Evaluation of utilization of maternal and child health services in el-minia district



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EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Kamel et al


EVALUATION OF UTILIZATION OF MATERNAL AND CHILD HEALTH SERVICES IN EL-MINIA DISTRICT
By

Emad G. Kamel*, Hala I Awadalla**,

Eman M. Mahfouz* and  Tahany M. Refaat*

Departments of *Public Health, El-Minia Faculty of Medicine,



**Institute of Environmental Studies & Research, Ain Shams University
ABSTRACT:

Background: Like many countries, Egypt faces difficult choices in trying to meet the rising demands and expectations of its population. Appropriate primary care is essential for Egypt to develop an efficient and equitable national health care system, as well as the best way of meeting many of the important health needs of the majority of Egyptians. Recent surveys show that antenatal care coverage remains insufficient, and that much of the care that is provided is given by private practitioners. Primary health care centers provide outpatient health care and primary preventive activities for people in general and for mothers and children in particular.  Medical care aims not only to improve health status but also to respond to patients' needs and wishes and to ensure their satisfaction with care. Patient-health provider relationship is a central feature of primary care.

Objectives: to examine key indicators of the Maternal and Child Health (MCH) services in particular utilization pattern in urban and rural health centers in El-Minia and to explore client's satisfaction with MCH services and reasons leading to the gap between satisfaction and utilization in randomly chosen urban and rural health centers in El-Minia district.

Design: Cross sectional descriptive study.

Method: The study is a cross sectional descriptive study conducted among two MCH centers randomly selected from El Minia district MCH centers, this study included 400 female clients; 200 from each center. An anonymous questionnaire was designed by the research team to assess the utilization of the provided services as well as clients' satisfaction. The clients' satisfaction part of the questionnaire included 5 items: waiting time, environment, doctor-client interaction, nurse-client interaction, economic feasibility. Assessment of clients' satisfaction was done using a scoring system rated by three levels of response categories: satisfied, accepted and dissatisfied. A Pareto chart was drawn according to the frequency of each category showing the level of 80% cumulative percentage as cutoff that identifies the corresponding factors related to dissatisfaction. 

Results: The study showed that the rural center had higher frequency of attendance regarding the curative services, AnteNatal Care (ANC) and delivery care while the urban center had higher attendance as regard family planning service. Despite higher utilization of the rural center, histories of abortion and under 5 years moralities were more prevalent among customers of rural center than those of urban center and clients of the urban center reported more satisfaction than those of the rural one. The most common causes of dissatisfaction were long waiting time and improper environment. Nearly 15% of deliveries of clients of rural center were attended by non skilled personnel, about half of the attendants of the family planning section used intrauterine device as a method of contraception.

Conclusion: MCH centers provide a lot of services for the mothers and their children, the majority of the attendants satisfied with the services however the most common reason of dissatisfaction was the long waiting time.

Recommendations: encouraging and rewarding of any health facility which fulfill the highest rate of attendance and clients' satisfaction, reduction of the waiting time, attention should be directed to the environmental conditions of the rural center.

KEY WORDS:

Family planning Delivery

Clients' satisfaction Pareto chart.



INTRODUCTION:

The quality of care delivered by Maternal and Child Health (MCH) facilities in Egypt is perceived by the public as poor, which explains underutilization despite unusually good coverage. Utilization rates vary significantly by region and urban/rural areas where individuals lived. The utilization of some essential health services is critically low. Many Egyptian mothers do not receive antenatal care, and only 39% of births received antenatal care (ANC), Egyptian Demographic and Health Survey, EDHS, 1995. In rural areas, this proportion is only 15% and, overall, 70% of deliveries take place at home with 46% of these receiving assistance by a trained professional (EDHS, 1995). Sixty-five percent of deliveries took place in a health facility, with delivery care provided somewhat more often at private than governmental facilities. (EDHS, 2005)


Quality of care and client satisfaction are interrelated concepts. According to
Donabedian (1982) “the degree of quality is the extent to which the care provided is expected to achieve the most favorable balance of risks and benefits”. The more commonly accepted approach for health care quality assessment is “structure, process and outcome” model.

Evaluation is the systematic collection of information about active-ties and characteristics of a program to make judgments about its effectiveness and can also help gain community support, generate ideas about how a program can be more effective, and contribute to overcoming resistance to its implementation (Evaluation Toolkit for Integrated Health Information Systems, 2007).

 

High attendance rate does not necessarily signal that the program is performing in an adequate fashion. Studies have revealed positive correlation between patient satisfaction and health care utilization: a more satisfied patient seeks health care more frequently (Deccache, 1997 & Naomi, 2006).


Maternal and Child Health are mandated to provide antenatal care, labor and delivery, postnatal care, and early childhood health services. Changes in the availability of many dimensions of health services provide the means to influence contraceptive use that limit childbearing. Findings show that family planning as well as maternal and child health services have independent effects on the rate of childbearing, for example, the provision of child immunization services increases the rate of contraceptive use to limit fertility independently of family planning services (Brauner-Otto, et al.,2007).

  

Utilization of health services is affected not only by access but also by demand for services, which is determined largely by socioeconomic factors, personal health beliefs, and perceptions of illness. Programs that maximize quality as well as access to services enhance client satisfaction, leading to greater utilization (Koenig and Khan, 1999)


About 50% of children one year old in developing countries die during the first month of life, and 97% of all infant deaths occur in developing countries. Major factors contributing to these deaths are the mother's poor health before and during pregnancy, unhygienic childbirth practices, and inadequate care after delivery. Of the estimated 500,000 women who die each year from causes related to pregnancy and childbirth, 99% are from developing countries. The main causes of maternal mortality are postpartum hemorrhage, inappropriate timing and spacing, too many pregnancies, unsafe abortion, and insufficient prenatal care and care during delivery (WHO, 1990). In countries with high fertility, major reductions in maternal and infant deaths result from reductions in the number of pregnancies through family planning and from improved obstetric care (Walsh  et al., 1994).

 

The focus of family planning programs has shifted away from an emphasis on controlling fertility towards helping individuals achieve their reproductive goals (Maharaj & Munthree, 2005). Maternal and child health care services are usually provided by primary health care centers and by maternal and child health care and family planning units. The staff of these health facilities are responsible for determining and following up women of reproductive age living in their working area, improving the use of family planning methods, identifying and following up pregnant and postpartum women and infants and carrying out immunization (Aslan et al., 2004).



 

The aim of this study is to examine utilization pattern of Maternal and Child Health services in urban and rural health centers in El-Minia district and exploring factors affecting client dissatisfaction of the services provided by the two centers.

 

SUBJECTS AND METHODS:

  The study is a cross sectional descriptive study conducted among two MCH centers randomly selected from El Minia district MCH centers. El Minia city is the capital of El Minia governorate which is one of upper Egypt governorates located at 240 Kilometer to the south of Cairo . The first center was selected to represent the urban area (called Eastern Health Unit) and the second one was selected to represent the rural area (called Nazlet Ebead Health Unit). This study included 400 female clients; 200 from each center during the period from September 2007 to November 2007.


Revision of health records in each center before starting the study revealed that in the urban center, 59.1% of clients attended the center for their baby immunization, 13.7% attended for sick-child services, 17% attended for family planning and 10.2% attended for antenatal care. On the other hand, in the rural center, 48.3% of clients attended the center for their baby immunization, 18.4% attended for sick-child services, 22.1% attended for family planning and 11.2% attended for antenatal care. According to the utilization pattern in the records, the sample was proportionately divided into: 100 clients attended the center for their children immunization, 30 clients for sick-child care, 40 clients for family planning services and 30 clients for antenatal care.
The research team conducted the interview in 2–3 consecutive days every week in each center. Although it is not usual for a woman to visit the health care center in consecutive days, the researchers asked each new participant who accepted to participate in the study if she had interviewed today or days before to avoid repeated participation of the same subjects, there were no refusal to participate.

 

An anonymous questionnaire was designed by the research team to assess the performance of the provided services as well as clients' satisfaction, it was constructed with the aid of the previous literatures about MCH services and patients' satisfaction and it was validated by experts in this field. Every participant was asked about personal history, past history of abortion, under five years mortality and her satisfaction about the services provided by the center. The clients' satisfaction part of the questionnaire included 5 items: waiting time, in minutes (for ticket taking, clinical examination, laboratory investigation and drug taking), environment (cleanliness, temperature, lighting, noise and ventilation), doctor-client interaction (interest to client questions, explanation of  the health problem, technical experience and explanation of the treatment), nurse-client interaction (care of the client, interest in client questions, technical skill and time of response to client), economic feasibility (price of traffic method, ticket, laboratory service and prescribed medication). Permissions were obtained from the director of each of the centers involved in the study.



 

Assessment of clients' satisfaction was done using a scoring system rated by three levels of response categories: satisfied was representative of very good perceived quality of services, accepted for good quality and dissatisfied for below good quality of services. A pilot study was carried out on 40 clients (not included in the study) in order to identify any difficulties in understanding or completing the questionnaire. Modification of the questionnaire was done according to the results of the pilot study.


The total frequencies of different items scored below good were calculated. The frequency of each category was counted, this represented the left vertical axis "Frequency" where the count of each category will appear. After descending ranking of the different categories for each center, the cumulative percentage was calculated. Each category's cumulative percentage was the percentage for that category added to the percentage of the category of larger category before it, this represented the right axis from 0 to 100%, the different categories appeared on horizontal axis, Excel program was  used for Pareto analysis formulation. A pareto chart was drawn according to the frequency of each category showing the level of 80% cumulative percentage as cutoff that identifies the corresponding factors related to dissatisfaction. 

 

Statistical analysis was carried out using Statistical Package for Social Sciences (SPSS) Statistical Software version 13 (SPSS Inc., Chicago, USA). Qualitative data are presented as frequencies and percentages, while quantitative data are presented as mean ± standard. Chi-square, t test and test of proportion were used to calculate p values. P values less than 0.05 were considered as statistically significant. 


RESULTS:

This study included 400 female clients; 200 from urban area and 200 from rural area in El-Minia district. The mean age of mothers in the urban center was 27±3.1 and in rural center was 26.6±3.6 with no significant difference between the two centers (t=1.19, p=0.12). It was found that 55% of urban mothers read and write compared to 65% of rural mothers, while highly educated mothers (university level or above) were 10% of urban mothers and 5% of rural mothers. These differences were not statistically significant (χ2=5.04, p=0.08). Urban mothers had lower number of children than rural mothers (3.2±1.1 vs 4.1±2.3) this difference was statistically significant (t=4.99, p=0.002).

 

Table (1) clearly shows that the outcome indicators chosen for evaluation of MCH services as abortion rate and under five mortality rates were better in urban than rural ones since women who experienced previous abortion were (18.5% and 25% respectively). This difference was statistically significant (p=0.04), while the under 5 years mortality percent was 8% in the urban center and 11.5% in the rural center (p>0.05).



 

Nearly one-third of urban women (33.5%) used to utilize MCH for curative services in comparison to slightly less than two-thirds (61.5%) of the rural women who used to do so. Thirty percent of urban women and 17% of rural counterparts used general hospitals for curative services instead of MCH ones. Private doctors were attended by 34.5% of urban clients and 18.5% of rural clients. The difference between the two groups were highly statistically significant, table (2).

 

Table (3) represented the utilization pattern of the health centers for maternal services. Six women from the urban center and five from the rural center came for antenatal care during the current research in their first pregnancy. It was found that only 38.7% of urban women and 50.7% of rural women attended the centers for antenatal care services during the previous pregnancy. About fifth of the rural women and 14.9% of urban women did not receive any form of antenatal care. About half of the urban women and one fourth of the rural women preferred other health care centers for antenatal care. Minority of urban women (8.8%) and only 16.9% of rural women reported delivery of their last pregnancy at the studied centers. The results also showed that 18% of deliveries among urban women and 40% among rural women were not attended by doctors. Non professional personnel were involved in 4% and 14.9% of deliveries in urban and rural women respectively. The overall utilization pattern of antenatal care among the two centers showed statistical significant differences.



 

Concerning utilization of family planning services (n= 40 in each center), the results revealed that the majority of women got their contraceptive methods from the centers (97.5% of the urban center and 87.5% of the rural center). Intrauterine device was used by nearly half of women in both centers. Injectable hormones were the second commonly used method among urban and rural women (35% and 42.5% respectively). The most common recorded reason for contraception use was for limiting the number of children (57.5% in urban center and 70% in rural center), while 40% of urban women and 25% of rural women were using contraceptive methods for proper spacing between pregnancies, table (4). There were no significant differences between the two centers regarding methods, sources of contraceptives and reasons for use among attendants for family planning services.

 

Women attending different clinics for preventive and curative maternal and child health services were expected to receive a set of services at each clinic. There was no significant difference between urban and rural clients as regard weighing and clinical examination. Health education was provided for urban clients (87.5%) more than rural clients (70.5%) (p<0.001), table (5). Measuring blood pressure, laboratory investigation and tetanus toxoid vaccination was provided for majority of clients attending antenatal care clinic in both centers, table (6)



 

Perception of the attendant women toward the health provider’s interaction was highly satisfactory, about 92% for urban center, table (7) and about 89% for rural center, however half of the women (50%) in the urban center and nearly one fourth (25.5%) of women in rural center were not accepting the time they waited.


As depicted in table (8) that as satisfaction score grades increased the utilization rates of both curative and natal services provided by the MCH centers significantly increased. There was an obvious trend. Still, as satisfaction score increase the utilization of antenatal care increase.
Two Pareto charts  were drawn for the two centers, according to Pareto rule; the first items ranked by order were identified as the most important factors causing patients dissatisfaction. The frequency of each category identified below good was counted. The most common cause of dissatisfaction (about 20% of the studied factors) among attendants of the urban center was the long waiting time, figure (1) while the identified factors of dissatisfaction among attendants of the rural center were long waiting time and improper environment which represented about 35% of the studied factors. figure (2)


Table (1): History of abortion and under five years mortality among the study groups

in the two centers in El-Minia district in 2007




Urban_center__No_(%)__Rural_center__No_(%)'>Centers__Service__Urban_center__No._(%)__Rural_center'>Centers__History_of__Urban_center__No_(%)__Rural_center'>Centers

History of

Urban center

No (%)

Rural center

No (%)

z-test

p

Abortion:

Yes

37 (18.5%)

50 (25%)

1.70

0.04

No

163 (81.5%)

150 (75%)

1.58

0.06

Total

200(100%)

200(100%)

 

<5 years mortality:

Yes

16 (8%)

23 (11.5%)

1.18

0.12

No

184 (92%)

177 (88.5%)

1.18

0.12

Total

200(100%)

200(100%)

 

 
Table (2): Types of health care facilities utilized by mothers for MCH services in the

two centers in El-Minia district in 2007




                                 Centers

Health Facility

Urban center

No. (%)

Rural center

No. (%)

Health center

67 (33.5%)

123 (61.5%)

General hospital

60 (30%)

34 (17%)

Private doctor

69 (34.5%)

37 (18.5%)

Others

4 (2%)

6 (3%)

Total

200(100%)

200(100%)

χ2= 33.76                  p= 0.001

 

Table (3): Utilization pattern of maternal health services by the study group for the last pregnancy in the two centers in El-Minia district in 2007


                                            Centers

Service

Urban center

No. (%)

Rural center

No. (%)

Ante Natal Care:

             At the center

             Other health care center

             Never attended



 

75 (38.7%)

90 (46.4%)

29 (14.9%)



 

99 (50.7%)

54 (27.8%)

42 (21.5%)



Total

194*(100%)

195* (100%)

χ2= 14.69                  p= 0.001

Delivery at the center:

                      Yes

                      No


 

17 (8.8%)

177 (91.2%)


 

33 (16.9%)

162 (83.1%)


Total

194* (100%)

195* (100%)

χ2= 5.78                 p= 0.016

Last delivery was attended by:

                      Doctor

                      Nurse or midwife

                      Non-professional



159 (82%)

     27 (13.9%)

     8 (4.1%)


              117 (60%)

49 (25.1%)

29 (14.9%)


Total

194* (100%)

195* (100%)

χ2= 24.68                  p= 0.001

*Only available data

 

Table (4): Methods, sources of contraceptives and reasons for use among attendants for family planning services in the two centers in El-Minia district in 2007




                                             Centers

Variables

Urban center

No. (%)

Rural center

No. (%)

Method:   

                        IUD

                        Pills

                        Injectable



 

            22 (%55)

4 (10%)

14 (35%)


 

17 (42.5%)

6 (15%)

 17 (42.5%)



Total

40 (100%)

40 (100%)

χ2= 1.33                   p= 0.51

Given by the center:

                        Yes

                         No


 

39 (97.5%)

1 (2.5%)


 

35 (87.5%)

  5 (12.5%)


Total

40 (100%)

40 (100%)

χ2= 2.88                   p= 0.09

Reasons for use:

                         Limiting number

                         Spacing

                         Medical reasons



 

23 (57.5%)

           16 (40%)

             1 (2.5%)



 

28 (70%)


10 (25%)

2 (5%)


Total

40 (100%)

40 (100%)

χ2= 2.2                   p= 0.33


Table (5): Comparison between urban and rural client regarding health services provided by the two centers* in El-Minia district in 2007


                                         Center

Service

Urban center

No (%)

Rural center

No (%)

z-test

P

Weighing

80 (40%)

75 (37.5%)

0.51

0.30

Clinical examination

67 (33.5%)

67 (33.5%)

0.00

0.50

Health education

175 (87.5%)

141 (70.5%)

4.17

0.001

* n=200 in each group

 


Table (6): Comparison between urban and rural client regarding Ante Natal Care

services provided by the two centers* in El-Minia district in 2007




                               Center          Service

Urban center

No (%)

Rural center

No (%)

z-test

p

Blood pressure

29 (96.7%)

27 (90%)

1.04

0.15

Laboratory investigation

28 (93.3%)

26 (86.7%)

0.85

0.20

Tetanus Toxoid vaccination

28 (93.3%)

27 (90%)

0.46

0.32

* n=30 in each group
 Table (7): Comparison between urban and rural client satisfaction for different

categories in El-Minia district in 2007




          Satisfaction      
Categories

Satisfied (very good)

Accepted (good)

Dissatisfied  (poor)

Urban

(n=200)

Rural (n=200)

Urban

(n=200)

Rural (n=200)

Urban

(n=200)

Rural (n=200)

Waiting time

94

(47%)


139

(69.5%)**



6

(3%)


10

(5%)


100

(50%)


51

(25.5%)**



Environment

136

(68%)


169

(84.5%)**



32

(16%)


7

(3.5%)**


32

(16%)


24

(12%)


Doctor-client interaction

190

(95%)


179

(89.5%)*


6

(3%)


16

(8%)*


4

(2%)


5

(2.5%)


Nurse-client interaction

184

(92%)


178

(89%)


11

(5.5%)


18

(9%)


5

(2.5%)


4

(2%)


Economic feasible

185

(92.5%)


172

(86%)*


4

(2%)


5

(2.5%)


11

(5.5%)


23

(11.5%)*


* p<0.05 ** p<0.001
Table (8): Relation between client satisfaction and utilization of selected health services in the

two centers in El-Minia district in 2007




               Satisfaction  
Utilization

Satisfied (very good)

Accepted (good)

Dissatisfied  (poor)

Total

No. (%)

No. (%)

No. (%)

No. (%)

Curative services

At the center

Outside the center

98 (51.6%)

69 (32.6%)

73 (38.4%)

102 (48.6%)

19 (10%)


39 (18.8%)

190* (100%)

210* (100%)


χ2= 15.78                    p= 0.001

Ante Natal Care:

At the center

Outside the center

141 (81%)

161 (74.9%)

21 (12.1%)

32 (14.9%)

12 (6.9%)

22 (10.2%)

174* (100%)

215* (100%)


χ2= 2.25                   p= 0.32

Delivery:

At the center

Outside the center

30 (60%)


285 (84%)

12 (24%)


35 (10.3%)

8 (16%)


19 (5.7%)

50* (100%)

339* (100%)


χ2= 16.65                   p= 0.001

*= Only available data


Figure 1: Pareto chart for client satisfaction in urban center in El-Minia district in 2007



Figure 2: Pareto chart for client satisfaction in rural center in El-Minia district in 2007




DISCUSSION:

  Population growth is a major challenge in most developing coun-tries. This high rate of growth is the result of an imbalance between infant mortality and fertility (Youssef, 2005). In Egypt growth rate was 1.9 (WHO, 2005), so this study was conducted on two MCH centers to identify the pattern of utilization of MCH services and determine the reasons of dissatisfaction of the clients.

 

About half million women in developing countries die annually due to pregnancy and childbirth. Maternal mortality risk in the poorest countries can be 200 times that of developed countries. Inappropriate timing and spacing, too many pregnancies, unsafe abortion, and insufficient prenatal care and care during delivery contribute to high maternal mortality in developing countries (WHO, 1990). The current study showed that one fourth of the females attended rural center prev-iously experienced abortion, however this figure was higher than that of the urban center (18.5%), this result can be explained by a multitude of factors as higher prevalence of consanguinity in rural than urban area, prevailing anemia among rural women, work over load of rural women and low coverage by antenatal care. Yassin (2000a) reported a higher prevalence of abortion in rural upper Egypt (40.6%). In Alexandria, consanguinity frequ-ency was 68.8% among couples with reproductive losses (Mokhtar & Abdel-Fattah, 2001).



 

  The most common reasons for taking children to a private physician in cases of serious illness rather than to a physician at a government health clinic were confidence in physician's ability and convenience (Herman et al.,1994). In this study about one third of mothers in the urban center and 18.5% of mothers in the rural center consulted private doctors for curative services, this difference might be attributed to economic abilities.

 

The first-time mother's coping with child care is affected by the social support received from their social network and from the public health nurses at the child welfare clinic (Tarkka et al., 1999). Egypt began training of physicians in case manage-ment of diarrhea and acute respiratory infection in the 1980s and 1990s respectively (Langsten et al., 2005), under five years mortality was 26.2/1000 live births (WHO, 2005), however in a study carried out in upper Egypt, Yassin (2000b) reported that under five years mortality rate was 130.8 per 1000 live births and the leading causes of mortality were: diarrhoeal diseases (39.4%), acute respiratory infection (26.8%), comb-ined episode of both (5.1%), febrile illnesses including meningitis (10.6%), neonatal causes (12.6%), and accidents (2.5%). Diarrheal morbidity is still unacceptably high in rural Upper Egypt. The current study revealed that 11.5% of  attendants  of rural center and 8% of  attendants  of urban center gave history of under five years mortality.



 

The most cost effective mix of interventions were chosen by WHO, these were  the community based newborn care package, followed by antenatal care (tetanus toxoid, scree-ning for pre-eclampsia, screening and treatment of asymptomatic bacteriuria and syphilis); skilled attendance at birth. (Adam et al., 2005). In Egypt the coverage of ANC was 70% (WHO, 2005), in this study about fifth of the rural women and 14.9% of urban women did not receive any form of antenatal care. In rural center about 50% of ANC and 16.9% of deliveries were done at the center while in urban center 38.7% of ANC was done in the center and 46.4% of ANC was done in other health facility and only 8.8% of deliveries were carried out in the center. About 60% of mothers used curative services in the rural center and about one third of the studied sample in the urban center used this services which indicate higher utilization of the rural than the urban center.

 

A trained person attends only 20% of births in developing countries (WHO, 1990). In Egypt 73% of births was attended by skilled health personnel (WHO, 2005), the results of this study showed that most of deliveries of clients of the urban center were attended by health personnel while in rural center, about 15% of deliveries were attended by non professional birth attendants.



 

Contraception use increases the birth interval by increasing the time until the next conception with a subsequent decline in fertility (Youssef, 2005). Numerous commonly used medical contraception methods have been presented, most of them are described only in general. The importance of selecting a method individually for every patient, taking into accounts her request, efficacy and safety of the method, was particularly emphasized (Debski, 2007).

 

The most common used method of contraception was intrauterine device (IUD), followed by the injectable then the least method was the pills, in a study carried out in urban and rural areas of Khartoum state, contraceptive pills were the most frequently used method followed by intrauterine devices and injections (Ibnouf et al., 2007), in Kenya, the most frequently used method was contraceptive pills followed by injectable and IUD (Miller et al.,1991).



 

Living in a community, in which women have widespread health service contact, is related to both prenatal care use and subsequent modern contraceptive use (Zerai & Tsui ,2001). The majority of urban women (97.5%) and rural women (87.5%) were given the contraception methods by the center which reflected high utilization of family planning sections. The most common reason for using contraception was limiting number of children, this was in agreement with another study conducted in Egypt, it showed that families required better quality of health used MCH for limiting family size (Ahmed  & Mosley, 2002). In India, majority of women (70.5%) used a family planning method for the first time only after completing their desired family size (Chandhick et al., 2003).

 

Service quality is an important determinant of use of clinical contraceptive methods in Egypt. Improving quality of family planning services may help further increase use of clinical contraceptive methods and reduce fertility (Hong et al., 2006). Health education is an important component of maternal and child health services, it promotes appropriate contraceptive use for better health of the mother and child. Counseling sessions improved the couples' knowledge and practice of contra-ception, integrating family planning counseling into antenatal care in all facilities were recommended by Soliman (1999).



 

Regarding health services provided by the two centers (weighing, clinical examination, health education,

laboratory investigation, tetanus vaccinetion and providing medicine for sick children), attendants of the urban center were generally more satisfied than attendants of the rural center, this result was in accordance with Maharaj & Munthree (2005) who found that clients visiting urban health facilities reported greater satisfaction with services than clients visiting rural health facilities

 

Patient satisfaction is an important component of the quality of care. In this study, it was found that as satisfaction score grades increased the utilization rates of curative, antenatal care and natal services provided by the MCH centers increased. Satisfaction is a function of the discrepancy between what is expected and what is perceived to be actually occurring. Therefore, it is imperative to identify patients' per-ceptions to assess the extent to which these ideals are met by their institutions. Various studies have concluded that satisfied patients are more likely to continue using the medical care service, to maintain the relationship with a specified provider and to comply with medical regimen. (Fan et al., 2005).


The present study considered that rating below good are rating of dissatisfaction, about 92% of attend-ants of urban center reported that they satisfied about doctor-client interaction , nurse client interaction and  economic feasibility of the service. In rural center about 89% of attendants satisfied with doctor-client interaction and nurse client interaction. These results were in agreement with a similar studies in other countries such as in Ethiopia (Melkamu et al., 2005) and in Sri Lanka (Senarath  et al., 2006) who reported that interaction between service providers and patients were important in client satisfaction toward the provided services.
Patient satisfaction with nursing care quality is an important indicator of the quality of care provided in hospitals (Laschinger et al., 2005). A study by Cleary et al., (1989) found nursing care to be the most important factor for evaluation of patients' satisfaction with care. Cleary's finding was supported by results from a survey conducted by Koska (1989), where 97.3% of 663 chief executives interviewed ranked nursing care as the top factor in quality of patient care

 

Pareto analysis is named after Vilfredo Pareto, an Italian economist who presented a formula that showed that income was distributed unevenly, with about 80% of the wealth in the hands of about 20% of the people. In a similar way, a disproportionately large percentage of errors or defects in any process are usually caused by relatively few problems (Bonacorsi, 2007). So, it allows the user to focus on a few important factors in a process (Abd El Hamid et al., 2005) and thus screen out the less significant factors. Pareto chart method was successfully used for analysis of highly aggregated and complex data on hospitalizations of patients, (Mayer et al., 2005),  it is a tool  to identify the key issues constrai-ning performance (Seltzer et al., 1994).


Pareto chart applied in the current study identified factors related to  client dissatisfaction, in the two centers. Long waiting time was an important cause related to dissatis-faction, this was in accordance with (Baraitserp et al., 2003) and (Askew et al.,1994), longer waiting time progre-ssively diminished satisfaction (Meuwissen et al., 2006). In rural center another factor was added which

was the environment, this was in agreement with Senarath  et al, (2006) who reported lower satisfaction rates with physical environment.

 

CONCLUSION:

From this study it was concluded that rural center had higher frequency of attendance regarding the curative services, ANC and delivery care while the urban center had higher attendance as regard family planning service. Despite higher utilization of the rural center, histories of abortion and under 5 years moralities as an indication of maternal needs to special health care were more prevalent among customers of rural center than those of urban center and clients of the urban center reported more satisfaction than those of the rural center. The most common causes of dissatisfaction that need to be modified were long waiting time and improper environment. Nearly 15% of deliveries of clients of rural center were attended by non skilled personnel, about half of the attendants of the family planning section used intrauterine device as a method of contraception.


RECOMMENDATIONS:

- Encouraging and rewarding of any health facility which fulfill the highest rate of client attendance and satisfaction

- Improving quality of care which increase client satisfaction by reduction of the waiting time through increasing the human resources (doctors, nurses and technicians) and by arranging appointments for the clients.

- Upgrading the health services at the rural center, specific attention should be directed to the environmental conditions of the center and availability of medication

- Health education about the importance of safe delivery that should be attended by skilled person, this message can be provided through local television channels of upper Egypt governorates.

 

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تقييم استخدام ورضاء المنتفعين بالخدمات الصحية لمراكز رعاية الأمومة

والطفولة في مركز المنيا
عماد جرجس كامل*- هالة عوض الله** - إيمان محفوظ* - تهاني رفعت*

*قسم الصحة العامة – كلية طب المنيا

**معهد الدراسات البيئية والبحوث – جامعة عين شمس
 

تقدم مراكز الرعاية الصحية الأولية ومراكز رعاية الأمومة والطفولة الخدمات الوقائية للمستخدمين وتهدف هذه المراكز إلى الارتقاء بالمستوى الصحي وكذلك تحقيق رضاء المنتفعين عن الخدمة المقدمة. تهدف هذه الدراسة إلى التعرف على نمط استخدام الخدمات المقدمة من هذه المراكز وكذلك تحديد العوامل التي تؤثر على مدى رضاء  المنتفعين بهذه الخدمات عن مستوى الأداء. وقد أجريت هذه الدراسة في مركزين من مراكز الأمومة والطفولة بمركز المنيا تم اختيارهما عشوائيا وكان حجم العينة 400 من المترددين على المركزين لتلقى خدمات تنظيم الأسرة و متابعة الحمل و كذلك خدمات رعاية الطفل. وتم التعرف على آراء المستخدمين لهذه الخدمة وعن مستواها و الأسباب التي تؤثر على هذا المستوى. وقد أوضحت النتائج أن استخدام المركز الريفي كان أكثر بالنسبة للخدمات العلاجية و رعاية الحمل و الولادة بينما كان التردد على المركز الحضري أعلى بالنسبة لخدمات تنظيم الأسرة. وكانت اللولب أكثر الوسائل استخداما لتنظيم الأسرة و أن 15% من الولادات بين المترددات على المركز الريفي تتم في عدم حضور أيا من أفراد الفريق الطبي المدرب و كان أهم أسباب عدم رضاء المنتفعات عن الخدمة المقدمة هو طول فترة الانتظار وأوضحت الدراسة وجود علاقة بين رضاء المنتفعات ونسبة استخدام الخدمات الصحية المقدمة.  و قد أوصت الدراسة بالاهتمام بالخدمات المقدمة بهذه المراكز و تقصير  مدة الانتظار عن طريق زيادة عدد أفراد الفريق الطبي وتنفيذ نظام الحجز والمواعيد وكذلك أهمية وجود أحد أفراد الفريق الطبي في أثناء الولادات وإلزامهم بذلك و يمكن أن تقدم هذه الرسالة من خلال القنوات التليفزيونية المحلية التي تخدم إقليم الصعيد وتقديم الحوافز للمراكز المتميزة في هذا الصدد.





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