 25 (2019) 202 - 220 202

Print ISSN 1023-1757; Electronic ISSN: 2519-5476; DOI https://doi.org/10.29086/2519-5476/2019/sp25.3a9
 Assessment of Antenatal Maternity Service Quality

environment, delivering quality service is an essential strategy for

organisational success (Ramseook-Munhurrun et al. 2010). Hospital service
quality has become a determinant of organisational success and survival in an
environment where patients have become critical and selective of the quality
of health services they receive (Mensah, Yamoah & Adom 2014). This
research determined the expectations and perceptions of antenatal patients of
MPH Service Quality.
In reviewing the research, key concepts were derived from the problem
statement and in turn used to search for literature. A literature review concept
matrix was developed and different sources were classified according to the
concepts. This paper is presented as follows: Introduction, the problem
statement, research used and concludes with recommendations.

Problem Statement and Research Questions

Mortality rate among women of reproductive age has increased in South Africa
(Burton & Acquah 2014). The level of maternal mortality is a concern to the
South African Government as expressed in its population policy (Millennium
Development Goals Country Report 2013). Millennium goal number five seeks
to improve maternal health and had set a target of Maternal Mortality Rate
(MMR) for South Africa at 38 per 100 000 live births by the year 2015
(Millennium Development Goals Country Report 2013).
The South African Government has taken steps towards reducing
MMR, including implementing policies that emphasize primary health care
and providing free antenatal care (Amnesty International Report 2013). The
government has, however, failed to reach the target of millennium goal number
five that was set to have achieved a reduction in the maternal mortality ratio of
38 deaths per 100 000 live births by 2015 (Millenium Development Goals
Report 2013).
Provision of quality antenatal maternity services remains a component
towards reducing maternal mortality rates and ensuring happy mothers and
healthy babies. This paper therefore investigates the quality of antenatal
maternity services that pregnant women receive from Mafikeng Provincial
Hospital in the Northwest Province.
This research answered the following questions:
a) What expectations do maternity patients have of Mafikeng Provincial
Hospital’s service quality?

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Munyaradzi Mushunje, Sam Lubbe & Jan Meyer

b) What perceptions do Maternity patients have of Mafikeng Provincial

Hospital service quality?
c) How are expectations and perceptions of maternity patients’
contributors of MPH service quality?

Overview of Theory
Antenatal care (ANC) is the care, supervision and attention given to a pregnant
woman and foetus during pregnancy up to delivery. It is an entry point for a
pregnant woman to receive a broad range of health promotion and preventive
health services (Baffour-Awuah, Mwini-Nyaledzigbor & Richter 2015). The
role antenatal care plays in reducing maternal mortality is not debated. It is
agreed that ANC maximizes positive pregnancy outcomes and reduces
maternal and perinatal mortality (Afulani 2015; Baffour-Awuah, Mwini-
Nyaledzigbor & Richter 2015; Ejigu, Woldie & Kifle 2013; Fagbamigbe &
Idemudia 2015. Lori et al. 2014; Naariyong et al. 2012; Villadsen et al. 2015).
In a bid to improve on the quality of antenatal care services provided
to pregnant women and reduce maternal mortality rates in developing
countries, The World Health Organisation introduced the Focussed Antenatal
Care (FANC) programme. FANC is aimed at reducing waiting times during
antenatal visits while increasing the time for direct contact between the patient
and healthcare providers (Baffour-Awuah, Mwini-Nyaledzigbor & Richter
2015). African countries have adopted FANC, while other countries have
modified FANC to suit local circumstances (e.g., South Africa, Zimbabwe,
Argentina, Saudi Arabia and Cuba) (Ngxongo 2011). The SA Government
introduced basic antenatal care (BANC) as a modification of FANC in 2007 to
improve on antenatal care services to address the maternal and perinatal
mortality rates (Ngxongo 2011).
There is no consensus on the definition of service quality (Dehghan,
Shahin & Zenouzi 2012; Zaim, Bayyurt & Zaim 2013). Zeithaml, Parasuraman
and Berry (1990: 19) define service quality as the extent of discrepancy
between customers’ expectations or desires and their perceptions. These
determinants of service quality are divided into two groups, that is, the
tangibles and the intangibles (Zaim, Bayyurt & Zaim 2013).
Quality of Care Model
A number of models of quality of care have designed. Some of these are
perspective and characteristics models (Raven et al. 2012). According to

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 Assessment of Antenatal Maternity Service Quality

Živaljević, Mitrović, and Petković (2013), any quality improvement or

assurance model should either decrease or even eliminate non-conformity.

The Perspective Model

This model uses the underlying principle that there are different perspectives
on the quality of care.

Characteristics Model
The institute of medicine recently condensed the quality of healthcare
characteristics into six main characters: safety, patient centeredness,
timeliness, equity, and efficiency (Raven et al. 2012).

Service Quality Gaps

Information obtained from analysis of service quality gaps plays an important
managerial role in finding ways of narrowing service quality gaps and
prioritizing which gaps to focus on (Dehghan, Shahin & Zenouzi 2012).
Zeithaml, Parasuraman, and Berry (1990: 19) identified some factors that
influence customers’ expectations: word of mouth communications, personal
needs, past experience and external communications. The SERVQUAL instru-
ment ascertains the level of service quality based on key dimensions. It iden-
tifies where gaps in service exist and to what extent. Gap 0ne to four are within
the control of an organisation and need to be analysed to determine the causes
and changes to be implemented which can reduce or eliminate gap five, that is
the discrepancy between customer expectations and their perceptions of the
service delivered (Ramseook-Munhurrun, Lukea-Bhiwajee & Naidoo 2010).

Measuring Service Quality

Public hospital managers should realise that, to confront the competition of the
private sector hospitals, they should measure quality of the service and use the
findings as a basis of seeking improvement (Chaniotakis & Lymperopoulos
2009).
Zarei et al. (2012) state that quality measures can be divided into two:
process and outcome. Measuring maternal mortality rate is a good example of
an outcome based measure (Janakiraman and Ecker 2010). Zarei et al. (2012)

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Munyaradzi Mushunje, Sam Lubbe & Jan Meyer

equally note that quality in healthcare services entails two dimensions:

technical quality (outcome quality) and functional quality (process quality).
Holder and Berndt (2011) highlight the following instruments to have
been developed specifically for evaluating medical services:

• Newcastle satisfaction with nursing scale (NSNS).

• Picker patient experience questionnaire (PPEQ).
• The Customer quality index (CQI) cataract questionnaire.

Multi-criteria decision making (MCDM) is another method used to

evaluate service quality (Bakİ & Peker 2015). In light of the above service
quality measurement challenges, Lupo (2013) calls for consideration of the
analytical hierarchy process (AHP) model. AHP is one of the most
considerable MCDM approaches that assist decision makers facing complex
problems with multiple conflicting and subjective criteria (Lupo 2013). The
other MCDM method is a technique for order preference by similarity to ideal
solution (TOPSIS). According to this method, the chosen alternative should be
the shortest distance from the positive ideal solution, while being farthest from
the negative solution (Bakİ & Peker 2015).

Quality Measures in Antenatal Care

Global efforts to improve maternal and perinatal health outcomes are
continuing, however, these efforts largely depend on quality measurements.
Measuring the quality of service of obstetric patients has become important,
each obstetric admission may affect the health of not one but two individuals
and most maternity patients are healthy individuals admitted only for obstetric
reasons in whom the goal is nothing but full preservation of health (Crofts et
al. 2014).

Maternity Care and Patient Satisfaction

Patient satisfaction emerged as an area of focus in obstetrics from as early as
the 1970s and has since become a commonly reported outcome measure of
health-care quality and has obvious implications for organisations and service
provision (Clark, Beatty & Reibel 2015). Clark, Beatty, and Reibel (2015)
further emphasise that expectation fulfilment is the most consistent factor
associated with childbirth satisfaction. Women’s expectations and perceptions

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 Assessment of Antenatal Maternity Service Quality

of maternity care have therefore increasingly become important to healthcare

providers, policy makers and administrators as decision making tools (Jenkins
et al. 2014).
Hulton, Matthews, and Stones (2000) identified 10 elements that can
be used to assess quality in maternal health care services. Six elements related
to the provision of care are: Human and physical resources, Referral system,
Maternity information systems, use of appropriate technologies,
internationally recognized good practice and appropriate management of
emergencies. Service quality expectations of antenatal patients are shaped by
factors, for example, word-of-mouth communication and what patients hear
from others (Nyongesa, Onyango, and Kakai 2014). Atinga and Baku (2013)
emphasise on attentiveness and responsiveness as critical factors in the
provision of service quality in antenatal care.

Research Methodology
The quality of antenatal service has been found to play a role in alleviating this
problem. A validated SERVQUAL questionnaire was used to gather informa-
tion on expectations and perceptions of antenatal patients on MPH service
quality. In this study simple random sampling was used to select participants
in the study, respondents were randomly chosen on each single clinic day
amongst the total number of women who attended ANC at MPH maternity
department. All under 18 expectant mothers and psychiatric mothers were
excluded from the study. A total of 80 questionnaires were handed out over a
duration of two weeks where 70 questionnaires were collected properly
completed.

Method of Primary Data Collection Used in this Research

The questionnaire was distributed by the researchers with the help of two
nursing sisters. The questionnaire was divided into three sections. The first
section was the introduction. The second is the demographic details of the
patient. The third section of the questionnaire explored the expectations and
perceptions of patients and it contained a total of 15 questions covering the
SERVQUAL tool.

Discussion of Results

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Munyaradzi Mushunje, Sam Lubbe & Jan Meyer

A total of 80 questionnaires were distributed, of the 80 questionnaires given

out to patients, 70 completed questionnaires were collected back. The response
rate was 87.5 percent but not representative enough to be used to conclude for
the sample used. Most antenatal patients were aged between 21 and 30 years
(57.15%). Patients with one child formed most of the proportion at 57 per cent.
Seventy-two per cent of antenatal patients had a matric certificate, 14 percent
had at least a tertiary qualification. The majority of the pregnant women were
not married (68.57%) and were booked (97.14%). Uses of antenatal care
services during pregnancy are high in South Africa with all women utilising
antenatal care (Millennium Development Goals Country Report 2013).

Antenatal Service Quality Variables

Seventy-one per cent of antenatal patients agree that they expect not to be kept
waiting unnecessarily. According to Asubonteng, McCleary, and Swan (1996)
responsive services reduce waiting times and ensure that patients are promptly
attended to. Responsiveness was isolated as an important factor in arresting
danger signs and managing obstetric complications.
Antenatal patients agree that they should be assisted according to their
needs (85.71%). Failure to assist antenatal patients according to their needs,
poor relationships with healthcare providers and disrespectful harsh healthcare
providers are some of the reasons that discourage women from attending
antenatal clinics (Afulani 2015). Factors that underlie provision of quality
maternity services are responsiveness and promptness of staff (Atinga & Baku
2013)). Hill and McCrory (1997) emphasise that women view the presence of
modern healthcare technology as a source of security and comforting in the
event of complications occurring.
Table 1 indicates that all the respondents agree that MPH maternity
department is clean and comfortable. The cleanliness and comfortability of a
clinic is regarded as a sign of respect a facility offers to clients and hygienic
conditions relieve fears of infection among patients (Hulton, Matthews, and
Stones 2000). Appearance of staff and the wards are tangibles in maternity
institutions used as cues of expected service (Holder & Berndt 2011).

Table 1: The maternity department is clean and comfortable

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 Assessment of Antenatal Maternity Service Quality

Frequency Percent Valid Cumulative

percent percent
Valid Strongly
Agree 40 57.14% 57.14% 57.14
Agree 30 42.86% 42.86% 100.00
Total 70 100.00 100.00

Table 2 shows that 100 percent of the respondents believe that MPH maternity
staff show sincerity in solving their problems. However, Mensah, Yamoah, and
Adom (2014) noted healthcare providers often have brief encounters with
patients and do not show sincere interest and attention to what women talk
about.

Table 2: Does the Maternity staff show sincere interest in solving problems?

Frequency Percent Valid Cumulative

Percent percent
Valid Strongly
Agree 20 28.57 28.57 28.57
Agree 50 71.43 71.43 100.00
Total 70 100.00 100.00

Most of the respondents agree that maternity staff perform their services right
the first time. All the respondents agree on maternity staff having adequate
knowledge to manage patients. Respect, dignity and equity of care a pregnant
woman receives during her stay at a facility is one of the major elements of
quality maternity care as alluded to by (Hulton, Matthews & Stones 2000).

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Munyaradzi Mushunje, Sam Lubbe & Jan Meyer

80,00% 71,43%
70,00%
60,00%
50,00%
40,00%
30,00%
20,00% 14,29% 14,29%
10,00%
0,00%
Strongly agree agree disagree

Figure 1: Maternity staff does perform the services right the first time

Table 3 shows a mixed response on the operating hours of the maternity

department. The majority (71.43%) of respondents concur that maternity
doctors and midwives do give each patient individual attention.Antenatal care
services should be available every day of the week, this prevents clients either
from being turned away or asked to come back another day, a practice which
creates opportunity for early ANC attendance (Ngxongo 2011).

Table 3: Maternity department operates within hours convenient to all

pregnant patient

Frequency Percent Valid Cumulative

Percent percent
Valid Strongly
Agree 30 42.86 42.86 42.86
Agree 20 28.57 28.57 71.43
Disagree 10 14.29 14.29 85.72
Strongly Disagree 10 14.29 14.29 100.00
Total 70 100.00 100.00

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 Assessment of Antenatal Maternity Service Quality

Relationship between Variables

Most of the patients were para one, meaning they already had one baby before.
There was a negative correlation -0.379 between parity and Maternity staff do
have adequate knowledge to manage patients. It means as parity increased the
more patients felt maternity staff did not have adequate knowledge to manage
patients. The majority agreed that MPH maternity wing has modern looking
equipment. There is a correlation of 0.567 with maternity staff should offer
prompt attention to patients. The more antenatal patients notice modern
equipment in the clinic, the more they expect prompt action from doctors and
midwives.
Many antenatal patients (71.40%) expected prompt attention from
maternity staff. There was a positive correlation +0.567 with patients should
not be kept waiting unnecessarily. All antenatal patients expected prompt
attention and there was a positive correlation +0.567 with the variable:
maternity staff do have adequate knowledge to manage patients. The more
antenatal patients expected prompt attention, the more they felt maternity staff
do have adequate knowledge to manage patients.

Research Questions, Conclusion and Recommendations

This section presents a discussion on expectations and perceptions raised by
antenatal patients.

Research Questions
What expectations do antenatal patients have on Mafikeng
Provincial Hospital service quality?
Nyongesa, Onyango, and Kakai (2014) noted that service quality expectations
of antenatal patients are shaped by a number of factors, for example, word of
mouth communication and what patients hear from others.

Do you expect MPH maternity staff to demonstrate willingness

to help patients and provide prompt services?
All antenatal patients indicated they don’t expect to be kept waiting. All
antenatal patients indicated they expected prompt attention from maternity

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Munyaradzi Mushunje, Sam Lubbe & Jan Meyer

staff and agreed that maternity staff should offer prompt attention to patients.
This finding is further underpinned by Amin & Nasharuddin (2013) when they
emphasize responsiveness as a critical factor that underlies service provision
in maternity services by reducing waiting times and offering prompt services.
This finding may possibly mean that patients have adjusted
expectations of the public healthcare system since the volumes of patients
overwhelm service providers. The desire not to be kept waiting unnecessarily
increased with age, this finding where older patients felt they should not be
kept waiting unnecessarily indicates that as patients become older the more
they feel they are at risk of complications. This finding emphasises the
importance of responsiveness in antenatal care service.

Do you expect MPH maternity staff to be courteous and to

communicate trust and confidence in patients?
All antenatal patients expressed the need to feel secure while in the maternity
department. All antenatal patients indicated they expect maternity staff to be
polite and courteous to patients. Responses to questions indicate the
importance of assurance in the provision of maternity services. Courteous and
respectful and caring staff create comfortable environments that promote
pregnant mothers to discuss their problems with service providers (Nyongesa,
Onyango & Kakai 2014).

What is the quality of the physical facilities at MPH maternity

wing, including appearance of its personnel?
The majority of antenatal patients strongly agreed that MPH maternity
department has modern looking equipment. The MPH maternity department
was coined as clean and comfortable by all antenatal patients. All the maternity
patients indicated that MPH staff are professional and neatly dressed. Above
findings indicate that the appearance of Maternity personnel and its physical
facilities overwhelmingly satisfy its antenatal patients. These findings are in
line with the findings of Ejigu, Woldie, and Kifle (2013) when they found out
that comfortable waiting rooms and clean toilets were amongst reasons
associated with patient satisfaction. Holder and Berndt (2011) emphasize that
tangibles are the only tangible cues in service quality provisioning and thus

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 Assessment of Antenatal Maternity Service Quality

they are important cues used to evaluate expected service before and
satisfaction after receiving the service.

Does MPH maternity staff deliver their services dependably and

accurately?
All maternity patients felt that maternity staff is dependable and accurate in
their dealings with the patients and that maternity staff show sincerity in
solving their problems. The majority of respondents (85.72%) believe that
maternity staff do perform services right the first time, while 14.29 per cent
disagreed to this notion. While all patients agree that maternity staff do show
sincerity in attending to their problems, there was a mixed response to the
ability of maternity staff performing services right the first.
As noted above 14.29 percent of patients disagree that maternity staff
perform services right. Nesbitt et al. (2013) noted that evaluation of maternity
care is a complicated and culturally sensitive issue where most users are
healthy, but serious complications can develop unpredictably. It therefore is
very important that the right services are performed right from the onset, failure
of which may result in complications to both mother and baby.

Does MPH maternity staff provide individualised attention to

patients?
Maternity patients generally feel maternity staff do provide individualised
attention to patients. All the antenatal patients feel that maternity staff do care
for them, 71.43 per cent simply agreed, while 28.57 per cent strongly agreed
that maternity staff had a caring attitude towards patients. Janakiraman &
Ecker (2010) isolated caring/empathy of healthcare professionals as elements
of quality in maternity care. Antenatal patients are satisfied by the
individualised treatment they receive from the High-Risk Clinic. This finding
is in contradiction with Manithip et al. (2013) who reported that healthcare
givers spend limited time with antenatal mothers, paying less attention and not
offering opportunities for women to ask questions. Convenience of operating
hours of High Risk Clinic received a mixed response. Shortage of staff and
unavailability of supporting services like ultrasonography may be contributory
factors. The current national call on operating times of Antenatal clinics as

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Munyaradzi Mushunje, Sam Lubbe & Jan Meyer

noted by Ngxongo (2011) is to ensure that antenatal care services are offered
every day of the week.

Does maternity staff have adequate knowledge to manage

patients?
All antenatal patients feel that the doctors and nursing staff have adequate
knowledge to manage their conditions. This finding clearly indicates that
antenatal patients feel assured and safe in the hands of maternity staff of
Mafikeng Provincial Hospital. Janakiraman and Ecker (2010) also isolated
empathy as an important quality measure in maternity services. In this study,
the more maternity staff promptly attended to patients according to their needs,
the more patients felt that maternity staff had adequate knowledge to manage
them.

Recommendations
Taking into consideration the findings of this research and literature reviewed,
five recommendations are proposed. These recommendations have been
identified by the researcher as gaps in maternity service quality.

Training of Healthcare Personnel on Service Quality

Service Quality is a field that has generally received little attention despite its
significant role in organisational success and profitability. The researcher
therefore recommends that healthcare personnel must undergo in-service
training in service quality. This training will assist in ensuring that service
providers are able to meet the expectations of their patients. This is supported
by Amin and Nasharuddin (2013). The training of healthcare professional can
be championed by the Hospital as well as the Provincial Health Office.
Improvements in quality of services provided to maternity women can only be
realised by continuous training.

Implementing Communication Channels and Systems between

Maternity Service Providers and the Patients
Communication is an important tool in shaping of service quality expectations.

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 Assessment of Antenatal Maternity Service Quality

The researcher therefore recommends that MPH management puts in place a

system that ensures patients are informed of procedures, hospital protocols and
any special events or developments that may impact on the quality of service
to be delivered. The maternity department must have visible signage and
appoint a dedicated person who assists with ushering patients and ensuring that
patients are assisted accordingly. Overall, this was also supported by Baffour-
Awuah et al. (2015).

Appointing Doctors and Nursing Staff that have a Passion for

Maternity
Staff appointed to work in maternity must have a strong passion and liking for
maternity. It is no secret that different people have different interests.
Passionate healthcare personnel show empathy and a caring attitude to their
patients and will always endeavour to perform services right the first time.
Maternity care is therefore not only defined by qualifications, but service
providers must have a passion for pregnant mothers.

Managerial Resource Allocation to Investing in Tangibles

Mafikeng Provincial Hospital maternity wing should invest heavily in the
tangibles of the Clinic, especially maternity equipment. Other aspects of
tangibles like cleanliness and comfort of the clinic, neatness and professional
appearance of staff need to be emphasised.
In this research, through correlation studies, tangibles emerged as a major
driver of other quality attributes. This finding is supported in literature Crofts
et al. (2014) noted pregnant women associate the presence of modern
equipment in clinics with security in the event of complications.

Relook into Operating Hours of the High-Risk Clinic

The results quite evidently show a mixed response regarding the convenience
of operating times of the High-Risk Clinic. The researcher therefore
recommends that the operating hours of the clinic be revisited in a way that
will suit all pregnant women. Other women are working and cannot afford to
take the whole day off from work. The current call is to offer antenatal care

215
Munyaradzi Mushunje, Sam Lubbe & Jan Meyer

services daily, this one stop shop or supermarket approach has been found to
offer convenience to the pregnant mother notwithstanding current shortages of
staff and mass resignations of staff from the public sector.

Conclusion
This research sought to assess the quality of antenatal care services at Mafikeng
Provincial Hospital through determining service quality expectations and
perceptions of antenatal patients. The research found that antenatal patients
have high responsive expectations from maternity staff. Antenatal patients also
expressed a high desire to be treated politely and courteously by maternity staff
and the needy to feel secure while using the facilities of the maternity
department.
The findings of this study have provided information on important
service quality attributes that pregnant women value most. It also managed to
assess antenatal patient perceptions of MPH service quality. The findings of
this study have added to the body of knowledge on antenatal service quality
and have also provided a platform for a number of recommendations on how
managers can improve upon antenatal service quality to curtail maternal
mortality rate.

Acknowledgements
We would like to thank the Chief Executive Officer and Management of
Mafikeng Provincial Hospital for permitting this research to be carried out in
the hospital. Many thanks to Antenatal Clinic Sisters for their assistance with
data collection.

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Munyaradzy Mushunje
Graduate School of Business & Government Leadership
North West University
Mafikeng
South Africa
[email protected]

Sam Lubbe
Faculty of Management Sciences
Mangosuthu University of Technology
Umlazi
South Africa
[email protected]

Jan Meyer
NWU Business School
North West University
Mafikeng
South Africa
[email protected]

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