Journal of Primary Care and General Practice

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Research Article - Journal of Primary Care and General Practice (2021) Volume 4, Issue 3

Consumer's satisfaction with integrated maternal, neonatal and child health (IMNCH) services in model primary health care centers in Najaf District, Iraq.

Abdulkareem A Mahmood1*, Mohammed Zaidan2, Ahmed S Noory3, Ali k Hoesh1, Sara H Naeem1, Qamar T Hamed1, Aseel S. Abbas1, Eman R Mahdi1

1Department of Family and Community health, University of Kufa, Iraq

2Department of internal medicine, Directorate of Health in Najaf, Iraq

3Department of Community health, College of Health and Medical Technology, Kufa, Iraq

Corresponding Author:
Abdulkareem A Mahmood Al Radhi
Department of Family & community medicine
Faculty of Medicine, University of Kufa Iraq
E-mail: [email protected]

Accepted date: May 17, 2021

Citation: Mahmood AA, Zaidan M, Noory AS, et al. Consumer's satisfaction with integrated maternal, neonatal and child health (IMNCH) services in model primary health care centers in Najaf District, Iraq. J Prim Care Gen Pract. 2021;4(3):84–89.

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Abstract

Introduction: The integrated program of maternal and child health is promoting, preventing, therapeutic and rehabilitation facility or care for mother and child. Some primary health care centers were developed by Ministry of Health to be ideal and considered model centers to provide standard health care services which prepared to be family health adopted centers. Objectives: To evaluate the integrated maternal ,neonatal and child health (IMNCH) services in model primary health care centers in comparison with traditional non-model centers through consumers' satisfaction . Methods: A cross sectional survey of consumers to measure their satisfaction through December 1st 2017 to February 25th 2018 .The study conducted in six PHC centers ,three model and three non-model primary health care center from districts of North and south Najaf city . Three sections of a well prepared questionnaire had been applied including interviewing overall satisfaction with the IMNCH services provided by selected centers. A convenient sample of 240 consumers was selected and directly interviewed for data collection. Result: About 97% of attendants were unsure of their satisfaction with premarital examination and 65.4% found satisfied with diagnosis of pregnancy. High rate of satisfaction (82.5%) was reported in tetanus immunization provided to pregnant women. About 89 % of consumers were satisfied with antenatal services; weight, height measurement, and blood pressure measurement. Nearly half of clients (49.6%) were satisfied with breast examination services. Only 46 clients (19.2%) reported satisfaction with treatment of mild pre-eclampsia /eclampsia and early referral by the selected PHC centers. Twenty-six clients (10.8%) were satisfied with management of post-partum psychosis. Very low rate of satisfaction (2.1%) was verified in screening and treatment of sexually transmitted illnesses provided in all the selected centers. Conclusion: The services of immunization and growth monitoring of children found more satisfied to consumers in addition to the basic antenatal services and assisting normal deliveries. Though other services need more improvement and reviewing principally premarital services, basic emergency obstetric care if referral is not possible, management of post-partum psychosis in addition to diagnosis and treatment of sexually transmitted illness.

Keywords

IMNCH, Primary health care, Integrated health services.

Introduction

The integrated program of maternal and child health is promoting, preventing, therapeutic and rehabilitative care for the mother and child. They aim to reduce maternal and child mortality and morbidity. In most countries, the maternal and child health program is a part of the general health services provided by the government. In many developed countries, very few mothers or babies die during the delivery process, unless there are pathological events beyond medical control, such as congenital malformations or rare unpredictable complications. However, in many developing countries, progress has not been so impressive [1].

The primary health care elements were suggested in Alma-Ata conference in 1978. Maternal and child health services include integrated management of neonatal and child health services and dispensaries. Primary health care(PHC) services provide both curative and preventive aspect of care. In 1986, Iraq started expanded program of immunization (EPI) and the number of centers increased rapidly [2] . The expansion in the PHC creates a need for various types of evaluation to measure the quality of the services provided, and to determine the extent to which their objectives have been achieved [3].

Client satisfaction is an expression of the gap between the expected and perceived characteristics of a service. Satisfaction is a subjective phenomenon and could be elicited by asking simply how satisfied or not the patients might be. Client satisfaction is a component of healthcare quality and is increasingly being used to assess medical care in many countries in the world [4]. Until recently, traditional assessments of medical care were done purely in important outcomes of health care services. Satisfied clients are more likely than unsatisfied ones to continue using health care services, maintain their relationships with specific health care providers, and comply with care regimens and advice. Modern healthcare systems are seeking to adopt a more client-oriented approach to the delivery of healthcare. With this paradigm shift, client satisfaction and quality of life are becoming increasingly as important as the more traditional clinic outcomes in the monitoring and evaluation of health- care delivery. The preventive care and referral system are the corner stone of public health in Iraq to reduce mortality and morbidity [4,5].

The Maternal and Child Health (MCH) programme is primarily directed at women who are pregnant, in labour or postpartum, and at the newborn, infants, and children. In most countries, the maternal and child health programme is part of the general health services provided by the government [6]. Routine maternal and child health services; routine MCH and family planning (FP) services are globally accepted interventions proven to be effective measures to improve maternal and child health. These are parts of the basic services that should be made available to women and children [7].

A review of literature reveals that there are several levels of health evaluation. The Iraqi ministry of health(MOH) , agrees on three main levels ; structure, process and outcome which were first proposed by Donabedian according to the world health organization (WHO), the components of the structure level in the evaluation consist of the resources in terms of health manpower, facilities and equipment [7,8]. Recent studies conducted in developing countries found considerable differences in the patterns of staffing and equipment's across the centers. The shortage or inadequacy in resources may play as a constraint in meeting the standards and achieving the objectives of IMNCH services. There are three main model PHC centers in Najaf District . These centers were developed by Ministry of Health to be ideal and considered model centers to provide standard health care services which prepared to be family health adopted centers [9].

Few studies were conducted in Iraq to evaluate PHC services and verified their quality in general and no such evaluation was done in Najaf specially the satisfaction with IMNCH services [10,11] . The current study is an attempt to study the quality and consumers satisfaction with these important integrated maternal and child health services in the selected model and traditional PHC centers in Najaf.

Methods and Methods

Study design

Evaluation study with a crosses sectional survey of consumers to measure their satisfaction.

Setting of the study

The study was conducted in six PHC centers three model PHC (Al-Hassan Al-Mujtaba, Al-Jamaa, Al-Amam AI-Jawad ) and three non-model PHC center ( Khawla Zwain, Al-Ansar, Al- Nasser) from districts of North and south in Najaf city. The study time frame was three months starting from December 1st 2017 to February 25th 2018.

Instruments (tools of study)

The process of evaluation was conducted through three interviewing sections to collected required data. The first; about demographical characteristics of mother and child and the second about Implementation of IMNCH(integrated management of maternal, neonatal and child health services) standards by districts. The third was about overall satisfaction with the IMNCH services provided by selected PHC centers.

Sampling design

The chients were randomly selected from six PHC centers in north and south Najaf districts with identical IMNCH units and the available structures, manpower ,resources and equipments. A sample of 240 consumers had been selected systematically at random (every fifth client) from the centers (40 consumers a part) to measure their satisfaction. The criteria for selection include Iraqi mothers with one child at least, having a file served by the center for a period of at least 6 months.

Ethical issues

Agreement of Directorate of Health in Najaf in addition to official consent of Public Health Department in the province. A verbal consent from each client of the sample was taken before interviewing by investigators including provided relevant information about the study objectives and confidentiality.

Data processing

Descriptive statistics was done to estimate the frequency and percentage of sociodemographic characteristics of the clients, resources availability and client satisfaction with the PHC centers services by applying SPSS version 24.

Results

The implementation of standard PHC services and principle structures showed no significant difference (P?0.05) between model and non-model primary health care centers in Najaf district. All mothers were satisfied (100%) with growth monitoring and vaccination services provided to their children in both model and model setting Table 1.

Primary Heath Care Centers Standard implementation ( 33 standards) Total
implemented partially implemented Not implemented
  *Al Hassan Al mujtaba Count 26 3 4 33
    % 78.8% 9.1% 12.1% 100.0%
*Al Jameaa Count 26 2 5 33
% 78.8% 6.0% 15.2% 100.0%
Khawla Zwain Count 24 6 3 33
% 72.7% 18.2% 9.1% 100.0%
Al Ansar Count 24 5 4 33
% 72.7% 15.2% 12.1% 100.0%
Al Nasser Count 25 5 3 33
% 75.7% 15.2% 9.1% 100.0%
*Imam Jawad Count 25 4 4 33
% 75.7% 12.1% 12.1% 100.0%
  *   Model PHC centers

Table 1: Standards implementation by selected model and traditional PHC centers structure (P> 0.05).

 

The interviewed mothers were 240 from them 151 (62,9%) within age group 20-29 years, 195(81.3%) were multigravida , and about two thirds of women reported moderate level of socioeconomic status. More than half of mothers attended the PHC centers seeking for vaccination schedule, and 233 (97.1%) received thier required services Table 2. The infants (n=240) of the selected mothers revealled 124 (51.7%) aged one to twelve months, 239( 99.6%) had growth chart and all of them had vaccination chart Table 3.


Maternal  variables
No. %
Mother age (Years)
(n=240)
10-19  18 7.5
20-29  151 62.9
30-39  62 25.8
40-49  9 3.8
Occupation employee 16 6.7
non employee 224 93.3
Education level illiterate 26 10.8
primary school 93 38.8
secondary school 86 35.8
university or more 35 14.6
Parity multigravida 195 81.3
primigravida 45 18.8
Husband age (Years)  < 30  121 50.4
30-39  83 34.6
40-49  30 12.5
= 50  6 2.5
Husband occupation Work 238 99.2
doesnot work 2 0.8
Socioeconomicclass good 48 20
moderate 159 66.3
low 33 13.8
Distance from PHC (Km) =1 200 83.3
>1 40 16.7
Smoking smoker 6 2.5
non smoker 234 97.5
Chronic disease yes 11 4.6
no 229 95.4
Reason for attendince vaccination 142 59.2
IMCI 35 14.6
pregnant care 10 4.2
treatment 50 20.8
others 3 1.3
Service received yes 233 97.1
no 7 2.9
Access per month <1 3 1.3
1 111 46.2
2 95 39.6
3 13 5.4
=4 18 7.5
Type of delivery normal delivery 129 53.8
cesarean section 111 46.2

Table 2:Distribution  of  sample according  to mother characteristics(n=240 ).

Newborn variables   N   %
  Gender Male 115 47.9
Female 125 52.1
  Age group 1-28 days 11 4.6
29 day  1 year 124 51.7
1-3  year 86 35.8
4-5  year 19 7.9
Having   growth  chart yes 239 99.6
no 1 0.4
Congenital disease  of the child yes 0 0
no 240 100
Chronic disease of the child yes 2 0.8
no 238 99.2
Having  vaccination chart yes 240 100
no 0 0

Table 3:Distribution of  sample according to newborn characteristics ( N=240).

About 97% of attendants were unsure of their satisfaction with premarital examination and 65 % found satisfied with diagnosis of pregnancy. High rate of satisfaction (82.5%) was reported in tetanus immunization provided to pregnant women. About 89 % of consumers were satisfied with antenatal services .weight, height measurement, and blood pressure measurement Figure 1, while only 50 % of clients were satisfied with breast examination services. Only 46 clients (19 %) reported satisfaction with treatment of mild pre-eclampsia /eclampsia and early referral by the selected PHC centers. Twenty-six clients (10.8%) were satisfied with management of post-partum psychosis. Very low rate of satisfaction (2 %) was verified in screening and treatment of sexually transmitted illnesses provided in all the selected primary health care centers Figure 2.

Figure 1: Maternal health services with higher satisfaction percentage in both model and traditional PHC centers in Najaf District.

Figure 2: Maternal and child health services with low satisfaction rate (%) in Najaf District.

Discussion

The implementation of standard PHC services showed no significant difference within the selected modal and non-modal primary health care centers in locality of Najaf district under this evaluation study. The standard structures for primary health care included thirty three implemented services [12] . The best available services were found in Al-Hassan Al-Mujtaba model center and Al-Nassar non model center. The current findings suggested that programs encourage integration take hold unevenly across facilities, and we have sought to better understand how to encourage greater effective integration of services. Common themes identified across settings related to; 1) dedicating appropriate space for maternal and child health services. 2) Considering health workforce composition, capacity, and motivation. 3) Ensuring consistent and affordable supply of a range of contraceptive methods.

The consumers satisfaction of services with provided integrated health services represented highier rates in both in model and traditional PHC centers . Both types of centers had shared the same standards of structures and same available resources of the programes. The study found that the Al-Jamaa model PHC center was the best between the selected centers in consumer’s satisfaction with the provided services, while Al-Nassar traditional PHC center was the least one. The best services were provided in all PHC centers in Najaf included (antenatal visits ,weight and height measurement, blood pressure measurement, breast examination ,counseling on exclusive breastfeeding ,counseling on family planning, tetanus toxoid immunization and documentation) . There was insufficient data to consistently analyze level of integration in prenatal and child health services [13,14]. The levels of integration in antenatal care were applied to disaggregate health facilities with high and moderate levels of integration and were grouped in addition to those with low-level of integration. The assumption in this study that the integration was unlikely to be by chance, but as a result of the program effect [15].

The services were not implemented or need improvement involved; premarital examination, screening for and treatment of STD and assisting normal deliveries, and providing basic emergency obstetric care if referral is not possible including management of post-partum psychosis [16,6]. These services need improvement and activation. Technical experts generally agree that optimal delivery of IMNCH requires: taking advantage of existing contact points; direct provision of counseling or services during maternal, newborn, and child health consultation; or facilitated referrals to the family planning provider [17,18]. The provider of services in a facility has not been shown to increase the use of multiple services. The minority of antenatal and postnatal care clients receive advice about family planning or birth spacing; as a result, unmet need for family planning has not decreased [19,20]. A systematic review of integrated HIV and family planning services noted that facilitated referrals between available services were difficult to implement without a good health system foundation [21,9]. Changing the organization of services for the purposes of integration requires one or more interventions, such as training, new tools, supervision, and performance improvement [22,23]. A fully integrating family planning and maternal and child health services across the continuum of care may have trade-offs for resource allocation and attention to other aspects of service quality in both model and non-mailed primary health care centers in this locality [23].

Conclusion

The implementation of standard primary health care services showed no significant difference within the selected modal and non-modal primary health care centers in locality of Najaf district. Premarital examination, screening for and treatment of STD and assisting normal deliveries, provide basic emergency obstetric care if referral is not possible ,management of post-partum psychosis , were services need improvement and activation in both model and traditional PHC centers.

Recommendation

1. Improving or implementing certain services such as; premarital examination, screening for and treatment of STD, and assist normal deliveries , provide basic emergency obstetric care if referral is not possible ,management of post-partum psychosis through training of personnel.

2. Training and encouraging PHC providers to use the methods of positive communication for dealing with consumers to increase the number of visits to PHC center to achieve their satisfaction in addition to activation of home visitor activities.

3. Reforming and evaluation of the MCH health services annually to improve and strengthen their efficiency and effectiveness.

Patient Consent Declaration

The authors certify that they obtained valid appropriate form of patient consent.

Acknowledgments

The authors acknowledge all the medical and nursing staff from Najaf district in directorate of health for their help during visiting the primary health care centers to collect the necessary demographic and clinical data. More thanks to the department of community health in the College of Health and Medical Techniques in Kufa for their help in reviewing the manuscript.

Author’s Contribution

All authors contributed in equal during preparation of the manuscript. Final proof reading was made by the first author.

Conflicts of Interest

The authors declare that there were no conflicts of interest.

Financial support and sponsorship

Nil

References

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