Anambra State has 21 Local Government Areas (LGA) and 75% of them are classified as rural. There are public and private owned health facilities in the state. The State Ministry of Health manages the public health facilities. These public health facilities comprise of 560 primary healthcare centres, 36 secondary health facilities and 2 tertiary health facilities. There are 305 primary health facilities and 1394 secondary facilities owned and managed by individuals and private organizations. Most public health facilities are not functional leading to high dependence on the private facilities. No record was found on the staff strength of the private facilities but there are 85 doctors and 613 nurses in the public owned facilities. Most of the free commodities like RDT Kits, LLIN, anti- malaria drugs are distributed mostly to the public owned facilities through the state central medical store and the state malaria elimination programme.
A cross-sectional study conducted between May and August 2018. Mixed data collection method was used to collect data among ANC attendees in facilities offering ANC. These comprise quantitative study and three focused group discussions to explore and triangulate findings qualitatively.
We recruited 284 antenatal attendees, who have attended clinic more than once using a three-stage probability sampling technique. Only attendance who were 18 years and above were included. In stage one; we selected one LGA each from the three senatorial districts in the state by balloting. In stage two; health facilities in the selected LGAs were stratified into primary health care, public secondary and private secondary health facilities then one facility was selected from each stratum by simple random sampling by balloting. Number of participants per facility was proportionally allocated using average antenatal attendance per month from daily attendance register. In the third stage; systematic random sampling was used to select the participants. Sample size was estimated using formula for single proportion; p was estimated using satisfaction level of pregnant women towards antenatal care at Ibadan southwest Nigeria.8
Three focused group discussions were conducted in three health facilities not participating in the survey. From the already selected LGAs, we randomly selected one health facility (three facilities in all). At the health facilities, pregnant women were selected purposively and they are homogenous in Age (25-35 years) and education (secondary level). Each group consisted of about 10 participants and the discussion lasted for approximately 60 minutes.
Quantitative data was collected using pre-tested semi-structured interviewer administered questionnaire. The questionnaire had three sections: socio-demographics, Knowledge and satisfaction questions which was divided into five domains: - process of care (7 items), interpersonal relationship/communication (7 items), hospital/clinic environment (8 items), accessibility (2 items), cost of healthcare (2 items) and overall satisfaction (1 item). The part on knowledge was designed after literature search while the section on satisfaction was adapted from a standardized questionnaire, patient experience questionnaire and modified it to suit our study. Translation to native languages was done in cases where the respondents may be uneducated. Back-translation was also done to avoid ambiguity and ensure uniformity of understanding. A guide was developed and used to facilitate the focused group discussions. Discussions were recorded using audio tapes and note taking.
The quantitative data was collected by three research assistants who are trained nurses working as disease surveillance and notification officers in the state. The research assistants were trained for 2 days. Interviews were conducted as exit interviews using open data kit software. Focused group discussion sessions were also facilitated by two trained data collectors. During the sessions, one person serves as the interviewer and the second person as the note taker. Each session lasted about 30 minutes on the average.
We exported the data to excel and analyzed using epi-info 7.2.1. We ensured that the data was complete during the collection stage by building in check codes into the electronic questionnaire and making all the questions required. Responses to knowledge questions were scored one every correct answer and zero for every wrong answer. Composite score of ≥75% was graded as good knowledge otherwise knowledge was graded as poor. Satisfaction questions on satisfaction were on a 5-point Likert scale with score values ranging from 1 (strongly disagree) to 5 (strongly agree). Then a cut off of ≥75% of composite score was classified as satisfied, otherwise unsatisfied. Univariate analysis was done to generate frequencies and proportions. Chi square was used to test for association between client satisfaction and independent variables in the bivariate analysis at 5% level of significance. Focused group discussion tapes recordings were transcribed. The text and field notes were analysed by content analysis that is by identifying, coding and identifying into teams. Content analysis was carried out. The analysis of the data was arranged according to the domains assessed in the qualitative study
Ethical approval with ref number COOUTH/CMAC/RP/Vol.1/0029 was obtained from ethical committee of Chief Odumegwu Ojukwu University Teaching Hospital. A written informed consent form was obtained from each respondents. Participants were only included in the study if they agree to participate and interview was conducted in a room with audio-visual privacy and confidentiality was ensured. All the participants were 18 years and above so no parental / guardian consent was required