ASSESSMENT OFTHE SERVICE QUALITY OF FOCUSED ANTENATAL CARE

AT HEALTH CARE FACILITIES IN BAUCHI STATE

BY

Adamu ALHAJI

DEPARTMENT OF NURSING SCIENCES,

FACULTY OF MEDICINE,

AHMADU BELLO UNIVERSITY,

ZARIA

May, 2017

1
ASSESSMENT OF SERVICE QUALITY OF FOCUSED ANTENATAL CARE AT

HEALTH CARE FACILITIES IN BAUCHI STATE

BY

Adamu ALHAJI
P14MDNS8013

A DISSERTATION SUBMITTED TO THE SCHOOL OF POSTGRADUATE STUDIES,

AHMADU BELLO UNIVERSITY,

ZARIA
IN PARTIAL FULFILLMENT OF THE REQUAREMENTS FOR THE AWARD
OF
MASTERS DEGREE IN NURSING SCIENCES

DEPARTMENT OF NURSING SCIENCES,

FACULTY OF MEDICINE,
AHMADU BELLO UNIVERSITY,
ZARIA, NIGERIA

MAY, 2017

i
 DECLARATION

I, Adamu ALHAJI, hereby declare that this research work was carried out by me and to the

best of my knowledge; it has been presented for the award of Msc Nursing.

-------------------------------- -----------------------------

ALHAJI, ADAMU Date

ii
 CERTIFICATION

This Dissertation entitled ASSESSMENT OF SERVICE QUALITY OF

FOCUSED ANTENATAL CARE AT HEALTH FACILITIES IN BAUCHI STATE by
ADAMU ALHAJI meets the regulations governing the award of the degree of Msc
Nursing Sciences of Ahmadu Bello University, and is approved for its‘ contribution to
knowledge and literary presentation.

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Chairman, Supervisory Committee Signature Date

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Member, Supervisory Committee Signature Date

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Member, Supervisory Committee Signature Date

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Head of Department Signature Date

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Dean, School of postgraduate Studies Signature Date

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 ACKNOWLEDGEMENT

All thanks and praises be to Almighty Allah (S.W.T) for granting me life and good health

to see the end of this vital course in my nursing career. May Allah‘s Peace and Blessings be

upon our noble Prophet, Muhammad (S.A.W), his household, companions and all those

who follow his path till the Day of Judgment.

I am very much indebted to my Dissertation supervisor, Prof Hayat I. Gomma and Dr

Hamza Yusuf for their guidance and corrections at various points in time for the
completion of this research work. My appreciation goes to Dr S.N Garba (Head of
Department, Nursing Science), Malam Tukur B.M, and the entire lecturers of Faculty of
Medicine, ABU Zaria.

My special thanks go to my beloved wife and children for their patience, endurance and
prayers during my four year stay at Zaria, may Allah continue to bind us together.

My profound gratitude goes to my brother, Alhaji Umar for his moral support. I also
appreciate my brothers and sisters such as Mal Yayaji, Mal Garba, Mal Muktar late, Bello
and my Wife for their support and prayers.

I acknowledge the immense importance of the Management of Federal Medical Centre

Azare for the sponsorship given to me and the Head of Nursing Services (Alhaji Dahiru
Magaji) for his guidance.I thank Dr Ibrahim Bichi (Medical Director) for assistance given
to me.

This write up would not be complete without mentioning my friends both at home and
school for their togetherness and assistance, Mohammad Auwal, Mal Danladi Gambo, Mal
Yayangida, Mohammad kardam, Umar Amin, Abdussalam, and the rest of them as the list
is not exhaustive. I am grateful to you all.

Alhaji, Alhaji

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May,2017

ACRONYMS AND ABREVIATION

AF Available and functioning

ANC Antenatal Care

ANF Available not functioning

CHEW Community Health Extension Workers

DNS Done not satisfactory

DS Done and satisfied

EDD Expected Day of Delivery
FANC Focused Antenatal care

Hb Hemoglobin

HHR Health Human Resource

HIRG Health Workforce Information Reference Group

HIV Human Immunodeficiency Virus

HRIS Human resource information systems

IPHS Indian public health standard

IPTp Intermittent preventive treatment of malaria in pregnancy

ITNs Insecticide-treated bed nets
LNMP Last normal menstrual period
N&MCN Nursing and Midwifery Council of Nigeria

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NA Not available

ND Not done

PMTCT Prevention of Mother to Child Transmission

PPH postpartum haemorrhage
PV per vagina

SPSS Statistical Package for Social Sciences

USAID United States Agency for International Development

WHO World Health Organization

WISN Workload Indicators of Staffing Need

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 Operational Definitions of terms

1. Focused Antenatal care Care given to a pregnant woman during pregnancy.

2. FANC: Focused Antenatal Care Services.

3. Quality of services: Antenatal care services provided according to the set WHO

standards and national guidelines, based on Evidence-Based

Medicine, and meeting client needs.

4. Quality of care: The degree to which health services for individuals and populations

increase the likelihood of desired health outcomes and are consistent

with current professional knowledge

5. Standards: Statements or an expression that spells out the best practice and

gives some ideas on how the level of care is to be achieved.

6. Guidelines: Systematically developed statements, which assist in making

decisions about appropriate health care for specific conditions

based on evidence or research. Focused antenatal care (Targeted

ANC): Minimum number of four personalizes clinic visits each of

which has specific items of client assessment, education and care

to ensure prevention or early detection and prompt management of

complications.

7. Clients: Pregnant Women in the antenatal clinics seeking for Focused

antenatal Care services.

8. Maternal Mortality: Maternal deaths due to pregnancy and childbirth complications.

9. Satisfaction: Sensitive to and meeting the needs of clients in terms of quality,

privacy and confidentiality, meeting clients needs in a culturally

acceptable way.

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10. Material resources: physical set up, infrastructure, supplies, equipment and

pharmaceuticals needed for focused antenatal care services

11. Human resources: All people engaged in actions whose primary intent is to enhance health‖

include physicians, nurses, midwives, community health workers and

social health workers

viii
 ABSTRACT
The aim of this study was to assess the Service quality of focused antenatal care at health

care facilities in Bauchi State. Five research objectives were stated: to determine the

availability of material resources for focused antenatal care, to assess the capacity of human

resource for focused antenatal care, to assess the quality services of focused antenatal care,

to assess the focused antenatal care services utilization and to assess the level of clients‘

satisfaction with focused antenatal care services .A cross sectional descriptive design was

adopted. A total of three hundred and eighty four pregnant women that attended antenatal

care clinic in twenty two health care facilities in Bauchi State were recruited. Multi-stage

sampling technique was used. The data collected using semi-structured questionnaire and

observational checklist through face to face interview and audit observation check list

during the period of first May to the end August 2016. Descriptive statistics was used.

Donabedian Bruce quality model (1980) was adopted as a theoretical framework. The

result revealed that: Eighty percent of the respondents were over 35 years old, 66% of them

were Hausa/Fulani, almost half of them had secondary school certificate, and more than

half of them had parity above six times. Eighty percent of the sample utilized focused

antenatal care always. Only 43% of material resources in the health facilities were

available and functioning. The human resources rate in the health facilities were 0.81, 0.5,

2.7 and 1.8 Doctors, Nurses, Midwives and CHEW respectively. The quality of care in the

studied health facilities was 54.2% satisfactory. The total mean satisfaction was 2.3 /4 .It

can be concluded that: there were inadequate material resources, shortage of human

resources , high utilization of focused antenatal care services and the client satisfaction

was little bit low . Recommendations: Government should Ensure adequate material

resources for focused antenatal care services in each facility in Bauchi State, Ensure

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adequate health care providers to improve quality focused antenatal care services, Periodic

In-service training ,monitoring and evaluation to improve the quality services, Health

education for the clients to increase the awareness and the importance of focused antenatal

care and Regular assessment of the level of clients‘ satisfaction is needed to improve the

lacking areas

Keywords: Focused Antenatal care, Quality of services, client Satisfaction. Healthcare

services

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 TABLE OF CONTENT

TITLE PAGE i
DECLARATION ii
CERTIFICATION iii
ACKNOWLEDGEMENT iii
ACRONYMS AND ABREVIATION v

Operational Definitions of Terms vii

ABSTRACT ix
LIST OF TABLES
ixiv
LIST OF FIGURE x
CHAPTER ONE 1
INTRODUCTION 1
1.0 Background to the study 1
1.2 Statement of the Problem 4
1.3 Objectives of the Study 5
1.4 Research Question 6
1.5 Significance of the Study 6
1.6 Scope (Delimitation) 7
CHAPTER TWO 8
LITERATURE REVIEW 8
2.0 Introduction; 8
2.1 Focused Antenatal Care 8
2.1.1 Goals of Focused ANC 9
2.1.2 Objectives of focused antenatal care 9
2.1.3 Schedule of visits during pregnancy 9
2.1.4 The essential elements of a focused antenatal care 11
2.1.5 Material Resources for Focused Antenatal Care 13
2.1.6 Human Resource for Focused Antenatal Care 14
2.1.7 Clients‘ Satisfaction with focused antenatal care services 18
2.2 Service quality 21

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 2.3 Quality of Care 23
2.3.1 Definition of quality of care 23
2.3.2 Quality of health care 24
2.3.3 Dimensions of quality of care 24
2.4 Nurses Roles for Focused Antenatal Care 25
2.4.1 Quick Check 26
2.4.2 History taking 26
2.4.3 Physical Examination 26
2.4.4 Abdominal Examination: 27
2.4.5 Laboratory investigations 27
2.4.6 Decision Making 28
2.4.7 Documentation 28
2.4.8 Calculation of EDD 28
2.5 Empirical Studies 28
2.6 Summary 33
2.7 Theoretical Frame Work 33
2.7.1 Application of Donabedian Model 35
CHAPTER THREE 37
MATERIALS AND METHODS 37
3.0 Introduction 37
3.1 Research Design 37
3.2. Study Area/setting 37
3.3 Target Population 38
3.4 Sample size 39
3.5 Inclusion criteria: 39
3.6 Exclusion Criteria: 39
3.7 Sampling Technique 39
3.8 Sample Size Distribution 40
3.9 Tools / Instrumentation for data collection 40
3.10 Validity of the instrument 42
3.11 Ethical Consideration 42
3.12 Method of data collection 43

xii
 3.13 Method of Data Analysis 44
RESULTS 45
4.0 Introduction 45
CHAPTER FIVE 54
DISCUSSION 54
5.0 Introduction 54
5.1 Discussion of the Findings 54
CHAPTER SIX 63
SUMMARY, CONCLUTION AND RECOMMENDATION 63
6.1 Summary 63
6.3 Recommendation 65
6.4 Limitation 66
6.5 Implication of the Study 66
REFERENCES 67
Appendix i 76
APPENDIX ii 84
APPENDIX iii 85

xiii
 LIST OF TABLES
Table PAGE

Table 2.1 Four visit Antenatal Care Model 11

Table 3.1 Sample size Distribution 40

Table 4.1 Socio-demographic characteristic of the respondents 46

Table 4.2 Distribution of availability of material resources 48

Table 4.3 Distribution of qualification and characteristics of health care providers. 49

Table 4.4 Distribution of Focused Antenatal Care Services 50

Table 4.5 Distribution of respondents according to the utilization of FANCS 51

Table 4.6 Distribution of level of clients‘ satisfaction with FANCS 53

xiv
 LIST OF FIGURE

List of Figures PAGE

Figure 2.1 Donabedian System Model of Quality 34

Figure 2.2 Application of Donabedian system Model of Quality 35

xv
 CHAPTER ONE

INTRODUCTION

1.0 Background to the study

Maternal mortality is a global issue as a result of low focused antennal care; approximately

about 830 women die from pregnancy complications around the world every day (World

Health Organization, 2015). The differences between regions are stark: There are currently

12 maternal deaths per 100,000 live births in developed regions compared with 546 in sub-

saharan Africa. Nigeria is ranked the second in the world with maternal mortality rate (630

per 100,000 live births), Nigeria Demographic and Health Survey, (2013)

The goal established by United States to reduced the worldwide maternal mortality ratio

(MMR) –the number of maternal deaths per 100,000 live births by 75% between 1990 and

2015 was not achieved, but significant progress has been made (43.9% decline). The 2015

global MMR is estimated at 216 deaths per 100,000 live births, down from 385 in 1990.

(Zolat and pa,2016).

.Maternal morbidity and mortality has remained high in sub-Saharan Africa as a result of

poor antenatal cares, despite concerted efforts at its reduction, by various stakeholders and

development partners (Sholeye, Abosede, and Jeminusi, 2013).Seeing that it is possible to

accelerate the decline, countries have now united behind a new target to reduce maternal

mortality even further. One target under Sustainable Development Goal 3 is to reduce the

global maternal mortality ratio to less than 70 per 100 000 births, with no country having a

maternal mortality rate of more than twice the global average by focused antenatal care.

Focused Antenatal Care is a Goal oriented care that is client centered, timely, friendly,

simple, beneficial and safe to pregnant women. (United States Agency for International

1
Development,2009).World Health Organization recommended a minimum of 4 visits

antenatal care for pregnancies without complications scheduled as First visit: within 16

weeks or when woman first thinks she is pregnant, Second visit: At 20 - 24 weeks or at least

once in second trimester, Third visit: At 28 - 32 weeks and Fourth visit: At 36 weeks or

later. Limited resources of developing countries like Nigeria can be redirected to give better

quality antenatal care services across the recommended four visits (villar and Bergsgo,

2001).Currently, (WHO, 2016) Recommended eight visits of focused antenatal care with

first contact at 12 weeks of gestation, with subsequent contacts taking place at

20,26,30,34,36,38, and 40 weeks of gestation.

The essential elements of a focused approach to antenatal care are; identification and

surveillance of the pregnant woman and her expected child; Recognition and management of

pregnancy-related complications; particularly pre-eclampsia, Recognition and treatment of

underlying or concurrent illness and screening for conditions and diseases such as anemia

(Ademola, 2011). The objectives of focused antenatal care are; Maintenance of health of

mother during pregnancy, Identification of high risk cases and appropriate management;

Prevent development of complications; Decrease maternal and infant mortality and

morbidity. Remove the stress and worries of the mother regarding the delivery process;

Teach the mother about child care, nutrition, sanitation and hygiene; Advice about family

planning, and Care of under fives accompanying pregnant mothers,(Johnson,2015).

Global health, (2014) Stated the goals of focused antenatal care as; Identification of pre-

existing health conditions. Early detection of complications arising during the pregnancy,

Health promotion and disease prevention and Birth preparedness and complication readiness

planning. United States Agency for International Development (2009) Stated the services

2
provided during FANC as; History taking; Personal information , Medical history-

Medication, allergies, HIV status , Surgical history , Obstetrics and gynecological history

,Family and social history , Immunization. Physical examination; General appearance,

Blood Pressure, Weight, height, Pulse and Respiratory rates, Head to toe assessment.

Laboratory investigations; Urine test for albumin and sugars, Hb, Blood grouping and

Rhesus factor, VDRL/RPR for syphilis screening ,HIV testing, CD4 count if indicated,

Blood examination for malaria parasites where indicated.

Quality in FANC is based on performance standards that are safe and have capacity to

improve quality of antenatal services within available resources. (United States Agency for

International Development, 2009). The six domain of health care quality are;

(i )Safe: Avoiding harm to patients from the care that is intended to help them., (ii)Effective:

Providing services based on scientific knowledge to all who could benefit and refraining

from providing services to those not likely to benefit (avoiding underuse and misuse,

respectively), and (iii)Patient-centered: Providing care that is respectful of and responsive to

individual patient preferences, needs, and values and ensuring that patient values guide all

clinical decisions, (iv)Timely: Reducing waits and sometimes harmful delays for both those

who receive and those who give care, (v)Efficient: Avoiding waste, including waste of

equipment, supplies, ideas, and energy, (vi)Equitable: Providing care that does not vary in

quality because of personal characteristics such as gender, ethnicity, geographic location,

and socioeconomic status (Institute of Medicine,2001).

Service quality is a comparison of expectations about a service with performance. It has five

dimensions namely; Tangibles, Reliability, Responsiveness, Assurance, and Empathy,

(Zeithaml, Parasuraman and Berry, 2008). Human resources can be defined as all the

3
practices, systems and procedures implemented to attract, acquire, develop and manage

human resources to achieve the goals of an organization (WHO,2010). The higher the

quality of human resources the better the maternal health. The material resources for focused

antenatal care are sub divided in to 3 by Indian public health standard (IPHS) in 2012 as

follows; Infrastructure , Equipment, and Consumables.

Various factors including attitude of staff, cost of care, time spent at the hospital and doctor

communication have been found to influence patient satisfaction (Nweze, Enabor, and

Aimakhu, 2013).

Patient satisfaction is the extent to which specific client needs are met, Satisfied

patients are likely to continue with care and compliance with visit time and various factors

including attitude of staff, cost of care, time spent at the hospital and doctor communication

have been found to influence patient satisfaction in previous studies (Nweze, Enabor, and

Aimakhu, 2013)

1.2 Statement of the Problem

Although overall levels of antenatal care are relatively high across regions, disparities are

revealed when coverage is examined in light of household wealth and urban or rural

residence. In South Asia and sub-Saharan Africa the urban-rural gap in coverage of four or

more antenatal care visits exceeds 20 percentage points in favor of urban areas. This gap has

not closed within the last decade (WHO, 2015). Antenatal care (ANC) coverage is a success

story in Africa, since over two-thirds of pregnant women (69 percent) have at least one ANC

contact. However, to achieve the full life-saving potential that ANC promises for women

and babies, four visits providing essential evidence transmitted infections. ANC is also an

4
opportunity to promote the use of skilled attendance at birth and healthy behaviours such as

breastfeeding, early postnatal care, and planning for optimal pregnancy spacing

(WHO,2015). Many of these opportunities continue to be missed, even though over two-

thirds of pregnant women receive at least one antenatal visit. There are various factors

including attitude of staff, cost of care, time spent in waiting and health care providers

communication has been found to clients utilization of the services and their satisfaction.

(WHO,2015) .Adequate infrastructure are influential key elements of successful FANC that

benefit the wellbeing of women, their newborns and families. Client satisfaction is essential

for further improvement of quality of focused antenatal care and to provide uniform

health care services for pregnant women. However, studies on

level of client satisfaction with focused antenatal care and associated factors are lacking.

How can we strengthen ANC to provide the priority interventions, especially given Africa‘s

current critical shortage of human resources for health? Lacking in the resources? Are there

particular barriers or challenges to increasing coverage and quality that could be overcome?

Are the pregnant women satisfied with level of quality services? How can the nurses play

their roles to improve the quality of care in maternal child center? So the aim of the study

was to assess the services quality of focused antenatal care at health care facilities in

Bauchi State.

1.3 Objectives of the Study

The aim of the study was achieved through the following objectives:

1. To determine the availability of Material resources for focused antenatal care in

health facilities in Bauchi State

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 2. To explore the capacity of human resource for focused antenatal care in health

facilities in Bauchi State

3. To assess the quality service of focused antenatal care in health facilities in Bauchi

State

4. To assess the level of utilization of Focused Antenatal Care services among

pregnant women in health facilities in Bauchi State

5. To assess the level of clients‘ satisfaction with focused antenatal care services in

health facilities in Bauchi State

1.4 Research Question

1. What is the availability of materials resources for focused antenatal care in health

facilities in Bauchi State?

2. What is the capacity of human resources for focused antennal care services in health

facilities in Bauchi State?

3. What is the level of quality services provided during focused antenatal care in health

facilities in Bauchi State?

4. What is the level of utilization of focused Antenatal care Services among pregnant

women in health facilities in Bauchi State?

5. What is the level of client satisfaction with focused antennal care services in health

facilities in Bauchi State?

1.5 Significance of the Study

Improvement of the service quality of Antenatal care is a major strategy used by hospitals

and health care facilities to reduce maternal death and morbidity. The study will help to

identify the area of lacking in the material resources, human resources and provision of

6
service quality of FANC in Bauchi State, which when addressed will strengthening the

capacity and credibility of FANC. The study will be benefit to the following: The pregnant

women, health worker, community, researchers and Nigeria in general.

For the pregnant women, this study will empower pregnant women to make informed

decision on their health and reduces maternal mortality and morbidity through early

detection of complication arising during the pregnancy, health promotion and disease

prevention; it will also increase pregnant women satisfaction with focused antenatal care

services. For the health worker, the study would help them to identify areas of lacking in

material and human resources for focused antenatal care services in the State which when

addressed will go a long way in strengthening the capacity of FANC services and quality

services. This will result in improved sustained use of services quality and nursing practice.

While for the community, the study would enable them appreciate the effort of health

workers towards focused antenatal care services. It will also serve as reference to researchers

on the relevant areas of the study.

1.6 Scope (Delimitation)

The scope of the study is to assess the service quality of focused antenatal care at health

facilities in Bauchi State.

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 CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction;

This chapter presented the available review of related literature; it covers the following

sections;

A. Conceptual Review

1. Focused Antenatal Care

2. Service Quality

3. Quality of care

4. Nurses midwife role in Focused Antenatal Care Services

B. Theoretical frame work

C. Empirical Studies

D. Summary of the chapter

2.1 Focused Antenatal Care

Antenatal care refers to the regular medical and nursing care recommended for women

During pregnancy; It is a type of preventive care with the goal of providing regular checkups

that allow doctors or midwives to prevent, detect as well as treat Potential health problems

that may arise in a pregnant woman, (WHO, 2005).

Focused Antenatal Care is an individualized and quality care provided to pregnant

women which emphasizes on the woman's overall health; her preparation for childbirth and

readiness for complications during her term of pregnancy (Miriam, 2014). The new

8
approach to ANC emphasizes the quality of care rather than the quantity (Global health,

2014). Antenatal care is the care a woman receives throughout her pregnancy in order to

ensure that women and newborns survive pregnancy and childbirth (Ademola, Adenike, &

Motunrayo,2011).

2.1.1Goals of Focused ANC

The new approach to ANC emphasizes the quality of care rather than the quantity. For

normal pregnancies WHO recommends only four antenatal visits. The major goal of focused

antenatal care is to help women maintain normal pregnancies through:

Identification of pre-existing health conditions

Early detection of complications arising during the pregnancy

Health promotion and disease prevention

Birth preparedness and complication readiness planning (Global health,2014).

2.1.2 Objectives of focused antenatal care are;

(1)Maintenance of health of mother during pregnancy(2)Identification of high risk cases

and appropriate management(3)Prevent development of complications(4)Decrease

maternal and infant mortality and morbidity(5)Remove the stress and worries of the

mother regarding the delivery process(6)Teach the mother about child care, nutrition,

sanitation and hygiene(7)Advice about family planning(8)Care of under fives

accompanying pregnant mothers (Johnson, 2015).

2.1.3 Schedule of visits during pregnancy

Focused antenatal care (FANC) became the recommended type of antenatal care

following the publication of a (WHO,2014). Trial on antenatal care where it was

9
 discovered that more frequent visits (of the traditional antenatal care approach) do not

necessarily improve pregnancy outcomes and advocate a minimum of 4 visits for

pregnancies without complications scheduled as

o First visit: within 16 weeks or when woman first thinks she is pregnant.

o Second visit: At 20 - 24 weeks or at least once in second trimester.

o Third visit: At 28 - 32 weeks and

o Fourth visit: At 36 weeks or later.

Limited resources of developing countries like Nigeria can be redirected to give better

quality antenatal care services across the re- commended four visits (villar and Bergsgo,

2001).Antenatal services comprise complete health supervision of the pregnant women in

order to maintain, protect and promote health and well being of the mother and the fetus

(Ojo 2004). The services rendered to a pregnant woman at monthly intervals, to 28 weeks of

gestation, then fortnightly until 36 weeks and finally weekly visit until the birth of the baby.

Similarly, (Adesokan, 2010) describes antenatal services as the attention, education,

supervision and treatment given to the pregnant women from the time conception is

confirmed until the beginning of labour, in order to ensure safe pregnancy, labour and

puerperium. Qualitative antenatal services are care given to pregnant women by a skilled or

trained health provider to promote the health and survival of mother and child (Adesokan,

2010). The focused antenatal services refer to minimum number of four antenatal clinic

visits, each of which has specific items of client assessment, education and care to ensure

early detection and prompt management of complication (Ekabua, Ekabua&Njoku, 2011).

Focused antenatal care, which is evidence based, client-centered, goal directed care,

10
provided by skilled health providers with emphasis on quality rather than frequency of

visits, is an approach to be adopted globally (Ojong,Uga and Chiotu, 2015).

Table 2.1 the four-visit ANC model (WHO,2014)

INITIAL VISIT SUBSEQUENT VISITS

First visit Second visit Third visit Fourth visit
8-12 weeks 24-26 weeks 32 weeks 36-38 weeks
Confirm pregnancy Assess maternal and Assess maternal and Assess maternal and
and EDD, fetal well-being. fetal well-being. fetal well-being.
classify Exclude PIH, Exclude PIH, Exclude PIH,
women for basic anaemia, anaemia, anaemia,
ANC multiple multiple multiple pregnancy,
(four visits) or more pregnancies. pregnancies. malpresentation.
specialized care. Give preventive Give preventive Give preventive
Screen, treat and measures. measures. measures. Review
give Review and modify Review and modify and
preventive birth and birth and modify birth and
measures. emergency emergency emergency plan.
Develop a birth plan. Advise and plan. Advise and Advice and counsel.
and emergency counsel. counsel.
plan.
Advice and counsel.

2.1.4 The essential elements of a focused approach to antenatal care

The essential elements of focused antenatal care are as follows:

• Identification and surveillance of the pregnant woman and her expected child

• Recognition and management of pregnancy-related complications, particularly pre-

eclampsia

• Recognition and treatment of underlying or concurrent illness

• Screening for conditions and diseases such as anaemia,

11
STIs (particularly syphilis), HIV infection, mental health problems, and/or symptoms of

stress or domestic violence

• Preventive measures, including tetanus toxoid immunization, de-worming, iron and folic

acid, intermittent preventive treatment of malaria in pregnancy (IPTp), insecticide treated

bed nets (ITN)

• Advice and support to the woman and her family for developing healthy home behaviours

and a birth and emergency preparedness plan to:

o Increase awareness of maternal and newborn health needs and self care during pregnancy

and the postnatal period, including the need for social support during and after pregnancy to

Promote healthy behaviors in the home, including healthy lifestyles and diet, safety and

injury prevention, and support and care in the home, such as advice and adherence support

for preventive interventions like iron supplementation, condom use, and use of ITN to

Support care seeking behavior, including recognition of danger signs for the woman and the

newborn as well as transport and funding plans in case of emergencies to help the pregnant

woman and her partner prepare emotionally and physically for birth and care of their baby,

particularly preparing for early and exclusive breastfeeding and essential newborn care and

considering the role of a supportive companion at birth to Promote postnatal family

planning/birth spacing

Factors identified as militating against focused antenatal care are poor funding, culture,

religious practices, ignorance and inadequate training of health care providers on the

advantages of focused antenatal care (Ademola, 2011).

Recently, (WHO,2016) has issued a new series of recommendations to improve quality of

antenatal care in order to reduce the risk of stillbirths and pregnancy complications and give

women a positive pregnancy experience.

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Last year, an estimated 303 000 women died from pregnancy-related causes, 2.7 million

babies died during the first 28 days of life and 2.6 million babies were stillborn. Quality

health care during pregnancy and childbirth can prevent many of these deaths, yet globally

only 64% of women receive antenatal (prenatal) care four or more times throughout their

pregnancy.WHO‘s recommended new antenatal care model increases the number of contacts

a pregnant woman has with health providers throughout her pregnancy from four to eight.

Recent evidence indicates that a higher frequency of antenatal contacts by women and

adolescent girls with the health system is associated with a reduced likelihood of stillbirths.

This is because of the increased opportunities to detect and manage potential problems. A

minimum of eight contacts for antenatal care can reduce perinatal deaths by up to 8 per 1000

births when compared to a minimum of four visits.

The new model increases maternal and fetal assessments to detect problems, improves

communication between health providers and pregnant women, and increases the likelihood

of positive pregnancy outcomes. It recommends pregnant women to have their first contact

in the first 12 weeks‘ gestation, with subsequent contacts taking place at 20, 26, 30, 34, 36,

38 and 40 weeks‘ gestation.

2.1.5 Material Resources for Focused Antenatal Care

The material resources are sub divided in to three namely:

a) Infrastructure; is the basic structure or feature of focused antenatal clinics. It includes

furniture, fittings and sundry articles.

b) Equipment is an instrumentally needed for performing focused antenatal care

services in health facilities which includes basin, thermometer, touch light.

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 c) Consumables are material or product that is produced for focused antenatal care

consumption which includes surgical gloves, Savlon, sprit, papers and all disposable

materials (Indian public health standard, 2012).

2.1.6 Human Resource for Focused Antenatal Care

• HRM can be defined as all the practices, systems and procedures implemented to

attract, acquire, develop and manage human resources to achieve the goals of an

organization (Ikeoluwapo,2013).

• Health human resources (―HHR‖) — also known as ―human resources for

health‖ (―HRH‖) or ―health workforce‖ — is defined as ―all people engaged in

actions whose primary intent is to enhance health‖, according to the World Health

Organization's World Health Report 2006. Human resources for health

include physicians, nurses, registered nurses, midwives, dentists, allied health

professions, community health workers, social health workers and other health care

providers, as well as health management and support personnel – those who may not

deliver services directly but are essential to effective health system functioning,

including health services managers, medical records and health information

technicians, health economists, health supply chain managers, medical secretaries,

and others.

• Health human resources deals with issues such as planning, development,

performance, management, retention, information, and research on human

resources for the health care sector. In recent years, raising awareness of the critical

14
 role of HRH in strengthening health system performance and improving population

health outcomes has placed the health workforce high on the global health agenda.

The World Health Organization (WHO) estimates a shortage of almost 4.3 million

physicians, midwives, nurses and support workers worldwide. The shortage is most severe

in 57 of the poorest countries, especially in sub-Saharan Africa. The situation was declared

on World Health Day 2006 as a "health workforce crisis" – the result of decades of

underinvestment in health worker education, training, wages, working environment and

management.

The World Health Organization (WHO,2013) estimates a shortage of almost 4.3 million

physicians, midwives, nurses and support workers worldwide. The shortage is most severe

in 57 of the poorest countries, especially in sub-Saharan Africa. The situation was declared

on World Health Day 2006 as a "health workforce crisis" – the result of decades of

underinvestment in health worker education, training, wages, working environment and

management.

Shortages of skilled health workers are also reported in many specific care areas. For

example, there is an estimated shortage of 1.18 million mental health professionals,

including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000

psychosocial care providers needed to treat mental disorders in 144 low- and middle-income

countries. Shortages of skilled birth attendants in many developing countries remain an

important barrier to improving maternal health outcomes. Many countries, both developed

and developing, report misdistribution of skilled health workers leading to shortages in rural

and underserved areas.

15
Regular statistical updates on the global HHR situation are collated in the WHO Global

Atlas of the Health Workforce. However the evidence base remains fragmented and

incomplete, largely related to weaknesses in the underlying human resource information

systems (HRIS) within countries.

In order to learn from best practices in addressing health workforce challenges and

strengthening the evidence base, an increasing number of HHR practitioners from around

the world are focusing on issues such as HHR advocacy, surveillance and collaborative

practice.

An essential component of planned HRH targets is supply and demand modeling, or the use

of appropriate data to link population health needs and/or health care delivery targets with

human resources supply, distribution and productivity. The results are intended to be used to

generate evidence-based policies to guide workforce sustainability. In resource-limited

countries, HRH planning approaches are often driven by the needs of targeted programmes

or projects, for example those responding to the Millennium Development Goals.

The WHO Workload Indicators of Staffing Need (WISN) is an HRH planning and

management tool that can be adapted to local circumstances. It provides health managers a

systematic way to make staffing decisions in order to better manage their human resources,

based on a health worker‘s workload, with activity (time) standards applied for each

workload component at a given health facility.

Minimum staff requirement for this level of antenatal care should include a midwife,

receptionist/records clerk, orderlies and sanitation workers, and a laboratory assistant. A

community health extension worker where available is an asset; in carrying out-home visits

16
and assessing the environmental health needs of patient's residence. Also the introduction of

home-based record system will facilitate the process of clinic visit and reduce waiting time.

Within a county or local government area, secondary health facilities providing antenatal

care should be sited within 20 kilometers of each other. Where population density is high,

the distance between such facilities may be shorter to improve coverage. Antenatal clinics at

the secondary level should provide service for all pregnant women in their area of coverage

and for pregnant women with complications referred from the primary health care level.

Each province, state, or geopolitical area should have a tertiary health facility providing

antenatal care service. Care, preferably, should be limited to all pregnant women with

medical and obstetric complications who register directly for ANC or are referred. This will

justify the huge resources and personnel invested in these centers of excellence.

Health systems in both developed and developing countries are under pressure to improve

service delivery in an ever increasing population with limited or reduced resources

(Namgada, 2008). This is due to increased burden of diseases; desire to receive best quality

care, advanced technology in health care, awareness of health rights, improved access to

diverse health service. In health care systems, the following are needed for the provision of

health services to patients/clients, efficient health polices, sufficient trained health personnel,

appropriate equipments, finance (Olade, 2005).

The primary goal of all health systems is to render quality care; however, certain factors

seem to hinder the efforts towards achieving this goal maximally. The global shortages of

health professionals, as well as the caliber of health providers, for example, have been

reported to affect the quality and outcome of care (Olade, 2005). World Health Organization

17
(2010) report shows that in some developed countries, the ratio of staff to the population is

1000 to 100,000. In developing countries, it is 100 to 100,000. A report on health workforce

country profile for Nigeria revealed that there were 52,408 doctors on the medical register as

at December 2010, and 128,918 registered nurses (Labran, Mafe, Onajole and Lambo,

2011). According to Needleman (2005), the standard staff mix to patient ratio depending on

unit size is 1:4-6 patients. In more intensive care units, it is 1:2-3 patients.

The Nursing and Midwifery Council of Nigeria (N&MCN, 2005) stipulates that the

staff/patient ratio in Clinical practice for different cadres of staff and depending on the unit

and type of patient managed, is 1:4-5,( for general wards) and 1:1-3 (for intensive care

units). Similarly, pate (2015) stated that average Doctor-Patient ratio of 1: 53,333 and

Nurse- patient ratio of 1:1,066. According to (WHO,2010) a Doctor should see 30 patients

per day and a nurse to four patients ratio. Nursing World(2015) stated that The nurse-to-

patient ratio for day shifts in the general wards in the public hospitals was 1:5 in 2014, as

compared to 1:8 in 2004.

2.1.7 Clients’ Satisfaction with focused antenatal care services

Patient satisfaction has traditionally been linked to the quality of services given and the

extent to which specific needs are met. Satisfied patients are likely to come back for the

services and recommend services to others. Various factors including attitude of staff, cost

of care, time spent at the hospital and doctor communication have been found to influence

patient satisfaction in previous studies (Nweze, Enabor, Oluwasola, and Aimakhu, 2013).

18
 A study conducted by Onwujekwe, Etiaba and Oche (2013) identified waiting time, time

spent with doctors during consultation as influencing the level of patient satisfaction with

healthcare services. Other factors that influence the level of satisfaction include the nature of

patients‘ illness and patient perception of the hospital environment. Of the two-time based

measures, time spent with the doctors during consultation is the most powerful determinant

of the overall patient satisfaction. However, combination of long waiting times and short

consultation times produced the lowest level of patient satisfaction and suggests that both

measures are important.

In a study conducted by Sholeye, Abosede and Jeminusi (2013) on Are Women Satisfied

with Antenatal Care Services at Primary Health Centers in Mushin, Lagos it was affirmed

that 300 respondents, About (50.8%) of clients were very satisfied with the cost of services

and the facilities‘ opening hours, while 43.5% as well as 44.1% were satisfied with the cost

of services and opening hours respectively. A quarter (25.1%) of respondents were very

satisfied with the waiting time, 44.1% were satisfied with it, while 30.4% were either

dissatisfied or totally dissatisfied with the waiting time

In a study conducted by Olufemi,Oladapo, Christianah, Iyaniwura, AdewaleandSule-Odu

(2008) on Quality of Antenatal Services at the Primary Care Level in Southwest Nigeria

confirmed that 457 respondents, (96.7%) of the respondents expressed satisfaction with the

way their care providers were monitoring their health and that of their unborn babies. A total

of 419 (92.7%) respondents were satisfied with the level of expertise demonstrated by their

antenatal care providers.

In a study conducted by Harriet and Onyango-Ouma(2013) on Acceptability and

Sustainability of the WHO Focused Antenatal Care package in Kenya describes clients‘

satisfaction with various aspects of ANC. Clients in the intervention clinics were more
19
dissatisfied with the waiting time than any other aspect of focused ANC, and consistently across

all four visits with more than 50 percent of clients indicating their dissatisfaction during each

visit. Satisfaction ratings were high (>70 percent) for all other

aspects of ANC in the intervention and comparison clinics. In a study conducted by Nnebue,

Ebenebe, Adinma, Iyoke, Obionu, and Ilika (2014) 0n knowledge, perception and

satisfaction with quality of maternal health care services at the primary health care level in

Nnewi, Nigeria affirmed that 480 respondent, Nearly, all but one of the discussants was

satisfied with the services received. On the reasons for their satisfaction, some discussants

mentioned the low cost of services in the health facilities as well as use of local language,

compared to the hospitals around. Others said: "The drugs and money for registration cards

are cheaper here." "They also give us free drugs when it is available." "They attend to us

well, that is why we are still coming."

In a study conducted by Fantaye, Fessahaye and ,Desta (2014) on Satisfaction with

focused antenatal care service and associated factors among pregnant women attending

focused antenatal care at health centers in Jimma town found that 389 respondents, More

than half of the respondents (60.4%) were satisfied with the service that they received. As to

specific components, most of the respondents (80.7%) were satisfied with interpersonal

aspects, and 62.2% were satisfied with organization of health care aspect. Meanwhile,

49.9% of the respondents were not satisfied with technical quality aspect and 67.1% were

not satisfied with physical environment aspect. Multivariate logistic regression analysis

result showed that type of health center, educational status of mother, monthly income of the

family, type of pregnancy and history of stillbirth were the predictors of the level of

satisfaction. The study found out that dissatisfaction was high in mothers utilizing service at

20
Jimma health center, in mothers with tertiary educational level, in mothers with average

monthly family income >1000birr, in mothers with unplanned pregnancy and in mothers

with history of stillbirth

In a study conducted by Argago, Woldemichael, and Kitila (2014) on Client‘s

satisfaction with family planning services and associated factors among family planning

users in Hossana Town Public Health Facilities, South Ethiopia found that 324 respondents,

This study showed that about one forth (24.7%) of the clients were not satisfied with the

service they had received. As to obstetrics related variables, 41 (12.7%) of them had history

of abortion, 305 (94.1%) received the method they wanted, 68 (21%) of clients experienced

side effects on method they were using, 80 (24.7%) had an unwanted pregnancy, 243 (75%)

of the clients were informed on side effects of methods, and 295 (91%) were told how to use

the method and their function, 301 (92%) reported that they were politely treated by the

service providers and 271 (83.6%) reported that their privacy was maintained. 287 (88.6%)

said the way they were handled by supportive staffs was good, 189 (58.3%), 106 (32.7%) of

them waited from 30 min to 1 h. The mean waiting time was 26 minutes. Regarding the

level of satisfaction in four different categories, namely, technical competence, accessibility

of the health services, interpersonal component, and cleanness of health facilities, the

majority (88.3%) of the participants were satisfied on cleanness of health facilities, but

fewer participants were satisfied with technical aspect of health providers (70.1%).

2.2 Service quality

Is a comparison of expectations about a service with performance?

After extensive research, Zeithaml, Parasuraman and Berry.(2008) found five dimensions

customers use when evaluating service quality. They named their survey instrument

21
SERVQUAL. These dimensions defined by the SERVQUAL measurement instrument are

as follows:

i) Tangibles

One dimension of service quality has to do with the tangibles of the service. Tangibles are

the physical features of the service being provided, such as the appearance of the building,

cleanliness of the facilities, and the appearance of the personnel. Going to a restaurant and

finding that your table and silverware are dirty would negatively impact your assessment of

the service quality. On the other hand, walking into a beautifully decorated, clean restaurant

with impeccably dressed wait staff would positively affect your opinion of the service.

ii) Reliability

Another dimension of service quality is the reliability of the service. Reliability refers to

the ability to provide the service as it was promised on a regular basis. It is very

important that businesses are able to fulfill the service that they advertise. For example,

if you own a pizza restaurant and promise to deliver a pizza within 30 minutes, you must

consistently provide that service in order to meet your customers' expectations and be

considered a reliable business.

iii) Responsiveness

Responding to customers in a timely manner is another dimension that affects service

quality. It is very important that businesses are prepared to respond to customers quickly.

For example, if a customer calls a store with a complaint about a product they purchased,

they shouldn't be left on hold for an hour before being connected to a manager. The call

should be taken promptly and with a sense of urgency.

22
 iv) Assurance

Another dimension that plays role in service quality is assurance. Customers have to be able

to trust that service providers are knowledgeable about the service they are providing. Let's

say you go to a wine bar to try some different wines, but when you ask your server some

questions about the wines being served, they don't know any of the answers. It's reasonable

to expect that the staff would have some knowledge about wines, so if they didn't, this

would definitely have an impact on your view of the service quality.

v) Empathy - to what extend the employees care and give individual attention.

2.3 Quality of Care

Quality of care is important and complicated issue to define and measure (Donabedian,

1966). It is mistaken often incorrectly as goodness or luxury (Donabedian, 1980).

2.3.1 Definition of quality of care

There are many definitions of quality of care, but the Institute of Medicine (IOM)(2001)

Define it as ―The degree to which health services for individuals and populations increase

the likelihood of desired health outcomes and are consistent with current professional

knowledge.‖

Donabedian (1988) defined quality of care as the care that meets the information,

emotional, and physical needs of patients in a way that is consistent with their

preferences and expectations.

23
2.3.2 Quality of health care

The Institute of Medicine,(2001) defines health care quality as "the degree to which

health care services for individuals and populations increase the likelihood of desired

health outcomes and are consistent with current professional knowledge."

2.3.3 Dimensions of quality of care

The dimensions of service quality care are as follows:

o Effective, delivering health care that is adherent to an evidence base and

results in improved health outcomes for individuals and communities,

based on need

o Efficient, delivering health care in a manner which maximizes resource

use and avoids waste; Accessible, delivering health care that is timely,

geographically reasonable, and provided in a setting where skills and

resources are appropriate to medical need.

o Acceptable/patient centered, delivering health care which takes into

account the preferences and aspirations of individual service users and

the cultures of their communities.

o Equitable, delivering health care which does not vary in quality because

of personal characteristics such as gender, race, ethnicity, geographical

location, or socioeconomic status.

o Safe, delivering health care which minimizes risks and harm to service

users WHO,(2006).

24
2.4 Nurses Roles for Focused Antenatal Care

John, Kufre, and Charls (2011) outlined the role of health care provider for focused

antenatal care as follows;

Care from a skilled health provider and continuity of care.

Detection and early treatment of conditions that could severely affect maternal and

fetal well-being such as HIV, syphilis and other sexual transmitted infections,

malaria, tuberculosis, malnutrition and severe anemia, vaginal bleeding, hypertensive

disorders, malpositions after 36 weeks, and fetal distress.

Preventive interventions which include; tetanus toxoid prophylaxis, iron and folate

supplementation, intermittent preventive treatment for malaria, presumptive

treatment for hookworm, vitamin A supplementation, and iodine supplementation,

Counseling and health promotion on; recognition of danger signs during pregnancy

and labour and appropriate action to be taken, importance of good nutrition, risk of

alcoholism and substance abuse, adequate rest during pregnancy, family planning,

breast-feeding, and HIV prevention.

Preparation for childbirth and complication readiness: the skilled provider and the

woman should plan for the following: a skill provider to be present at the birth, the

place of delivery and how to get there, items needed for delivery, need to save

money in order to meet financial commitments/bills during childbirth, support during

and after childbirth, and appropriate response in case of life-threatening

complications: this will include a person designated to make decision on her behalf,

in case she is indisposed, a way to communicate with a source of help, a source of

25
 emergency funds, emergency transportation, and blood donors also, USAID, (2009)

Stated the following as the activities of health care provider for focused antenatal care;

2.4.1 Quick Check

General appearance, gait, and asking general screening questions

2.4.2 History taking

• Personal information

• Medical history- Medication, allergies, HIV status

• Surgical history

• Obstetrics and gynecological history

• Family and social history

• Immunization

2.4.3 Physical Examination

When conducting physical examination, have the woman remain seated or lying down and

relaxed:

General examination

• Take blood pressure, weight, height, pulse, temperature (if indicated) and respiration

• Check for pallor (conjunctiva, palms)

• Breasts and lymph nodes examination

Genital inspection

Female Genital Mutilation

Sores, swelling, discharge

PV Bleeding.

26
2.4.4 Abdominal Examination:

Inspection: Surface of abdomen (scars, movement with respiration, and shape of the

abdomen)

Palpation:

• Palpate for fundal height from 12 weeks of gestation age

• Fetal parts and movements from 20 weeks of gestation

• Fetal lie and presentation is of concern from 36 weeks of gestation.

(Abnormal lie or/and presentation if observed from 36 weeks is more unlikely to change

therefore decide appropriately for a place of birth)

• Fetal heart sound from 24 weeks of gestation.

• Genital inspection

Female Genital Mutilation

Sores, swelling, discharge

PV Bleeding

2.4.5 Laboratory investigations

• Urine test for albumin and sugars

• Hb

• Blood grouping and Rhesus factor

• VDRL/RPR for syphilis screening

• HIV testing

• CD4 count if indicated

• Blood examination for malaria parasites where indicated.

27
2.4.6 Decision Making

• Interprets information from client‘s history, physical examination and laboratory

investigations and deciding on the care to be given

2.4.7Documentation

The health care personnel should record all clients‘ information in his folder.

2.4.8 Calculation of EDD

• Know the first date of the Last Normal Menstrual Period (LNMP)

• Add 7 days to the date

• Subtract 3 months from the months (if the month is above March)

• Add 9 months to the month if the month is below April

• Add 1 to the year if it is above April.

2.5 Empirical Studies

In a study by (WHO,2013) on trial on antenatal care where it was discovered that more

frequent visits (of the traditional antenatal care approach) do not necessarily improve

pregnancy outcomes and advocate a minimum of 4 visits for pregnancies without

complications scheduled as First visit: within 16 weeks or when woman first thinks she is

pregnant, Second visit: At 20 - 24 weeks or at least once in second trimester, Third visit: At

28 - 32 weeks and Fourth visit: At 36 weeks or later. Limited resources of developing

countries like Nigeria can be redirected to give better quality antenatal care services across

the recommended four visits.

Amosu, Degun, Thomas, Olanrewaju, Babalola, Omeonu and Olao, (2011) Stated

that Kenya‘s Ministry of Health adopted the goal-directed ante-natal care package, which is

28
the focused ante-natal care model, to promote maternal child health in the Kenyan context.

The study done in this country showed that focused ante-natal care is acceptable to both

client and providers and is supported by government.

Nyarko, Birungi, Armar-klemesu, Arhinful and Deganus, (2006) Stated that the

Government of Ghana adopted the WHO focused ante-natal care model in a move to

improve access, service quality and continuity of ante-natal care services to pregnant

women. Clients and providers accepted the model because of its comprehensiveness and

individualized care. Clients appreciated the individualized care approach and privacy during

service delivery In South Africa the study done by (Chege, Askew, Mosery, Nbude, Kunene,

Beksinska, & Dalton, 2005) in KwaZulu-Natal informed that clinic preparedness was good in

terms of infrastructure and equipment. Although staffing levels were adequate, the clinics

fell short in number of qualified and skilled staff due to their migration to developed

countries. On the whole there was no detrimental effect on staff morale. Clinic preparedness

to offer focused ante-natal care reduced staff concerns about the working conditions. Client

satisfaction was already high so no new change was observed (Chege et al 2005).

In Gambia study conducted by (Ojo, 2014) showed that pregnant women are ill

equipped to make appropriate choices especially when they are in danger. Information,

health education and communication during ante-natal care were noted to be poor. All this

was assumed to contribute to the persistence of high mortality ratios in the country. The

Ministry of Health believes that the introduction of the focused ante-natal care service will

improve the situation because nurses will be interacting with women following the

guidelines.

29
 In a study on women‘s opinions on ante-natal care services conducted in Thailand

and Cuba some of the women expressed that they value the information they get from the

service providers during the implementation of the focused ante-natal care 29 services

(Nigenda, Langer,Kuchaisit, Romero, Rojas, Al-Osimy, 2003).

A study done in Tanzania showed that a more focused and client-centred application

of risk assessment is needed (Ikeoluwapo, Damilola, Osakinle, 2013). Focused ante-natal care

was introduced in Tanzania when it was most needed because the medical approach of ANC

categorizing pregnant women according to risk factors already showed that it was not

working. In 2002 the Ministry of Health of the United Republic of Tanzania therefore

developed a national adaptation plan based on the model of the WHO (Johson, 2015).

In Nigeria, a study by Fantaye, FessahayeandDesta, (2014) in southwest reported that

about 42.0% of respondent believed FANC is most important at first pregnancy while 9.9%,

5.9%, and 42.3% said ANC is most important at 2nd, 3rd and after 3rd pregnancy

respectively. The study also revealed that 72% of females were not at all satisfied with the

accessibility of the service as regard to location of the center in spite of being from the

catchment area of the center and this is probably due to the long distance between the center

and the nearest residential area.

In a study conducted by Sarah, Britt, Dereje, Abebe , Abebech, Henrik and Vibeke (2014)

on Antenatal Care Strengthening in Jimma, Ethiopia Affirmed that respondent of 1364

Predictors of being not satisfied with the service, as reported by 1132 ANC attendants who

had given birth within the previous 12 months in the Jimma area1, with odds ratios (OR) and

95% confidence intervals (CI) The measurement of satisfaction with care in the survey was

relevant as an overall assessment of the women‘s evaluations of the care received; however,

30
satisfaction has previously been shown to be dependent on the expectations towards care,

and, for example, primigravida as might have difficulties knowing what to expect from

ANC. In this study, a relatively small proportion of women reported being not satisfied with

ANC, and this might be due to underreporting dissatisfaction, as respondents tend to report

favorably on questions of perceived quality of care or satisfaction

Research has shown by Agency for Healthcare Research and Quality (2012) that science-

based measures can be used to assess quality for various conditions and for specific types of

care.

In a study conducted by Muhammad, Majrooh, Seema, Javaid, Arif , and Zahid (2014) on

Coverage and Quality of Antenatal Care Provided at Primary Health Care Facilities in the

‗Punjab‘ Province of ‗Pakistan. Found that the study finding revealed that overall 51.6% of

the expected pregnancies first time reported for the ANC and out of those 33% didn't return

back for follow-up. These findings straight way revealed that there is a gap of about 50% in

the coverage of ANC services in the Punjab. The dropout in follow-up indicates the poor

quality of the services that are annoying the clients not to return back for follow-up services.

The overall coverage indicated in this study is very closer to that (57%) claimed by the

HMIS cell Punjab in DHIS report of 2010 and MICS 2007–2008, that is about (53%) ]. This

study was focused on rural areas and there was no opportunity for urban comparison but

inequity in provision of ANC services to rural population have been reported in the

literature]. The variation in coverage is associated with the number of standard ANC visits

in assessment criteria e.g. in a study conducted in Alwar district of Rajasthan state, India, the

practices of 3 or more ANC visits were lower in rural (36.1%) as compared to (71.4%) in

urban areas].Fifty percent ANC-1 registration of clients does not mean that the services are

31
fulfilling quality of ANC services. It is just a registration figures. Although WHO

recommends four ANC visits for every pregnant woman but the facility register contains

only two columns one for the first visit and the other for revisits.

In a study conducted by Fantaye, Fessahaye, Desta (2014) 0n Satisfaction with focused

antenatal care service and associated factors among pregnant women attending focused

antenatal care at health centers in Jimma affirmed that more than half of the respondents

(60.4%) were satisfied with the service that they received. As to specific components, most

of the respondents (80.7%) were satisfied with interpersonal aspects, and 62.2% were

satisfied with organization of health care aspect. Meanwhile, 49.9% of the respondents were

not satisfied with technical quality aspect and 67.1% were not satisfied with physical

environment aspect. Multivariate logistic regression analysis result showed that type of

health center, educational status of mother, monthly income of the family, type of pregnancy

and history of stillbirth were the predictors of the level of satisfaction. The study found out

that dissatisfaction was high in mothers utilizing service at Jimma health center, in mothers

with tertiary educational level, in mothers with average monthly family income >1000 birr,

in mothers with unplanned pregnancy and in

mothers with history of stillbirth. Even though greater percentages of women (60.4%) were

satisfied with the focused antenatal care service, the level of satisfaction was lower

compared to other studies.

A study conducted to examine the implementation challenges of maternal health care

services in the Tamale Metropolis of Ghana revealed inadequate in-service training, limited

knowledge of health policies by midwives, increased workload, risks of infection, low

motivation, inadequate labour wards, problems with transportation, and difficulties in

32
following the procurement act, among others as some of the challenges confronting the

successful implementation of the MDGs targeting maternal and child health in the Tamale

Metropolis (Banchani & Tenkorang, 2014)

In a study conducted by Adeniyi and Erhabor,(2015) found that Measurement of blood

pressure and receiving iron supplementation were the most commonly offered ANC

component in Nigeria with 91.0 % each while Only 4.6 % of women received good quality

of ANC while nearly 1.0 % did not receive any of the components. About 11.3 % of the

attendees had minimum acceptable quality of ANC. Receipt of good quality ANC services

was higher among users who initiated ANC early, had at least 4 ANC visits, attended to by

skilled health workers, attended government and private hospitals and clinics. Higher odds

of receiving good quality of ANC were found among users who live in urban areas, having

higher educational attainment, belonging to households in upper wealth quintiles and

attended to by skilled ANC provider.

2.6 Summary

The previous pages are the available review of literature and it covers focused antenatal

care, service quality and conceptual frame work

According to this literature review, quality is now recognized as a planning tool for

achieving effective and improved performance in antenatal service sectors.

2.7 Theoretical Frame Work

The theoretical framework of this study is modified from the literature of Donabedian

(1980). Avedis Donabedian was a pioneer who developed a basic framework to assess the

quality of care.

33
The Donabedian Model (1980) is a conceptual model that provides a framework for

examining health services and evaluating quality of care. According to the model,

information about quality of care can be drawn from three categories: ―structure,‖

―process,‖ and ―outcomes."

STRUCTURE PROCESS OUTPUT

Figure 2.1The Donabedian Model (1980)

First, Structure.—Structure denotes the attributes of the settings in which care occurs.

This includes the attributes of material resources (such as facilities, equipment, and

money), of human resources (such as the number and qualifications of personnel), and of

organizational structure (such as medical staff organization, methods of peer review, and

methods of reimbursement).

Second, Process.—Process denotes what is actually done in giving and receiving care. It

includes the patient's activities in seeking care and carrying it out as well as the

practitioner's activities in making a diagnosis and recommending or implementing

treatment.

Finally, Outcome.—Outcome denotes the effects of care on the health status of patients

and populations. Improvements in the patient's knowledge and salutary changes in the

34
 patient's behavior are included under a broad definition of health status, and so is the

degree of the patient's satisfaction with care.

2.7.1 Application of Donabedian Model

Donabedian system model emphasizes on three major elements: 1-structure,2-Process and 3-

output. The model explains the relationship between the three elements: structure, process

and output.

STRUCTURE PROCESS OUTCOME

[ Available resources; Services provided during Quality of care

focused antenatal care* Utilization of
i- Human resources Abdominal examination FANC
ii-Material resources Pelvic examination Client
Infrastructure, equipment
Vital signs satisfaction
consumables material

Figure 2.2 Application of Donabedian model

In this study the model will be applied by the same way:

Structure Represents Manpower, hospital policies regarding practice, equipments,

infrastructure, consumables materials and in-service training unit.

Process- It represents processing which explain how input is put to use effectively

and efficiently to yield output. The processing represents Midwives, Doctors, Nurses

and CHEW actions in rendering focused antenatal care services such as utilizing of

35
 nursing care during Focused antenatal care services, Vaginal examination and

waiting time.

Output – Explains the effect seen after complete care has been rendered to the

pregnant women such as satisfaction, morbidity and mortality.

2.7.2 Rational for the selection of this model

The model was selected because:

i-It was easy, relevant and applicable to the research work in assessing the service quality of

Focused Antenatal Care through: input, process and output.

ii- The model is seen as depending on the attainment of the aspired outputs/outcomes, it

shows satisfactory quantity of service of focused antenatal care depends on quality input.

iii- The model is easy to apply to get a better outcome for focused antenatal care. An

important technical aspect of the instrumental effectiveness perspective is the model of

establishing the added value of care.

iv- Analysing the inputs, processes and outcomes will give equal or ―fair‖ distribution of

resources and utilization among pregnant women with different characteristics, equity is the

primary facet of judging service quality.

36
 CHAPTER THREE

MATERIALS AND METHODS

3.0 Introduction

This chapter discussed them methodological research design, population of the study,

sample and sampling techniques, instrumentation, ethical consideration, procedure for data

collection, and statistical techniques. The aim of this study was to assess service quality of

focused antenatal care in Bauchi State.

3.1 Research Design

The design used in the study was a descriptive cross-sectional design, quantitative parameter

was used. A cross sectional study allows information about the target population to be

obtained at that point in time, a descriptive study allowed collection of data that would

provide answers on the current status of care (Kothari, 2004). This design was suitable

because it explored all the necessary information regarding the study objectives and covered

a good number of the target population to allow generalization of the information.

3.2. Study Area/setting

The study Area was Bauchi state. It is a state in northern Nigeria. Its capital is the city

of Bauchi. The state was formed in 1976. It occupies a total land area of 49,119 km²

representing about 5.3% of Nigeria‘s total land mass and is located between latitudes 9° 3'

and 12° 3' north and longitudes 8° 50' and 11° east. It has twenty local governments and has

a projected population of 6,007,327 using population growth rate of 3.2% (national

population commission, 2016) reference to the 2006 census. From total population above

0.05% is (300,366.4) considered as the population of pregnant women in Bauchi State

37
(WHO,2012).The State is bordered by seven States, Kano and Jigawa to the

north, Taraba and Plateau to the south, Gombe and Yobe to the east and Kaduna to the west.

Bauchi State is one of the States in the northern part of Nigeria that span two distinctive

vegetation zones, namely, the Sudan savannah and the Sahel savannah. Bauchi State has a

total of 55 tribal groups in which majority of the people in the State Understand Hausa

language. There are cultural similarities in people's language, occupational

practices, festivals, dress and there is a high degree of ethnic interaction especially

in marriage and economic existence.

Bauchi State was divided into three senatorial districts namely: South Senatorial District

which has seven Local Governments, North Senatorial District which also has seven Local

Governments and Central Senatorial District which has six Local Governments making a

total of twenty Local governments. Each Local Government has a secondary health facility

and two tertiary health facilities from south and north senatorial districts making a total of

twenty two health facilities in the state affiliated to ministry of health Bauchi State. These

twenty two health facilities provide all the reproductive health services.(Appendix iii) The

staff running the work composed of Doctors, Midwives, Nurses and Community extension

workers.

3.3 Target Population

The population of the study comprises of all pregnant women (300,366.4) attended

focused antenatal clinic in Secondary and Tertiary hospitals in Bauchi State from May to

August, 2016.

38
3.4 Sample size

A total of 384 pregnant women were recruited from a total population of 300,366.4. This

selection is in accordance with krejcie and Morgan (1970) who stressed that (if the total

population of the study is between 75,000 to 1,000,000 sample size will be 384).(Appendix iv)

3.5 Inclusion criteria:

o All normal pregnant women who reported for focused antenatal care and

delivered at least once.

o Those who consented.

3.6 Exclusion Criteria:

o All women of high risk and primigravida

o Clients that refused to participate in the research were excluded

o Those who declined participation.

3.7 Sampling Technique

Multi-stage sampling technique was used.

Stage i. Bauchi State was taken as a unit

Stage ii. Bauchi State was divided in to three Senatorial Districts

Stage iii. Local Governments of each Senatorial District were used as follows; Bauchi south

Senatorial District has seven Local Governments, Bauchi Central Senatorial District has six

Local Governments and Bauchi North has seven Local Governments making total of twenty

Local Governments in the State.

All the Local Governments in the three Senatorial districts were used and all facilities that

render focused antenatal care services in all Local Government were purposively selected.

39
3.8 Sample Size Distribution

Sample was distributed to each facility based on proportion of the number of pregnant

women that attended the facility for FANCs. Using a sample size (384) divided by total

number of utilization (53770) multiply by each variable‘s number.

Table 3.1 Sample Size Determination and distribution according to the total population

S/N Local Government Facility FANC utilization Sampled

May.-Aug.2016.

1 Dass Gen. Hospital 3160 23

2 Bauchi Gen. Hospital 4770 34
3 Teaching Hospital 5200 37
4 Katagum FMC Azare 1080 8
5 Gen. HospitalAzare 3340 24
6 Tafawa Balewa Gen. Hospital 1120 8
7 Toro Gen. Hospital 3980 28
8 Alkaleri Gen. Hospital 2130 15
9 Warji Gen. Hospital 1620 12
10 Ningi Gen. Hospital 1980 14
11 Darazo Gen. Hospital 2180 16
12 Giade Gen. Hospital 1120 8
13 Shira Gen. Hospital 1400 10
14 Jama‘are Gen. Hospital 2100 15
15 ItasGadau Gen. Hospital 3180 23
16 Zaki Gen. Hospital 3000 21
17 Gamawa Gen. Hospital 1660 12
18 Kirfi Gen. Hospital 1780 13
19 Dambam Gen. Hospital 3000 21
20 Misau Gen. Hospital 2250 16
21 Ganjuwa Gen. Hospital 2100 15
22 Bogoro Gen. Hospital 1620 11
TOTAL 53770 384

3.9 Tools / Instrumentation for data collection

Two main tools were used for data collection namely;

A) Semi structured interview questionnaire

B) Observational Checklist

40
1) Semi structured interview questionnaire; It was developed by the researcher and has

three sections as follows;

Section one: Socio-demographic Characteristics of the respondents to collect the socio-

demographic characteristics of the pregnant women. It has four items namely: Age,

Ethnicity, level of education and parity of the respondents.

Section two: Utilization of focused antenatal care by pregnant women; to measure

prevalence of service utilization. It consists of ten items. Examples: proximity of Antenatal

clinic, months of present pregnancy at first visit and number of times of FANC visits in

previous pregnancy.

Section three: Client‘s satisfaction with focused antenatal care services; to measure the

level of clients‘ satisfaction with focused antenatal care service quality. It composed of

twelve items. The scoring system was ranked between high and low scale;

Very satisfied scale =4

Satisfied =3

Dissatisfied=2 and

Very Dissatisfied=1

Levels of satisfaction: 3.5-4 points high satisfaction, 2.5-3 points moderate satisfaction and

below 2.5 points low satisfaction.

2) Observational Checklist; It is adapted from WHO, (2014) and has four sections namely;

Section one: Availability of materials resources for focused antenatal care; to determine

the available material for focused antenatal care. It composed of the five items namely;

physical infrastructure, equipments, drugs, supply of consumables and health education.

41
 Section two: Capacity of human resources for focused antennal care; it consists of five

items namely; Adequacy of the staff; qualification of the staff; supervision of the staff;

skills of the staff; and in-service training for the staff.

Scoring for health personnel per facility was calculated by using number of Health

personnel in each facility divided by the total number of studied facilities representing

twenty two (22).

Section three: The services of focused antenatal care; it composed of the 14 items, the

services were categorized in to three namely; done satisfactory, done not satisfied and

not done and percentage of each was calculated.

3.10 Validity of the instrument

A draft questionnaire along with abridge copy of the work and objectives were

prepared and submitted to the researcher‘s supervisors and jury of five who specialized in the

following fields: community medicine, community health nursing, Administration, Education and

Statistician Comments, corrections and suggestions made were duly effected to give the face

and content validity for the instruments. Kelinger (2003) remarked that validation by

specialists is an effective method for content validity of research instrument.

3.11 Ethical Consideration

An official permission to conduct the research study was obtained from ethical committee

ministry of Health of Bauchi State. Participation in the study was voluntary and the ethical

issue considered includes; explaining the purpose and nature of the study, confidentiality

and there was no risk of participation. The researcher informed the trainee that the purpose

of the study was for academics and will be confidential.

42
3.12 Method of data collection

A letter of introduction from the Department of nursing Sciences, Ahmadu Bello

University Zaria was collected and taken to the Ministry of Health Bauchi State

. Official permission and ethical clearance were taken from ministry of health Bauchi

State before questionnaires were administered.

Five research assistances were recruited from primary health facilities

Research assistances were instructed and train on how to administer the

questionnaires and fill the checklist to ensure the objectiveness of the data.

The researcher introduced the research assistance to the health personnel of the

studied facilities.

Oral consent was taken from the Clients that had the right to participate or not to

participate in the research.

The aim of the research was explained to the clients.

The researcher wrote the list of the health facilities that render FANC services.

Purpose of the research was explained to the respondents.

Questionnaires were administered to the pregnant women individually upon their

consent. Respondent that could not read and write or understand English, each

statements of the questionnaire was translated to the Hausa language by the research

assistance and recorded it in English Language.

Respondents were discouraged to discuss their responses to the questions among

themselves so as to determine their individual level of satisfaction with Focused

Antenatal Care Services.

All pregnant women were thanked for their contribution

43
 All data collected were kept in confidentiality

The observational checklist was used to evaluate material, human resources and

service quality for Focused Antenatal Care services.

Three hundred and eighty four (384) Questionnaires were distributed and three

hundred and seventy six (376) were returned.

SPSS version 23 was used in data analysis.

3.13 Method of Data Analysis

The Data collected from the respondents were coded and entered in to the Statistical package

for Social Sciences (SPSS) Version 23. The Data were presented using descriptive statistic

in the form of Frequency Distribution, Percentages and Mean.

44
 CHAPTER FOUR

RESULTS
4.0 Introduction

The study is primarily aimed at assessment of service quality of focused antenatal care in

Bauchi State. A total of 376 pregnant women responded to the instrument and were analyzed.

A statistical Package for Social Sciences (SPSS) Version IBM23 was used for the analysis

which was presented in six (6) Sections as follows:

Section one: Socio-demographic data,

Section two: Availability of materials resources for focused antenatal care,

Section three: Capacity of human resources for focused antennal care,

Section four: The provision of focused antenatal care services, level of focused antenatal

Care services

Section five: Utilization of focused antenatal care by pregnant women

Section six: Level of client‘s satisfaction with focused antenatal care services. A total of

five research questions were answered using the descriptive statistics of means and

percentages.

In each set of items that answer the research question a cumulative mean is obtained and

compared with the decision/cut off mean of 2.5 which was computed based on the modified

4 Likert scale.

45
 Section one: Socio-demographic Characteristic

Table 4.1 Distribution of the pregnant women according to their socio-demographic

characteristics. n=376

Variables F %
Age
18 19 5.0
19-34 47 13.0
>35 301 80.0
Ethnic Group Mean age 26.5
Hausa 249 66.2
Igbo 23 6.1
Yoruba 27 7.2
Kanuri 38 10.1
Jarawa 19 5.1
Seyawa 20 5.3
Education
Informal education 34 9.0
Primary School 106 28.2
Secondary School 171 45.5
Tertiary education 65 17.3
Parity
1-3 times 78 21
4-5 times 118 31
6-7 times 92 25
>7 times 88 23

46
In relation to respondents age Table (1) shows that the majority of respondents (80 %) 301

were above 35 years, while 47 respondents (13%) were between 19-34 years, the mean age

was (30 years old).With regards to the ethnicity also the same table shows that more than

half of the respondents (66.2%) 249 of them were Hausa/Fulani while 34% divided among

Igbo ,Yoruba, Kanuri, Jarawa, Seyawa 6.1%,7.2% 10.1%, 5.1% and 5.3% respectively. With

regards to education all level almost half of the respondents 45.5% had secondary school

education, only 9% had informal education, while 28.2% and 17.3% had primary school

and tertiary education respectively. Less than half of the respondent 118(31%) were

pregnant eight times, 92(25%) were pregnant six time in previous pregnancy, 88(23%) of

the respondents were pregnant four times and 78(21%) were pregnant four times.

47
Section two: Availability of material resources

Table 4.2 Distribution of the availability of material resources and supply by observational
check list in the studied facilities. n=22

Available and Available not Not Available

Variables Functioning functioning
N % N % N %
Waiting area with seat for patients 16 73 6 27 0 0
Counseling room with table 2 9 3 14 17 77
and two chairs
A locked storage cupboard for drugs 15 68 2 9 5 23
Patient‘s toilet 4 18 18 82 0 0
Staff toilet 18 82 4 18 0 0
Source of water (portable) 6 27 10 46 6 27
Electricity 16 73 6 27 0 0
Reliable source of light 4 18 18 82 0 0
Examination Equipments 5 23 2 9 15 68
Drugs 19 86 1 5 2 9
Sustainable Supply of Consumables 4 18 4 18 18 82
Aggregate percentage 43 31 26

Table 4.2 Distribution of the availability of material resources in the studied facilities shows

that: Among the examined 22 secondary and tertiary health care facilities the data revealed

that: The available and functioning material resources had aggregate percentage of 43%

while a total of 57% not functioning and not available. Showed shortage of material

resources for focused Antenatal Care Services in the studied facilities

48
 Section three: capacity of human resources

Table 4.3 Distribution of qualification, characteristics and the number of the health care
providers in studied facilities N=22

Availability
F %
Variables Per each facility
Health care providers
Doctor 18 13.8 .81
Nurse 11 8.5 .50
Midwife 61 46.9 2.7
CHEW 40 30.8 1.8
Qualification of staff
Certificate 41 31.5 1.8
Diploma 71 54.6 3.2
Post degree 7 5.4 .3
Degree 11 8.5 .5
Consistent monitoring/ supervision of
services
Supervised 13 10 .5
Not supervised 117 90 5.3
In-services training in each facility
Available 7 32 .31
Not available 15 68 .68

Adequacy per each facility is calculated by dividing the number of personnel by total
number of studied facilities (22).

Table 4.3 Distribution of the number and qualification of the health care providers shows

that number of health care providers in each facility were inadequate in Doctors, Nurses,

Midwives and CHEW with 0.81, 0.5, 2.7 and 1.8 respectively per facility, Compared to the

WHO standard of doctors 1:30, Nurses 1:5, midwives 1:5 and CHEW 1:600. The highest

number of qualification of the health providers is Diploma 71 and the least is post degree 7.

49
Majority of the health care providers (68%) were not supervised. With regards to in-service

training majority of the health facilities do not have in-service training.

Section four: provision of focused antenatal care services

Table 4.4 Distribution of quality of focused antenatal care services in the studied facilities
by observational check list. (N=376)

Variables Done Done Not Not Done

Satisfactory Satisfactory
Focused antenatal care Services F % F % F %

Weighing client 301 80.1 54 14.3 21 5.6

Taking blood pressure 211 56 94 25 71 19

Tetanus toxoid vaccination 87 23 163 43 127 34

Preventive anti-malarial medication 192 51 72 19 112 30

Counseling for family planning 126 34 72 19 178 47

Treatment of STI 261 69.5 73 19.4 42 11.1

Blood test for syphilis 194 52 73 19 109 29

Counseling on birth plan and 207 55 109 29 60 16

emergency preparedness
VCT for HIV/AIDS 198 53 71 19 107 28

Blood test for anemia 252 67 54 14 70 19

Urine test for protein sugar and 297 79 78 21 1 0.2

acetone
PMTCT 50 13 53 14 273 73

TB screening and detection 271 72 54 14 51 14

Aggregate percentage 54.2 20.8 F 25

Table 4.4 Weighting area had highest percentage 80.1 and PMTCT had the lowest

percentage of 13. The focused antenatal care services that were done satisfactorily, done not

satisfactory and not done had aggregate percentage of 54.2, 20.8 and 25 respectively.

50
Section five: Utilization of focused antenatal care services

Table 4.5 Distribution of the respondents according to the Utilization of focused antenatal
care services in the studied facilities. n=376

Variables F %
Attend focused antenatal care regularly
Sometimes 76 20
Always 300 80
Gestational age at first visit
1st trimester 303 81
2nd trimester 62 16
3rd trimester 11 3
Pattern of focused antennal care after booking
Appointed days 287 76
Only work days 49 13
When I have complain 40 11
Number of visits the respondents received during the previous
pregnancy
4 times 183 49
3 times 102 27
Twice 80 21
Once 11 3
Pay a fee for focused antennal care
No 2 0.5
Yes 374 99.5
The fee is affordable
No 103 27
Yes 273 73
Proximity of focused antenatal care services
1-2km 105 28
3-4km 153 41
>5km 118 31

51
Table 4.5 shows that majority of the respondents 300 (80 %) attended ANC always while 76

(20%) sometimes, majority of the respondents 303(81%) booked for antenatal care in the

first trimester, 62(16%) in the second trimester and 11 (3%) register in the third trimester.

Only (76%) 287 attend on appointed days after booking, (13%) 49 attend on work days and

(11%) 31 only when they have complaints.

Most of the respondents (41%) 153 had a distance of 3-4km from their homes to the

facility, while 118 (31%) had the distance of greater than 5km from their homes to the

facility and the remaining respondents 105 (28%) had distance of 1-2 km. Most of the

respondents183 (49%) received focused antenatal care four times in their previous

pregnancy, while 102(27%) received care three times in their previous pregnancy, 80(21%)

received focused antenatal care twice, and only 11(3%) received focused antennal care once

in their previous pregnancy. Majority of the respondent 374(99.5) paid for focused antenatal

care services, only 2(0.5%) did not pay for the services provided .The payment for focused

antenatal care was affordable to273(73%) of the respondents, only 103(27%) was not

affordable to them.

52
Section six: Level of clients’ satisfaction with focused antenatal care services

Table 4.6 Mean of the Level of clients‘ satisfaction with focused antenatal care services in the
studied facilities N=376

Variables Mean

Cleanliness of the facility 2.73

Seat of waiting area 1.32
Waiting time before seen by healthcare provider 2.45
Time taken 2.18
Time given to ask questions 2.82
The way health care provider answered my question 2.86
Confidentiality 2.00
Privacy 2.73
Treatment by healthcare provider 2.18
Examination and information provided 2.95
Cost of services 1.32
Focused antenatal care service 2.59
Aggregate mean satisfaction 2.34

Table 4.6 Seat of waiting area and Cost of services had lowest mean score of 1.32 each

and Examination and information provided had the highest mean score of 2.95.The

Aggregate mean satisfaction of 2.34 which is below the cut off mean of 2.5 showed that

clients were dissatisfied with focused antenatal care services in the studied facilities.

Levels of Satisfaction:

High Satisfaction3.5-4 Points

Moderate Satisfaction 2.5-3 Points

Low Satisfaction < 2.5 Points

53
 CHAPTER FIVE

DISCUSSION

5.0 Introduction

The aim of the study was to assess service quality of focused antenatal care in the health

facilities in Bauchi State. This chapter discusses the findings of the study, Summary,

Conclusion, Recommendation, and Implication of the Study. It covered five research

questions.

5.1 Discussion of the Findings

This study assessed the service quality of Focused Antenatal Care in Health Facilities in

Bauchi State. The chapter discussed the results in relation to the socio demographic

characteristics of the sample and the stated research questions:

5.2 Socio-demographic characteristics of the pregnant women

With regard to the age : more than three quarter of the respondents (80%) were above 35

years of age, this result was expected as the high fertility rate and the reproductive age of

women in Nigeria. In (2013) Nigeria demographic survey Bauchi State has reported the

largest number of pregnant women within this range. Also this agrees with the findings of

Adeniyi and Erhabor , (2015) in the research titled : Assessment of quality of antenatal care

services in Nigeria. They found that 51% of 13410 pregnant women who claimed to have

used the ANC facilities at least once within five year preceding the 2013 Nigeria

Demographic and Household Survey (NDHS), Were between age of 30-40. It also conforms

to the findings of Yeoh, Hornetz and Dahlui (2016) in the research titled: Antenatal Care

54
Utilization and Content between low- Risk and High-Risk pregnant Women. They found

that the majority of pregnant women (76%) are of 35 years and above. Similarly, with the

study conducted by Vain, (2012) in the research titled: study on antenatal and delivery care

utilization in urban and rural contexts in Vietnam found that more than half of the pregnant

women were 35 years and above, In the same vain in a study conducted by Onasoga,

Afolayan , and Oladimeij, (2012) in the research titled: Factors influencing utilization of

antenatal care services among pregnant women in Ife, Nigeria. They found that 32.4% of

102 respondents were between 35-44 years of age, this shows that more than half of the

respondents were at risk (35 years). This advanced of age of pregnant women may be due to

the cultural practice of early marriage and malty parity within women in Northern Nigeria

and or lack of knowledge among them about the risks of pregnancy in elderly women.

In relation to the parity: Half of the pregnant women (69%) were multi-parous (2-7

pregnancies). It is the same with the study of Nwagha and Anyaehie (2008) in Enugu,

Nigeria that found majority of the respondents (62.07%) were multiparous. In the same vain

Onasoga, Afolayan and,Oladimeji (2012) in Ife, Nigeria found that majority of the

respondents (72.5%) were multiparous. It is also in line with the study of Emelumadu,

Ukegbu, Ezeama, Kanu, Ifeadike and Onyeonoro (2014) in Anambara State. Found that

majority of respondents (64.6%) were multiparous. Similarly, in a study conducted in

Indonesia majority of the respondents (66%) were multiparous. It is also in the same line

with the study of Grace,Oyin, Muyideen and Charles (2012) in Nigeria. They found that

majority of the respondents (87%) were multiparous. It could be as a result of early marriage

in the state that led to have more children.

55
5.3 Research Question one:

What is the Availability of material resources for focused antenatal care?

Materials resources is one of the important aspect to maintain high quality of antenatal care

and has been identified as the main intervention strategy with the highest impact on maternal

health (Chigozie, Achunam,Uzo, Prosper and Echendu, 2014).The result of this study;

revealed that more than half of the materials resources in the studied facilities were not

functioning (57%); only less than half (43%) were functioning. It is the same with the

finding of (WHO,2014) that there was shortage of material resource for health care services

in Africa. In the same vain Karin, Joanna, Flora, Constance, and Brigit (2011) Found

shortage of material resources for focused antenatal care services in South-eastern Tanzania,

Similarly, in a study conducted in Burkina Faso, Uganda and Tanzania by Paul, Gerhrd,

Justin, Arinaitwe, Silva, Florian, Olaf and Malabiki (2011) found that health care workers in

the three countries failed to perform most of the procedures stipulated in focused antenatal

care due to the shortage of material resources for focused antenatal care services. In the

same vain Angelo, Alise, David, Jaap , and Jos (2012) in Tanzania found that some

essential equipment like sphygmomanometer were in poor quality leading to short durability

contributing to the shortage.

Shortage of qualified staff and irregular supply of essential equipment, drugs and

consumables were considered by 91% and 64% of the respondents respectively as the major

underlying factors for substandard ANC. In the same vain Edmund, Emmanuel, Benjamin,

and Benjamin (2015) in Enugu, Nigeria found that most facilities (77.8%) had inadequate

water and power supply, as well as inadequate sanitary toilet facilities. In addition, 44.4% of

the health facilities reported lacked basic equipment and some had no maintenance plan.

56
Ambulance service was available in only 11.1% of the facilities. Only 33% of the facilities

could be accessed easily by public transportation. Stewardship was unsatisfactory as no

facility had a regular work schedule for its workers, none had a copy of the Essential Drugs

List, and only 22.2% of the facilities enjoyed community participation in planning and

management. In the same line with Chinomnso, Uzo, Prosper and Achunam (2014) in

Nnewi, Nigeria found that none of the health facilities is equipped with the minimum

equipment package, essential drugs nor staff complements required enabling them offer

quality maternal health services. Show that there was shortage of material resources for

focused antenatal care services in Bauchi State.

This lacking in facilities had really affected the quality of care, It could be as a result of the

services delivery point may not be open at the right time or supplies may not be adequate, as

such, clients do not receive services of their choices or due to poor maintenance culture in

the State or sub standard materials were used in the health facilities.

5.4 Research Question two:

What is the Capacity of Human resource for focused antenatal care?

While collectively the five main questions addressed in the study represent focused antenatal

care affecting and affected by human resources practices, The result shows that the number

of health care providers in each facility were inadequate in Doctors, Nurses, Midwives and

CHEW in all of the 22 health facilities, Compared to the WHO standard of doctors 1:30,

Nurses 1:5, midwives 1:5 and CHEW 1:600. It is the same with the finding of (WHO, 2014)

that there were gross shortage of health personnel in African countries. In the same vain a

study conducted by Robert, Sealy, Marshak, Manda, Gleason, and Mataya (2014)in Malawi

57
found that women complained that they often waited unnecessarily long for services because

the workers worked slowly due to the shortage of health human resources for focused

antenatal care services. Also, the World Health Organization (WHO,2014) estimates a

shortage of almost 4.3 million physicians, midwives, nurses and support workers worldwide.

Similarly, in a study conducted by Global Health Workforce alliance (2013) found that

Health worker shortages affect Germany and the USA, just like they affect India or Uganda.

Western countries ‗import‘ workers from developing countries, because they are also short

of trained health workers. In the same vain Merlin, Wim, Pierre ,Chiaka, Francis et al (2015)

found that in Sudan, Mali and Uganda have a critical shortage of health workers. In all five

countries, a minority of doctors, nurses and midwives are working in primary health care,

and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in

primary health care settings than at higher levels. In Mali, few community health centers

have a midwife or a doctor. Even South Africa has a shortage of doctors in primary health

care in poorer districts. It could be health personnel are available but may not be in adequate

proportion with the catchment population, not skilled or not trained and retrained on the

necessary skills required to offer the needed quality services, or there was no health care

personnel motivation and job satisfaction in the state

5.6 Research Question three:

What is the level of quality services of Focused antenatal care?

FANC emphasizes the quality of ANC, rather than the frequency of antenatal visits. FANC

is intended to reduce waiting times, increase the time spent educating women about

pregnancy-related issues and promote the use of skilled assistance at birth (Babalola and

Fatsui 2009; Gabrysch and Campbell 2009; WHO 2001)

58
Despite the multi-sectoral efforts to upturn the accessibility and quality of ANC services in

Nigeria, the chances of achieving the MDGs was low WHO (2013). More than half of the

services provided by the health care personnel (54.2%) were satisfactory. It is in line with

the study of Gregory et al that found 91% of the respondents were satisfied with the services

of Focused antenatal care provided for them. In the same vain with the study of (Chemir,

2014) found that 60.4% of the respondents were satisfied with the services provided for

them. Similarly, in a study conducted in Lagos by Sholeye, Abosede, and Jeminusi (2013)

found thatAlmost all (98.5%) respondents were satisfied with the Focused antenatal care

services they received. In the same vain Joseph (2012) conducted a study in Ghana and

found that the majority of the respondents (96.4%) were ―willing to come back to the ANC

clinics before delivery‖. The results further show that, 89.6% of the total respondents

perceived the care they received as ―quality‖ while 87.3% said they were generally satisfied

with ANC services. It could be as a result of the majority of respondents had only

secondary school education or it could be as a result of lack of exposure to the quality

services due to the cultural practices of early marriage in the State.

5.7 Research Question four:

What is the utilization level of focused antenatal care among women?

Effective utilization of focused antenatal care (FANC) is associated with improved maternal

and neonatal health

outcomes.(Bullough , Meda , Makowiecka , Ronsmans , Achadi & Hussein 2005) ;

Darmstadt, Bhutta ,Adam , Walker , & de Bernis 2005 ;WHO ,2005). The study

demonstrated that more than three quarters of the pregnant women (80%) attended

Focused Antenatal Care regularly while the remaining 20% occasionally attended the

59
focused antenatal care. It is in line with the study of Yeoh, Hornetz and Dahlui (2016) in

United State of America that found large proportion of women (63%, 330/522) with

―adequate-plus‖ or intensive ANC utilization, while 21% (107/522) of the women had

―inadequate‖ utilization. This corroborates with the statement of WHO,(2001) that found

60% of women received antenatal care in Nigeria, and not all of them attended the antenatal

clinic regularly. In the same vein, Kiplagat (2009) in Kenya found that 89.5% of the

respondents reported that they could use the same facility for ANC during another

pregnancy and 88.9% could recommend the facility to a relative or a friend for ANC

checkups. Similarly, in a study conducted by Nicholas, Collins, Sabine (2012) in Zambia

they found that 98% of the 4148 women in the Zambia attended ANC at least once and

94% attended at least once and saw a skilled health worker, only 60% had the recommended

four antenatal visits and 58% received the recommended ANC of at least four visits with a

skilled health worker. Only 19% of mothers who attended ANC had their first ANC visit in

the first trimester, while 74% attended for the first time during the second trimester. Most

mothers (72%) attended ANC at a health center and the vast majority (91%) received care

from a nurse or midwife. In the same vain USAID (2009) In Tanzania found that of high

antenatal attendance of pregnant women in various health facilities, maternal mortality rate

remains high at 578 per 100,000 live births and infant mortality rate at 68 per 1,000 births,

94% of all pregnant women received antenatal care at least once from health professionals.

May be due to proximity of their homes to the health facilities that made them to be regular

or they were health educated on the importance of been regular on focused antenatal care.

60
5.8 Research Question five:

What is the Level of clients Satisfaction with Focused antenatal care services?

The result shows that the aggregate mean satisfaction was 2.34 which were below the cut off

mean satisfaction of 2.5, showed that pregnant women had low satisfaction with focused

antenatal care services in the studied facilities. In Ogun State Nigeria Oladapo, Iyaniwura

and Sule-Odu (2013) found in their study that women attending antenatal clinics at these

centers, in general, were satisfied with the quality of services received in spite of some

inconsistencies between the received care and their expectations of the facilities. Besides the

overall assessment of their perspectives on care received, this deduction was also made from

the above average level of contentment with many elements of quality of antenatal care that

were explored in the study. Also Chanthanom et al (2014) found that the quality of antenatal

care services was poor due to lack of resources and providers limited skills that led to

clients‘ dissatisfaction.. In the same vain In a study conducted by Harriet and Onyango-

Ouma (2013) on Acceptability and Sustainability of the WHO Focused Antenatal Care

package in Kenya described Clients in the intervention clinics were more dissatisfied with

the waiting time than any other aspect of focused ANC, and consistently across all four

visits with more than 50 percent of clients indicating their dissatisfaction during each visit.

It is against the study of chemir ,Alemseged and Workneh (2014) who found that pregnant

women were satisfied with FANC services. Similarly, in the study conducted by Fantaye,

Fessahaye, Desta (2014) in Jimma Town of South West Ethiopia affirmed that More than

half of the respondents (60.4%) were satisfied with the service that they received. As to

specific components, most of the respondents (80.7%) were satisfied with interpersonal

aspects, and 62.2% were satisfied with organization of health care aspect. Meanwhile,

49.9% of the respondents were not satisfied with technical quality aspect and 67.1% were
61
not satisfied with physical environment aspect. In the same vain Olufemi, Christianah,

Iyaniwura and Adewale (2008) found that Four hundred and thirty seven (96.7%) of the

respondents expressed satisfaction with the way their care providers were monitoring their

health and that of their unborn babies in South-west Nigeria. Also, a study conducted by

USAID (2004) found that the degree of satisfaction (percentages expressing satisfaction)

ranged from as low as 7.1% regarding time spent in PHC centers, 24.5% regarding

accessibility.

It is against the study that El-Sayed (2015) In Egypt found that one half of the pregnant

women had moderate satisfaction score with antenatal care services. 53.6% of 420 pregnant

women Egypt. Similarly, with the study of FehmidaShaheen, Tahira Khalid, NaylaZamir

(2011) in Pakistan found that 76% ladies were satisfied with the time given by the doctor,

and their communication skills but only 60% ladies were satisfied with the attitude of the

doctors. Overall satisfaction in antenatal clinic was reported by 73% while 27% were either

unsatisfied or uncertain. It could be due to the shortage of the health personnel to provide

the quality services to the pregnant women that will make them satisfied with the focused

antenatal care services in the state.

62
 CHAPTER SIX

SUMMARY, CONCLUTION AND RECOMMENDATION

6.1 Summary

The aim of this study was to assess the service quality of focused antenatal care in Bauchi

State. Five research objectives were formulated: as follows: To determine the availability of

material resources for focused antenatal care, to assess the capacity of human resource for

focused antenatal care in, To assess the quality services of focused antenatal care, to assess

the utilization‘s level for Focused Antenatal Care services and to assess the level of clients‘

satisfaction with focused antenatal care services .A cross sectional descriptive design was

adopted. A total of 376 samples of pregnant women that attended antenatal care in the

twenty two health care facilities in Bauchi State were recruited during the period of first

May to the end August, 2016. Two main instruments were used for data collection, self

administered questionnaire and observational checklist. All ethical approvals were collected

before conducting the research. Donebedian Bruce quality model (1980) was used as

theoretical framework. The result revealed that Eighty percent of the respondents were over

35 years old, 66% of them were Hausa/Fulani, almost half of them had secondary school,

and more than half of them had parity above six times. Eighty percent of the sample utilized

focused antenatal care always. With the regard to the availability of material resources in

twenty two health care facilities only (43%) was available and functioning. In relation to the

human resources in comparing to the WHO (2014) standard they were shortage in Doctors,

Nurses, Midwives, and Community Health Extension Workers 0.81,0.5, 2.7 and 1.8
63
respectively in each facility. In relation to quality of care in the studied health facilities was

done satisfactory with aggregate mean percentage of 55.5%.The aggregate mean satisfaction

with focused antenatal care services was 2.34 below the cut off mean satisfaction of 2.5.

Clients satisfaction with treatment, examination and information provided by health care

provider had highest mean scores of 3.29 and 3.30 respectively while cleanliness of the

facility and seat of waiting area had lowest mean scores of 1.89 and 1.84 respectively. It can

be concluded that: there were inadequate material resources, shortage of human resources

for focused antenatal care Services, the services provided was not met the standard of WHO

(2014), high utilization of focused antenatal care services and the client satisfaction was

low .Based on the result the following were recommended: Ensure adequate material

resources for focused antenatal care services in each facility in Bauchi State, Ensure

adequate health care providers to improve quality focused antenatal care services, Periodic

In-service training ,monitoring and evaluation to improve the quality services, Health

education for the clients to increase the awareness and the importance of focused antenatal

care and Regular assessment of the level of clients‘ satisfaction is needed to improve the

lacking areas.

64
6.2 Conclusion

Based on the findings of the study the following conclusions were made;

In comparing to the WHO (2014) standard for focused antenatal care, there were

lacking in the availability of materials resources for Focused Antenatal Care

Services.

Shortage of human resources for Focused Antenatal Care Services.

Satisfactory provision of quality care were provided

Focused Antenatal Care Services was highly utilized and

The level of client satisfaction with the Focused Antenatal Care Services was a little

bit low.

6.3 Recommendation

Based on the findings the following were recommended:

Government should ensure adequate material resources for focused antenatal

care services in each facility in Bauchi State.

Government should ensure adequate health care providers to improve quality

focused antenatal care services.

Government should ensure Periodic In-service training, monitoring and

evaluation to improve the quality services.

The results suggest that improving the content of care during ANC visits may

foster adequate use of ANC and encourage early initiation of ANC visits.

Furthermore, health promotion programmes need to further encourage male

65
 involvement in pregnant women's decision to seek ANC to encourage

adequate use of services and Health education for the clients to increase the

awareness and the importance of focused antenatal care utilization.

Government should ensure regular assessment of the level of clients‘

satisfaction is needed to improve the lacking areas.

6.4 Limitation

The study did not cover primary health facilities; it covered only secondary and tertiary

facilities in the State.

6.5 Implication of the Study

Based on the findings, three implications were stated:

First, the result of this research will be useful to facilities, administrators and the ministry of

health to provide them with existing conditions of focused antenatal care in Bauchi State.

Secondly, the study will serve as reference to level of clients‘ satisfaction in Bauchi State

Finally, this study will help others in conducting their research of same nature in different

States.

The government has to discover the causes of lacking and shortage of the staff.

66
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Yeoh P, Hometz K and Dahlui (2016). Antenatal Care Utilization and Content between
low- Risk and High-Risk pregnant Women. PloS One 11
(3):e0152167.doi:10.1371/journal.pone.0152167.Retrieved November 12,2016 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4807004/

Zeithml V, Parasuraman A, and Berry L. (2008). Service Performance .Retrieved July, 2016
from http://www.serviceperformance.com/the-5-service-dimensions-all.customers-
care-about/

Zolot and pa (2016.) Trend in maternal mortality. American journal of Nursing.vol 116 issue
2:p17 Retrieved from
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.aspx?year=2016&issue=02000&article=00010/2008/3acf/en/index html

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 Appendix i

DEPARTMENT OF NURSING SCIENCES

FACULTY OF MEDICINE,

AHMADU BELLO UNIVERSITY ZARIA

Dear respondents,

I am Msc student of the above named department conducting a research on

‘ASSESSMENT OF SERVICE QUALITY OF FOCUSED ANTENATAL CARE IN

BAUCHI STATE’

Please read and answer the following questions, information obtained will be used
strictly for academic purpose only and total confidentiality will be ensured

76
Section A: Socio-Demographic Data of the Respondents
Age in Years…………………………………………………………………………

S/N VARIABLES Tick (√)

2. Ethnic Group Hausa/Fulani
Igbo
Yoruba
Others (Specify)

3. Level of education No formal

education
Primary School
Secondary School
Tertiary School

4. Parity 1-3 Times

4-5 Times

6-7 Times

>7 Times

77
Section B; Availability of material resources (physical facilities, infrastructures) for
maternal health care services (CHECKLIST)

Key; AF=A available and functional, ANF= available NOT functional, NA=Not available

ITEM AF ANF NA
1)Physical infrastructure;
a) A waiting area with sittings for clients
b) An area for counseling that is private equipped with a table or desk
and two chairs which is, not in waiting room
c) A locked storage cupboard for drugs
d) A toilet (indoor or outdoor latrine)that is regularly clean for clients
e) A toilet (indoor or outdoor latrine) that is regularly clean for staff
f) A roof that does not leak
g) Water source and electricity;
i)Access to portable water (running water or a well near health care
facility
ii)Electricity
iii)A reliable source of light( Generator, Lantern, Torchlight etc)
2) Equipments, different sizes of;
a) Speculum
b) Artery forceps
c) Scissors
d) Bowls
e) Bed/Table
f) Screens

78
ITEM AN AE NA
3) Drugs;
a) Antibiotics
b) Analgesics
c) Anticonvulsant
d) Antihypertensive
e) Anti-inflammatory
f) Haematenics
4)Supply and consumables;
a) Syringes
b) cotton wool and Bandage
c) stationeries
d) Disinfectants and Antiseptic solutions
e) Plaster and adhesives
f) Handgloves

5) Health education materials; An educational materials available for client

KEY; AN=Available not expired, AE=Available and expired, NA= Not available

79
Section C; Services Provided During Focused Antenatal Care

Focused Antenatal Care Checklist

Weeks of gestation
st
Parameters 1 Visit 2ND VISIT 3RD VISIT 4TH VISIT
20-24 Weeks 28 - 32 Weeks 36 Weeks
<16 weeks
DS DNS ND DS DNS ND DS DN ND DS DNS ND
Registration
Comprehensive history taking

Personal history
Family history
Social history
Past medical/surgical history
Past obstetric history
History of current pregnancy
History of complaints in current
pregnancy
Physical Examination
Head-to-toe (whole body)
Pallor
Oedema
Breast
Lung and heart
Observations and clinical investigations
Temperature
Pulse
Blood pressure
Weight
Height
Gait
Obstetric examination
Fundal height
Foetal poles/lie
Foetal presentation
Engagement of presenting part
Foetal heart sounds
Pelvic (vaginal) examination
Soft tissue assessment (genital ulcers,
vaginal discharge, cervix, uterine
enlargement position, adnexal masses)
Bony pelvis assessment
(cephalopelvic relationship)
Laboratory investigations
Blood
Haemoglobin
Grouping and rhesus factor
VDRL for syphilis testing
HIV testing (earliest opportunity)
Urine
Protein
Sugar
Acetone
Drug Administration and immunization
Iron
Folic acid

Key: DS=Done and Satisfied, DNS=Done Not Satisfied, ND=Not Done

80
 Section D; Capacity of Human Resources (CHECKLIST)

VARIABLE DOCTOR NURSE MIDWIFE CHEW CHO

1.Adequacy of staff in 24hours per week
2.Qualifications of staff;
a) Certificate
b) Degree
c) Post graduate degree
3) Supervision of staff;
4) Skills of staff;
a)Competent
b) competent but needs improvement
d) Not competent
5) In-service training for staff;
a) Available and full
b) Partially available
c) Not available

KEY; CHO=Community Health Officers, CHEW=Community Health Extension Workers. Adopted

fromTukur,(2015)

81
Section E; Utilization of Focused Antenatal Care Services

1. Do you attend Focused Antenatal Care Services regularly

a-Yes b-Sometimes c d-Never attended
2. Proximity of Antenatal Clinic

a-Working Distance b-One Bus c-Two or more Buses

3. How many Months Pregnant were you when you first received Focused Antenatal
Care Services(Booking)
a-1-3 Months b-4-6 Months c-7-9 Months
4. Pattern of Focused Antenatal Care after booking
a- Appointment Days b-Only week Days c-When I have
complaint d- I do not go at all
5. Booking Days/Days of the week
a-Throughout the week b-Only Week Days d-Anytime I
like
6. Working Time (Time in the Day)
a-In the Morning b-Anytime I want c-Not at all
7. How many times in total did you receive Focused Antenatal Care Services during
your previous pregnancy?
a-Once b-Twice c-Thrice Fourth

8. Did you pay for Focused Antenatal Care Services?

a-Yes b- No

9. If yes, was it affordable to you? a- Yes b-No

10. How many times in total have you been pregnant (Whether the child was born alive
or dead)
a-Once b-Twice c-Thrice d-Fourth
e-Others Specify……-

82
Section F; Level of Clients’ Satisfaction with Focused Antenatal Care Services

S/N ITEM VS S VDS DS

1 Waiting time before seen by health Care provider

2 Time taken with health care provider

3 Treatment by health care provider (with respect)

4 Seat of waiting area

5 The way health provider handles my information

(confidentiality)

6 The cost incurred for the service

7 Time given by health provider to ask question

8 The way health provider answered my question (understood)

9 Privacy (met the health provider privately )

10 Examination services and information provided

11 Cleanliness of the facility

12 Focused antenatal care services provided today

KEY; VS=VERY SATISFIED, S=SATISFIED, VD=VERY DISSATISFIED, D= DISSATISFIED

83
 APPENDIX ii

Focused Antenatal Care Checklist (WHO,2014)

Weeks of gestation
Parameters st
1 Visit 2nd visit 3rd visit 4th visit

Registration
Comprehensive history taking
Personal history X
Family history X
Social history X
Past medical/surgical history X
Past obstetric history X
History of current pregnancy X
History of complaints in current pregnancy X X X X
Physical Examination
Head-to-toe (whole body) X X X X
Pallor X X X X
Oedema X X X X
Breast X X X X
Lung and heart X
Observations and clinical investigations
Temperature X
Pulse X
Blood pressure X X X X
Weight X X X X
Height X
Gait X
Obstetric examination
Fundal height X X X X
Foetal poles/lie X X
Foetal presentation X X
Engagement of presenting part X
Foetal heart sounds X X X
Pelvic (vaginal) examination
Soft tissue assessment (genital ulcers, vaginal discharge, cervix, X X
uterine enlargement position, adnexal masses)
Bony pelvis assessment (cephalopelvic relationship) X
Laboratory investigations
Blood
Haemoglobin X X
Grouping and rhesus factor X
VDRL for syphilis testing X
HIV testing (earliest opportunity) X
Urine
Protein X X X X
Sugar X X X X
Acetone X X X X
Drug Administration and immunization
Iron X X X X
Folic acid X X X X
84
 APPENDIX iii
Setting of Bauchi State

Bauchi
State
South Central North
Senatorial Senatorial Senatorial
District District District

Bogoro Ganjuwa Katagum

T/balewa Gamawa
Warji

Dass Ningi Zaki

Toro Itas
Darazo

Alkaleri Jama'are
Misau

Kirfi Shira
Dambam

Bauchi Giade

85
 APPENDIX IV

Table for Determining Sample Size from a Given Population by Krejcie and Morgan(1970)

N S N S N S
10 10 220 140 1200 291
15 14 230 144 1300 297
20 19 240 148 1400 302
25 24 250 152 1500 306
30 28 260 155 1600 310
35 32 270 159 1700 313
40 36 280 162 1800 317
45 40 290 165 1900 320
50 44 300 169 2000 322
55 48 320 175 2200 327
60 52 340 181 2400 331
65 56 360 186 2600 335
70 59 380 191 2800 338
75 63 400 196 3000 341
80 66 420 201 3500 346
85 70 440 205 4000 351
90 73 460 210 4500 354
95 76 480 214 5000 357
100 80 500 217 6000 361
110 86 550 226 7000 364
120 92 600 234 8000 367
130 97 650 242 9000 368
140 103 700 248 10000 370
150 108 750 254 15000 375
160 113 800 260 20000 377
170 118 850 265 30000 379
180 123 900 269 40000 380
190 127 950 274 50000 381
200 132 1000 278 75000 382
210 136 1100 285 100000 384

86