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Indian Journal of Community Medicine

Quality of Reproductive Health Care at Primary Level

Author(s): Monika Agarwal, M.Z. Idris, U.Mohan

Vol. 26, No. 3 (2001-07 - 2001-09)

Abstract :

Research question: What is the quality of reproductive health care being delivered at primary care level in Lucknow district.

Objectives: 1. To assess the availability of physical facilities and infrastructure at Primary Health Care units. 2. To assess the technical skills and competence of service providers.

Participants: Total 274 clients; of which 177 were from rural area and 97 were from urban area.

Setting: Rural and urban primary care health facilities of Lucknow district.

Study design: Cross-sectional.

Statistical analysis: Percentages and chi square test.

Results: A total of nine primary health care units were studied, 6 were from rural area and 3 from urban area. All health centres were graded according to available physical facilities and quality of services using scoring method. All rural as well as urban centres were found `very good' and `good' for availability of drugs and equipments respectively, while poor for physical facilities. The overall quality of antenatal, postnatal and family planning services was poor at all the centres while natal services were very good.

Conclusion: A lot remains to be done to strengthen antenatal and family planning services. Specific strategies are needed to improve the technical competence of the health providers.

Keywords : Primary health care, Quality of health care, Reproductive health

Introduction:

Reproductive health i.e. "state of complete physical, mental and social well being which enables the people to have satisfying and safe sex life, capability to reproduce and information and access to safe, effective, affordable and acceptable methods of family planning of their choice", can be achieved only through delivery of reasonable quality of health care services. Delivery of quality care in turn, necessitates presence of physical infrastructure, proper logistics such as regular and adequate supply of drugs, contraceptives etc. and technically competent and motivated staff having good interpersonal communication skills.

The various programmes aiming at reproductive care have been unable to make an appreciable impact on reproductive health of women in India. Though the coverage in itself was inadequate, the available services were also not satisfactorily utilized. One of the reasons may be lack of awareness about availability or dissatisfaction with the available services either due to various infrastructural deficiencies or lack of technical skills in methods/procedures being practiced by the health care providers. The present study is, therefore, an attempt towards assessing the physical infrastructure, skills and competency of staff of primary care level and suggest measures to improve the quality of reproductive health care services.

Material and Methods:

The study was undertaken for the qualitative evaluation of reproductive health care at the primary health care level of Lucknow district. A multistage stratified random sampling was used in the present study for the selection of health centres based on the guidelines of the primary health care management advancement programme, service quality, user's guide, Module (6) by Aga Khan foundation. At the first stage, one block level PHC from the rural area and one maternity center from the urban area was randomly selected from a sample frame of all primary health care facilities within Lucknow district. At second stage, two additional PHCs attached to block level PHC and two health posts from already selected maternity centers were included. At the third stage one sub-center from each of the selected PHCs only was randomly chosen for the study. As there was no equivalent counter part of sub center at urban area, no such health care facility from urban area could be included at third stage.

A set of ten beneficiaries for each service was randomly selected from each of the health facility in rural as well as urban area. Structural quality was assessed against expected standards at the primary care level. Technical and communication skills of the health providers were observed during regular clinic sessions. Data was collected during health facility visits, using the check-list and structured interview as per the guidelines of the primary health care management advancement programme, user's guide, service quality module (6) by Aga Khan foundation. Scoring/grading has been done for overall rating of physical facilities and quality of services.

Rank Grade Score
1 Very poor <20
2 Poor 21-40
3 Average 41-60
4 Good 61-80
5 Very good 80+

Results:

Table I: Availability of Physical Infrastructure at primary health care center.

Facilities/Infrastructure Availability of Facilities/infrastructure G.Total
n=9 (%)
Rural  Urban
PHC
n=3 (%)
SC
n=3 (%)
Total
n=6(%)
HP
n=2 (%)
MC
n=1(%)
Total
n=3 (%)
Waiting space
Protected waiting area 33.3 0.0 16.6 0.0 100.0 33.3 22.2
Adequate sitting space 33.3 0.0 16.6 0.0 100.0 33.3 22.2
Consultation room
Separate room 33.3 0.0 16.6 0.0 100.0 33.3 22.2
Auditory privacy 0.0 0.0 0.0 0.0 100.0 33.3 11.1
Visual privacy 0.0 0.0 0.0 0.0 100.0 33.3 11.1
Examination Table 66.6 66.6 66.6 50.0 100.0 66.6 66.6
Weighing machine 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Stethoscope & B.P. instruments 66.6 66.6 66.6 50.0 100.0 66.6 66.6
Maternal & child health cards 33.3 0.0 16.6 100.0 100.0 100.0 44.4
Examination room
Separate room/screen 33.3 0.0 16.6 0.0 100.0 33.3 22.2
Auditory privacy 33.3 0.0 16.6 0.0 100.0 33.3 22.2
Visual privacy 33.3 0.0 16.6 0.0 100.0 33.3 22.2
Needles & syringes 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Foetoscope 66.6 100.0 16.6 100.0 100.0 100.0 88.8
Drugs
IFA tablets 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Contraceptives (All) 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Vaccines 100.0 100.0 100.0 100.0 100.0 100.0 100.0
IEC materials 66.6 33.3 50.0 0.0 100.0 33.3 44.4
Labour room 33.3 - 33.3 - 100.0 33.3 33.3
Laboratory facilities 33.3 0.0 16.6 0.0 100.0 33.3 22.2
Haemoglobinometer 100.0 66.6 83.3 0.0 100.0 33.3 66.6
Albuminstix 33.3 33.3 33.3 0.0 100.0 33.3 33.3
Drinking water facility 66.6 33.3 50.0 100.0 100.0 100.0 66.6
Electricity 66.6 0.0 33.3 100.0 100.0 100.0 55.5
Toilet facility 33.3 0.0 16.6 50.0 100.0 66.6 33.3

HP - Health post; MC - Maternity centre.

Table I shows that overall facility/infrastructure was best available at maternity center. The situation at sub center was found to be very dismal. The availability of drugs was 100% at each center. Auditory and visual privacy during counselling and examination was found to be lacking at most of the centers particularly rural centers and health posts. Urban centers were found to be much more equipped than the rural centers except for I.E.C. material, which was more at rural centers (100%) as compared to urban centers.

Table II: Quality of antenatal care services.

Service elements Percentage of elements correctly performed G.Total n=90(%) p value
Rural Urban R/U
PHC n=30 SC n=30 Total n=60 MC n=10 HP n=20 Total n=30
Reviewed and updated obstetrics records 86.7 100.0 93.3 100.0 100.0 100.0 95.5 0.038
Recorded date of LMP and EDD 100.0 66.7 83.3 100.0 100.0 100.0 88.8 0.001
Asked about h/o complication 33.3 0.0 16.7 0.0 0.0 0.0 11.1 0.069
Asked about chronic illness 0.0 0.0 0.0 10.0 0.0 3.3 1.1 0.309
Asked about drug abuse/any medications 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -
Recorded blood pressure 0.0 0.0 0.0 40.0 0.0 13.3 4.4 0.032
Measured weight 63.3 33.3 48.3 0.0 50.0 33.3 43.3 0.163
Measured height 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -

Examined for sign of edema

6.7 10.0 8.3 20.0 0.0 6.7 7.7 0.773
Measured fundal height 33.3 10.0 21.7 100.0 30.0 53.3 32.2 0.003
Heard foetal heart sounds 33.3 0.0 16.6 100.0 10.0 40.0 24.4 -
Administered TT injection 100.0 100.0 100.0 100.0 100.0 100.0 100.0 -
Gave IFA Tablets 100.0 100.0 100.0 100.0 100.0 100.0 100.0 -
Referred for Hb/urine/sugar/ albumin/VDRL/ABO/Rh type. 33.3 13.3 23.3 100.0 20.0 46.7 31.1 0.028
Advised regarding place/person of delivery 13.3 6.7 10.0 10.0 0.0 3.3 7.7 0..189
Reminded for next visit 66.7 50.0 58.3 100.0 85.0 90.0 68.8 0.003
Advised regarding nutrition and rest 36.7 33.3 35.0 40.0 25.0 30.0 33.3 0.63
Explained danger signs 6.7 0.0 3.3 0.0 0.0 0.0 2.2 0.15
Asked client if she had any question 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -

Table II shows that quality of antenatal care services was found to be good in respect to reviewing and upgradation of obstetrics records, recording of LMP and EDD, distribution of IFA tablets, administration of TT injections. Very few clients were asked about history of complication, chronic illness and drug abuse/any medications. In none of the case, height was measured. In rural areas, in none of the case B.P. was measured.

Table III: Quality of natal services (PHC & MC).

Service elements Percentage of elements correctly performed G.Total p value
Rural Urban n=20(%) R/U 
PHC n=10 Total n=10 MC n=10 Total n=10
History taking 100.0 100.0 100.0 100.0 100.0 -
Conducted physical examination 90.0 90.0 100.0 100.0 95.0 -
Assisted with progress of labour 100.0 100.0 100.0 100.0 100.0 -
Assisted with delivery 100.0 100.0 100.0 100.0 100.0 -
Established respiration 100.0 100.0 100.0 100.0 100.0 -
Cut/tied umbilical cord with sterilized razor/thread 100.0 100.0 100.0 100.0 100.0 -
Determined APGAR score at 1 min and 5 min after birth 0.0 0.0 0.0 0.0 0.0 -
Delivered placenta and examined for completeness 100.0 100.0 100.0 100.0 100.0 -
Monitored mother and provided needed care 100.0 100.0 100.0 100.0 100.0 -
Weighed infant 100.0 100.0 100.0 100.0 100.0 -
Recorded labour and delivery information on labour charts 100.0 100.0 100.0 100.0 100.0 -
Discussed about postnatal cleanliness/cord care 50.0 50.0 50.0 50.0 50.0 -
Advised about breast feeding 40.0 40.0 100.0 100.0 70.0 0.003

Natal services were not provided at subcentres and health posts.

Table III shows that all the measures were performed in all the patients but in none of the case APGAR was determined. Postnatal cleanliness/cord care was discussed with only half of the clients. In rural areas, only 40.0% clients were advised about breast feeding. Data for natal services as available in PHCs pertains to one PHC only as in remaining two PHCs, services were not being provided due to non-availability of infrastructure. Therefore, quality of natal services at these PHCs should be interpreted accordingly.

Table IV: Quality of postnatal services.

Service elements Percentage of elements correctly performed G.Total p value
Rural Urban n=74(%) R/U
PHC n=24 SC n=23 Total n=47 MC n=10 HP n=17 Total n=27
Asked outcome/problems of last delivery 58.3 100.0 78.7 100.0 100.0 100.0 86.5 0.000
Examined the mother 0.0 0.0 0.0 50.0 0.0 18.5 6.7 0.013
Examined the newborn child 0.0 0.0 0.0 60.0 0.0 22.2 8.1 0.005
Recorded findings of history and physical examination 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -
Provided iron/folic acid tabs to mother 33.3 0.0 17.8 0.0 0.0 0.0 10.8 0.002
Discussed family planning methods 41.7 65.2 53.2 60.2 70.5 66.7 58.1 0.247
Gave BCG or verified that child received vaccination 100.0 100.0 100.0 100.0 100.0 100.0 100.0 -
Inquired about mother's knowledge and practice concerning breast feeding 0.0 0.0 0.0 70.0 0.0 25.9 9.4 0.002
Instructed mother on health benefits of breast feeding 20.8 39.1 29.8 90.0 23.5 48.1 36.5 0.117
Instructed mother on method of breast feeding 0.0 0.0 0.0 10.0 0.0 3.7 1.3 0.308
Provided appropriate counselling on diet 20.8 43.4 31.9 50.0 29.4 37.0 33.8 0.656
Advised mother on weaning practices 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -
Told mother about next post-partum visit 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -

Table IV shows that in all the cases, either the child was given BCG or it was verified that the child had received it. Almost 90.0% of the clients were asked about outcome/problem of delivery. In rural areas, none of the mother was examined and no mother was enquired of her knowledge on breast feeding. In urban areas also these measures were performed in less than 10% cases. Very few mothers (1.3%) were instructed on method of breast feeding and no mother was advised on weaning practices to be adopted.*

Table V: Quality of family planning services.

Service elements Percentage of elements correctly performed G.Total p value
Rural Urban n=90(%) R/U
PHC n=30 SC n=30 Total n=60 MC n=10 HP n=20 Total n=30
Asked the client's age 33.3 26.7 30.0 100.0 75.0 83.3 47.7 0.000
Asked about number, spacing and outcome of previous pregnancies 100.0 100.0 100.0 100.0 100.0 100.0 100.0 -
Asked about previous use of FP methods 43.3 33.3 38.3 70.0 70.0 70.0 47.8 0.002
Took medical history 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -
Took weight 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -
Took blood pressure 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -
Examined for signs of anaemia 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -
Asked and examined for PID 26.7 0.0 13.3 20.0 20.0 20.0 15.5 -
Described contraceptive options 73.3 80.0 76.7 90.0 95.0 93.3 82.2 0.019
Discussed their side effects 0.0 6.7 3.3 10.0 5.0 6.7 4.4 0.514
Discussed their benefits 43.3 40.0 41.7 50.0 45.0 46.7 43.3 >0.5
Asked for client's preferences 53.2 46.7 50.0 80.0 55.0 63.3 54.4 >0.1
Recommended method that was free of contra-indications for this client 100.0 100.0 100.0 90.0 90.0 90.0 96.7 0.068
Explained the correct usage of the selected method 53.6 46.4 50.0 60.0 55.0 56.7 52.2 0.368
Explained where and when to go for resupplies 40.7 66.7 53.3 70.0 75.0 73.3 60.0 0.053
Asked the client if she had any question 3.3 0.0 1.7 0.0 0.0 0.0 1.1 0.313

Table V shows that all clients were asked about number, spacing and outcome of previous pregnancy. In none of the case recording of medical history, weight, B.P. and examination for signs of anaemia was done. To 80.0% of the clients contraceptive options were described but their side effects were discussed with only 7.7%. Almost 50-60% of clients were told about the correct usage of contraceptives and the place to get their supply. None of the client was encouraged to ask any question.*

Table VI: Overall rating of physical infrastructure and quality of services.

Facilities
of basic
amenities
Score (Rank)
Rural Urban Total
Infrastructure
Physical facilities 25(2) 52(3) 33(2)
Equipments 65(4) 62(4) 65(4)
Drugs 95(5) 95(5) 95(5)
Overall services 62(4) 69(4) 64(4)
Antenatal 35(2) 41(3) 35(2)
Natal 93(5) 97(5) 95(5)
Postnatal 28(2) 36(2) 31(2)
Family planning 38(2) 45(3) 40(2)
Overall 49(3) 55(3) 50(3)

Table VI shows that overall availability of physical infrastructure was poor in rural as well as urban centers. Availability of equipments, scored good grade for all the centers. All the centers, rural as well as urban were graded very good for the availability of drugs/vaccines. Quality of antenatal, postnatal and family planning services was graded poor at all the centers while that of natal services was graded very good.

Discussion:

Physical facilities:

Quality of physical facilities at health centers was assessed by observing physical infrastructure, equipments and drug supply etc. Protected waiting area and adequate sitting space was available at 22% health enters. Contrary to this, in Sitapur1 protected waiting area was at 82% PHCs and 43% sub centers. Adequate sitting space was available at 32% PHCs. In present study, visual and auditory privacy during examination was more (22.2%) than during consultation (11.1%). It was totally absent at health posts and subcentres. About 20% of the centers had a separate room for consultation and examination. In Agra2 and Sitapur1 also, in majority of the subcenters same room was being used for counselling and examination. In Sitapur1, visual privacy during counselling and examination was available in 41% and 64% of the PHCs respectively. In Agra2, around 40% of the PHCs had auditory and visual privacy. In the present study, toilet facility, electricity and drinking water was found to be available at one third, half and two third of the health centers respectively. All urban centers had these basic amenities and 33.3% of the subcentres had only drinking water facility. Situation analysis report of Agra2 revealed that 80% and 40% of the PHCs had facility of drinking water and electricity respectively; only 16% subcentres had a provision for these two.

In the present study, availability of weighing scale (adult), needles and syringes was 100% while that of BP instrument, stethoscope, examination table, haemoglobinometer and fetoscope was in the range of 66 to 88%. In Agra2, needles, syringes, examination table, weighing scale and BP instrument were available at 50 to 80% of the PHCs. Among sub centers, B.P. instrument was available at 50% subcenters, examination table and stethoscope at 20%, while weighing scale was available only at 6% subcenters. In rural as well as urban centers, contraceptives, IFA tablets and vaccines (except BCG) were in adequate supply. Similar situation was reported at Agra2. IEC material was available at 50% rural centers and 33.3% urban centers. However, the health providers were not using the available material for counselling purposes. Khan3 et al (1996) also reported non-utilisation of available health education material.

Technical skills of health providers:

Recording of medical history, FHS and fundal height was done in less than quarter of the cases and antenatal care was confined to recording of obstetric details, distribution of IFA tablets and administration of TT vaccine. Inspite of availability of equipments, weight and B.P. was recorded in 43.3% and 4.4% cases respectively. Similarly, ICMR4 has also reported that all the elements of the antenatal examinations were mostly not performed at all. Murthy5 reported 46% of women receiving a complete check-up and 50% of antenatal cases meeting the criteria of technical quality. Few clients were told about danger signs, place/person for delivery, nutrition and rest and every third client was referred for routine investigations. None of the client was encouraged to ask questions. Wickramasurya6 also observed dissemination of inadequate information and Gandotra7 found few ANMs to be aware of the importance and need of education on proper nutrition.

All elements of natal services were performed properly at PHCs and maternity centers. Inspite of it being an important service, it was unavailable at two of the additional PHCs, subcenters and health posts. As compared to 70% urban clients, only 40% rural clients were advised on breast feeding; similar to findings of Gulati8.

Very few mothers and newborns got adequate postpartum examination at urban centers while it was totally absent at rural centers. Similarly, World Bank9 also observed that very few women get adequate postnatal care. In the present study, health benefits of breast feeding were told to 36.5% clients but the method of breast feeding was explained to only 1.3% clients. Only 13.5% clients were advised on importance of breast feeding during illness and none of them was advised on weaning practices. Education on proper diet was provided to very few clients. Gulati8 reported only 14.4% women being advised on breast feeding while Gandotra7 et al, found few ANMs to be conversant with the importance of education on proper nutrition and breast-feeding. During the study, all newborns were verified for BCG immunization. Methods of family planning were discussed, with half of the clients. World Bank9 observed the ANM's visits during postnatal period to be more focussed on family planning and child immunisation rather than on mother's health.

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