Quality of perinatal care in the Western Province of Sri Lanka: application of qualitative methods for service evaluation

Abstract

The perinatal period continues to present challenges to the delivery of effective maternal and child care in the South Asian region. Even though we have achieved favourable statistics in antenatal care in Sri Lanka, this fail to highlight the inadequacies in quality of care provided especially during labour and delivery. Traditionally maternal and childcare has been evaluated using outcome measures such as maternal mortality rate and neonatal and infant mortality rates. However as these rates start falling and stagnating it has become increasingly difficult to use them in a meaningful manner for evaluation of services. A qualitative inquiry was undertaken to evaluate quality of peri-natal care in selected hospitals in western province from patients' perspectives and the usefulness of qualitative methods in service evaluation. A descriptive cross sectional study was done using qualitative methods (naturalist inquiry). A naturalistic inquiry approach was used as it was necessary to study variations in program implementation as this varies over time as participants and conditions change. Women attending state sector hospitals for labour and delivery during the study period and/or women who have delivered in one of these institutions within the study period were the study population. In-depth interviews were conducted with 20 mothers in the immediate post-natal period. Maximum variant sampling was used to select a socio-culturally diverse group from selected tertiary care hospitals in the area. Interview recordings were transcribed verbatim, content analysed and emerging themes discussed from a theoretical perspective. All twenty women were all with post natal mothers who had delivered without any complications. Many of the interactions as described by the mothers demonstrated confidence in the care giver especially the medical officers and in the majority of cases it was a positive trend where they felt that the doctor knows the best and is doing the best. Dependence on the care giver was also common in most descriptions and again this was mostly a positive dependence as well as assistance - most of them had described being helped through4he process. When the descriptions are examined it was also seen that they talk about the relationship with the care giver and the closeness of that relationship is often described in a negative tone meaning that it lacking in most interactions. The care givers except for some instances most often appear distant and there is no evidence of an attempt at relationship formation with the mothers. 31 Mothers' awareness of the process and outcome from the time of admission to delivery were low, despite pervious experiences of birth. Instructions; verbal and implied, given by the health care workers are carried out without question, discussion or processing. Patients lack control of the process and opportunities to express their views. However, this is deemed unnecessary as 'they can do no harm' and 'they are the experts'. When analyzing the present data set a recurring distinct concept was 'hero worship'. Hero worshipping the healer was evident across the social divide, reinforced by the attitude of care givers. This phenomenon is likely to affect quality assessments; especially in peri-natal care, as child birth is considered a 'gift from the gods' itself. Qualitative methods can be useful in programme evaluation, especially to capture its complexities and idiosyncrasies from a holistic perspective.